psr individualized treatment plan psr individualized treatment plan april-may 2005

PSR Individualized Treatment Plan


April-May 2005

PSR Services16.03.09.453

• The goal of PSR services is to aid participants in work, school, family, community or other issues related to their mental illness. It is also to aid them in obtaining developmentally appropriate skills for living independently and to prevent movement to a more restrictive living situation.

• All services provided must be clinically appropriate in content, service location and duration and based on measurable and behaviorally specific and achievable goals.

PSR ServicesWritten Individualized

Treatment Plan• IDAPA 16.03.09.453.02• Services must support the goals of PSR which are

maximum reduction of mental disability and achievement of the highest possible functioning level for that participant.

• For adults this means becoming independent or maintaining the highest level of independence.

• For children this means learning or maintaining developmentally appropriate role functioning.


Treatment Plan• The individualized treatment plan identifies

the issues, goals, areas of need, objectives and the total number of hours and types of services estimated to achieve all objectives based on the ability of the participant to effectively utilize services.

• The individualized treatment plan must be developed by the participant, family, other support systems and the provider agency.

• Must be documented by the provider agency.


Treatment Plan• Must include the following:

– An issue statement specifically describing the participant's behavior that directly relates to the mental illness and functional impairment that was identified in the assessment

– A statement which describes the participant's goals relative to the goals of PSR



– Overall goals and concrete, measurable objectives to be achieved, including time frames for completion.

– At least one objective is required for the focus areas which will most likely lead to the greatest stabilizing impact.

– This should include at least one objective in each of the two focus areas which qualify the participant for PSR.



– Tasks that are specific, time limited activities and interventions designed to accomplish the objectives in the plan and are developed by the participant and the provider.

– Each task description must specify the anticipated place of service, the frequency of services, the types of service and the person responsible to assist the participant in the completion of tasks.



– Documentation of who participated in the development of the individualized treatment plan.

– The participant must take part in the development of the plan.

– The adult participant or guardian must sign the plan or documentation must be provided why this was not possible, including refusal to sign.



– For a minor child participant, the parent or legal guardian must sign the plan.

– A copy of the plan must be given to the adult participant and the guardian or to the parent or legal guardian of the child.


Treatment Plan• The individualized treatment plan

must be developed within 30 calendar days from the initial face to face contact between the provider agency staff and the participant, or the parent or legal guardian of a minor child.


Treatment Plan• An individualized treatment plan review by

the provider agency staff and the participant must occur at least annually.– During the review, the staff and participant

review any objectives which may be added or deleted from the plan.

– Input from other participants in the plan including service providers must be considered.

– Other attendees of the review may be chosen by the participant/parent/guardian and the agency staff.


Treatment Plan• Must be reviewed and signed by a

physician or licensed practitioner of the healing arts at least annually indicating services are medically necessary. (licensed physician, physician assistant or nurse practitioner and clinical nurse specialist with experience prescribing psychotropic medication)


Treatment Plan• Once the date of a plan is established

( physician signature date unless past due), that date continues to be the annual date of the plan.

• Any subsequent plans must be received by the MHA on or before the expiration date of the plan.

• If a subsequent plan is not received on or before the expiration date of the current plan, services that are provided in the interim will not be reimbursed.


Treatment Plan• The eligible participant will be allowed to

choose whether or not he desires to receive PSR services and who the providers of services will be to assist in accomplishing the objectives stated in the plan.

• Documentation must be included in the participant's file showing that the participant has been informed of his rights to refuse services and choose providers.

Individualized Treatment Plan Authorization

Requirements• Required documentation

(16.03.09.451.03):– Participant demographic information– Comprehensive assessment– Written individualized treatment plan– Adult services- rehabilitation outcome data

(MH Profile Form)– Children's services- CAFAS/PECFAS

Changes in Plan Hours or Service Type

• Must be approved by the MHA.• A clear rationale for the change in

hours or service type must be included with the request.

Changes to Plan Objectives

451.06• Include recommendation and rationale

in the next 120 day review.• Substantial changes requiring

immediate changes in the plan need to be submitted to the MHA for approval. The request must include the recommendation and rationale for the change.

