Client Treatment Plan

Client Treatment PlanClient Treatment Pages/S.M.A.R.T. Objectives, Signature Page

Revised: August 2021Presented by: QA Department

Why complete the CTP?

➢The CTP and the goals/objectives guide our treatment interventions as we work with our consumers in overcoming barriers to meeting their recovery goals.

➢Allows those working with a consumer to see a comprehensive record of goals, interventions, and services provided to the consumer.

When do I complete the CTP?➢The CTP is created once the Full or Re-Assessment is fully completed

➢The CTP should be created before treatment services are provided, with the following exceptions: ✓ Assessment

✓ Crisis Intervention

✓ Plan Development – Treatment Planning with a client

✓ Linkage and Referral during the first 30 days for newly active clients

➢Services prior to the completion of an assessment and client treatment plan may provided for “emergent” (AKA “urgent”) services which would need to be clearly documented.

*REMINDER: Emergent services do require the establishment of medical necessity

When do I complete the CTP?

➢Non-assessment/non-crisis interventions should never routinely be provided prior to the completion of the assessment and CTP due to heightened risk of audit disallowance.

➢The CTP is completed w/in 30 days from the start date of your CTP.

➢Rewritten every 365 days for MHS, TCM and MSS

➢ This will help ensure that the Full or Re-Assessment and CTP relate to one another, which is important from a:

✓ Quality of Care perspective

✓ Audit perspective

Why complete the CTP?

➢A completed CTP also “covers” and “protects” the billing we submit for the services we provided. Therefore, if the CTP is not completed and services are provided, these services will be recouped in an audit.

➢Services will also be recouped if the CTP is not signed, services are provided, and there is no documentation indicating the clinical reason why it has not been signed.


➢The MHS goal(s) on the CTP is updated every 3 months for CalWorks and every 6 months for TBS and IHBS.

➢Whenever a goal on the existing CTP is being updated during treatment and not at the review period, the new goal is created on the existing CTP.

oSince a new CTP is not created in this scenario, the additional goal/objective does not reset the subsequent due date.


➢When the CTP is up for review or any time an update is made to the CTP, an accompanying progress note should document:

➢The collaboration made with the consumer to develop the objective.

➢The outcome of the previous treatment plan or objective.

✓This is imperative since we no longer have outcomes on the treatment plan (hard copy). The treatment team will need to know when objectives are closed out to prevent staff from using a closed objective (would result in recoupment).

What are the components of the CTP?➢ The Client Treatment Plan falls under two categories (hard copy):

✓Annual

• Annual Client Treatment Plan covers all services to be provided to the client

• Required after completion of a new client assessment, or returning client assessment and prior to the initiation of services for the client

✓Update

• An addendum to the Annual Client Treatment Plan

• Covers goals/objectives added, modified, etc., prior to the review deadline of the Annual Client Treatment Plan.

NOTE: When a goal is updated/added in our Electronic Health Record System (EHRS-Welligent) during treatment and not at the review period, the new goal will be created on the existing CTP. Since a new CTP is not created in this scenario the additional objective(s) does not reset the subsequent due date.

*Please refer to our LA County Training Manual for additional information on the Hard Copy version.

The Client Treatment Plan Page

➢ Plan Date

✓Include the date that the CTP was started ➢ Reminder: the CTP is started once the Full or Re-Assessment is fully completed

➢ For example: 11/22/14

➢ Plan End Date✓ Include the end date of the CTP (365 days from when the CTP was started)

➢ For example: 11/22/15

➢ Next Review Date

✓ Include the next review date based on when the CTP was started

✓ Include the next review date for specialized programs that are due prior to the Plan End Date:

➢ For example: 2/22/15 (e.g., CalWorks – see slide 6).

Client Treatment Plan Page – Continued

Child/Adolescent – WELLIGENT Example:

The Client Treatment Plan Page

➢ Client Long Term Goal(s)

▪ Document the consumer’s long-term goal(s) in his/her actual words.

➢REMEMBER…

▪ In the case of a child consumer, also document the caregiver’s long-term goal(s) for the child in the caregiver’s actual words.

▪ In the case of a conserved adult, also document the conservator’s long-term goal(s) for the conserved adult.

➢ Effective Date:

▪ Date the objective is created with the client, which should also match the date the consumer and/or caregiver/conservator signed the objective.