Minor Changes to Individualized Treatment

Plan Tasks 451.07• Submit amended plan to the MHA

detailing the necessary and specific changes to the plan so long as there is no change in hours or types of services.

• If no response received from the MHA after 10 working days proceed to incorporate those specific changes.


Treatment Plan• PSR services that must be specifically

identified on the Individualized Treatment Plan– Pharmacological Management– Individual PSR– Group PSR– Collateral Contact– Nursing Service– Psychotherapy– Occupational Therapy


• Client Name• Social Security Number• Healthy Connection Physician• Medicaid Number• Healthy Connections Number• CAFAS Score- Children only• Provider Agency Completing the Plan


• Date of Amendment- when applicable

• Amendment comments- Justification and description of what is being amended in the plan


• Date of Plan- date of physician signature• 120 Day Review- 120 days from plan date

240 Day Review- date due from plan date• Annual Update- date annual update

needs to be completed, submitted and authorized by (ongoing date of the plan)


• Diagnostic Summary-• Indicate Primary Diagnosis with (P)

– Axis I: Clinical Disorders, Other Disorders That May Be a Focus of Clinical Attention

– Axis II: Personality Disorders, Mental Retardation– Axis III: General Medical Conditions– Axis IV: Psychosocial and Environmental

Problems– Axis V: Global Assessment of Functioning (GAF)

• scores for both current and highest past GAF


• Duration of Principal Diagnosis• Select one

– Less than one year– On to two years– More than two years


• Functional Areas Identified as Deficits in the Assessment

• Must be documented and justified in the assessment– Health/Medical - Housing– Social Interpersonal - Family– Vocational/Educational - Community/Legal– Basic Living Skills - Financial


• Functional Areas– Areas identified in the assessment to be

addressed in the plan– Psychiatric– 2 functional areas identified in the

comprehensive assessment• Health/Medical - Housing• Social Interpersonal - Family• Vocational/Educational - Community/Legal• Basic Living Skills - Financial

Issues• Issues- identified for each functional

area• Brief summary statement that

specifically describes the participant's behavior that directly relates to the mental illness and functional impairment

• Should also describe their strengths

Goals

If you don’t know where you are going, you will probably end up somewhere else.

Lawrence J. Peter

Goals

• Broad general statements• Express the participant's desires,

what they want to change • Written in their words• Tied to discharge criteria

Goals

• Goals can reflect– Life goals– Service or treatment goals– Quality of life goals

Goals

• Directed towards recovery• Responsive to need• Strengths based• Written in “I want to…”

statements

Objectives

Measurable, objective steps to accomplish the goal

Short term, time limited with time frames for completion

Objectives• Immediate focus of treatment but not a

description of the intervention• Focus on positive changes in behavior,

improving functioning, attaining new skills not just decreasing symptoms or stopping a behavior

• Written in “The participant will…” statements

• Specify one change at a time

Objectives• Reasonable• Measurable• Appropriate to the treatment

setting• Achievable• Understandable to the participant

Objectives• Time specific• Written in behaviorally specific

language• Responsive to the participant’s

needs and recovery goals• Appropriate to the participant’s

age, development and culture

Objectives• At least one objective for every

goal• Keep the plan manageable

TasksThe services, interventions, and

activities that will be provided by the treatment team

• Assist the participant achieve their goals and objectives

Tasks• Describe the services to be

delivered• Specify

– Who– What– Where– When- frequency, intensity, duration– Why


• Expected End Date• Dates may vary depending on the

objectives and tasks needed to accomplish the goals


• Type, Frequency & Hours• Summarize totals by service code

H2017 (RHIP) 1hr/1x/wk 52 hrs/ yr


• Signatures- must be hand written, with credential and date also hand written

• Participant/guardian • PSR professional that wrote the plan• Physician • Others involved in the plan

development


• Service Plan Authorization Form– Provider/Region– Client Name– Provider Number– Agency Phone Number– Agency FAX Number

References Treatment Planning for Person Centered Care: The Road to Mental Health and Addiction Recovery

Neal Adams and Diane M. GriederElsevier Academic Press 2005

psr individualized treatment plan psr individualized treatment plan april-may 2005

Documents

adult participant

types of services

minor child participant

goal of psr services

frequency of services

overall goals

measurable objectives

psr services16