Child/Adolescent – WELLIGENT Example:


Adult – WELLIGENT Example:

Client Treatment Plan (CTP)

➢ The Welligent Treatment Plan has not been fully updated to reflect the new LA DMH Client Treatment Plan. What does this mean?

✓ You will still have to complete old fields that are no longer on the paper CTP (ex: outcomes of goals, fields associated with the coordination page).

✓ Cannot leave blank fields

✓ Some of the items on the Welligent Treatment Plan were redefined to ensure we remain in compliance.


Set Up Details of the Welligent Treatment Plan

➢In EHRS, the Plan Date will be your start date of the treatment plan.➢Must be the same as the Date Prepared.➢This will be what is used to trigger the alert of the next due date.

➢The Plan End Date will be used as the next date of review of the entire CTP.➢The Next Review Date will be the next date of review of goals.



➢The objective Effective Date will be used as the date the objective was created with the client.

Effective Date is the date that the treatment objective was created/collaborated with the client & caregiver (if

applicable). It may or may not match the start date (i.e.,

Plan Date) of the CTP.


➢Mental Health/Targeted Case Management/Medication Support Objectives are documented in the format.


S.M.A.R.T. objectives are…

Specific

Measurable

Attainable

Realistic

Timebound


Specific – the objective must be written in specific, observable and behavioral terms.

Measurable – the objective must include a measurement of how frequently the identified “goal” behavior will occur

Attainable – the objective must be able to be attained by the consumer/member leading to success vs. failure

Realistic – the objective must be realistic for the consumer/member to work on and accomplish

Time-bound – the objective must be able to be attained in the prescribed time period (i.e. 60 days, 3 months, 12 months, etc.)


Child/Adolescent Example (MHS-Rehabilitation):


Child/Adolescent Example (MHS-Therapy):


Adult Example (MHS-Rehabilitation):


Adult Example (Targeted Case Management):


S.M.A.R.T. Objectives must contribute to the reduction of the identified mental healthsymptoms/behaviors on the most recent

assessment document and the accompanyingFunctional Impairment(s) in at least one (1)

Life Area of the consumer


➢ Type of Service • Check the box that represents the “Type of Service” (i.e., MHS, IHBS, TCM, ICC,

Med Sup, TBS) that your interventions will reflect.

➢ Client Involvement• Document the specific actions that the consumer will engage in inside and outside of

the sessions to move towards goal attainment.

➢ Family Involvement (when applicable)• Document how the family will assist the consumer in meeting the identified

objective(s).

Note: Family involvement must be linked back to the SMART objective (e.g., Mother will model use of deep breathing technique to be used when angry).

➢ Clinical Interventions• The intervention section should include the following:

✓ Specific active interventions that directly connect to the objective

✓ Frequency of service ✓ Modality (select from down options)✓ Duration of services

Note: It is possible to combine different types of service interventions (i.e., individual rehabilitation and group rehabilitation) under the same objective.

Note: Ensure that in the intervention section of the CTP each type of modality is clearly indicated for the objective followed by the specific interventions for that specific modality.

CLIENT TREATMENT PLAN PAGE – CONTINUED



Drop down options


Child/Adolescent Intervention Examples (MHS-Rehabilitation Goal):


Adult Intervention Examples (MHS-Rehabilitation Goal):


➢Interpretation

➢Indicate what is the consumer’s preferred language

➢Indicate if the CTP was interpreted

➢Document “N/A” in Language section if there are no interpretive/linguistic needs


NOTE: The section is housed in the Setup and Review section of the CTP in our EHRS. Should the client have preferred a language other than English, the above items would be checked and a specific Language identified from the drop down.

The Signature Section

➢ Contains the signatures of staff members who created objectives on the CTP along with staff’s license/registration number, if applicable.

➢ Staff who are not designated as AMHDs must have a counter signature (i.e., co-signature) by the appropriate AMHD which include the following: ✓ MD/DO/NP will co-sign for nursing staff members’ medication support objectives✓ PhD/PsyD, LCSW/LMFT, BBS-Registered Associate Marriage & Family Therapist/ASW, RN,

CNS will co-sign for Case Managers’/Mental Health Workers’ MHS-Rehabilitation and Targeted Case Management objectives and will include their license/registration number.

NOTE: All Student Interns/Trainees must obtain a co-signature of a licensed staff acting within their scope of practice.

➢ All objectives for Medicare clients must have an MD/NP co-signature, even if medication support services are not provided.

Signature Section – Continued

➢ Contains the signature of the consumer

➢ Contains also the signature of the parent/legal guardian when the client is a minor

➢ Contains also the signature of the conservator when the adult client is conserved

❖NOTE: Signatures collected electronically and/or on hard copy should include staff’s license/registration number, if applicable


➢ Welligent CTP➢Each objective must be individually signed


➢Signature Reminder

Signatures must include staff’s title, license and/or registration number, if applicable (State requirement).

This information should be included when signing electronically in our EHRS and/or if signing on hard copy.


➢Date each signature (electronic signatures will automatically include this item). If gathering signatures on hard copy, please ensure the proper dates are included.

➢ Indicate if the client accepted or declined a copy of the Client Care Page.

➢ Input the staff’s initials that offered the copy of the Client Care Page and input the date that the offer was made.


➢All mandatory signatures must be obtained whenever objectives are created (initial, additional during the treatment period, and at the prescribed review period)

➢ If the required Client/ “Client Collateral” did not sign, document the reason why on the Signature Page

Note: Continued efforts to obtain the consumer’s and/or “other’s” signature must be documented in the record

Signatures During Covid-19➢What about signatures during COVID-19?

➢ Staff should document obtaining verbal consent from consumer agreeing to the objective(s) created

➢Verbal consent must be documented clearly

➢An explanation in the section provided on the Client Treatment Plan as to why they didn’t capture client signature should be noted

➢ Should staff be unable to obtain proper signatures in person from the consumer, they may include an explanation such as the following:

❖“Due to the current COVID-19 pandemic, client was unable to meet in person to sign current plan at this time; however, client/caregiver has provided verbal consent and staff will make ongoing attempts to obtain all proper signature(s)”.


➢ Welligent CTP

The CTP: Final Points

➢ The CTP should be started once the Full or Re-Assessment is fully complete

➢ The CTP is created before treatment services are provided

➢ Services prior to the completion of an assessment and client treatment plan may provided for “emergent” (AKA “urgent”) services

➢ The CTP is completed within 30 days from the Plan Date (i.e. start date)

➢ A CTP must be completed and placed in the Clinical Record of each Program providing services to the consumer

➢ All non-emergent, planned direct services provided to a consumer should be listed on the CTP

The CTP Final Points – continued

➢ A goal/objective must be completed for every type of service provided:

➢Mental Health Services (MHS)➢Medication Support Services (MSS)➢ Targeted Case Management (TCM)➢ Intensive Care Coordination (ICC)➢ Intensive Home Based Services (IHBS)➢ Therapeutic Behavioral Services (TBS)

REMINDER: All treatment services need to have an objective(s) on the CTP with the below exceptions:

➢Assessment➢Crisis Intervention➢Plan Development – Treatment Planning with a client➢ Linkage and Referral during the first 30 days for newly active clients

Brief Note on Coordination of Care

Primary Program of Service:

➢This will be the original program that opened the case or the single program that is treating the consumer.

The Primary Program of Service is responsible for:

➢Coordinating treatment with the other PC provider.

➢Ensuring that documentation is completed and updated based on the new timeframes (ex: that new objectives are created by the secondary program).

Note: Primary Program of Service is a concept created by LA DMH.

➢In Welligent, the Primary Program of Service information will be housed in the Record Navigator under Client Information in the Demographics (Intake/Discharge Tab) section in EHRS.

BRIEF NOTE ON COORDINATION OF CARE

Important Note!

Should our Electronic Health Record System (EHRS-Welligent) be down, staff should follow

our down-time procedures and utilize the hard copy CTP.

Please note, for further instructions on how to complete the Hard Copy DMH Client

Treatment Plan, please refer to the step-by-step instructions in our LA County Training

Manual housed on PCWeb.

Important Note

The CTP is only as good as the information documented in the Full Assessment/Re-Assessment and when

Applicable – the Assessment Addendum

Review of Due Dates

➢ This example includes when a consumer is a new client and then terminates and returns for treatment.

➢ The consumer also transfers to another program midway.

➢ It demonstrates what documentation is needed in each case.

Documentation Example Scenario

Resource Page ➢ This training may be accessed by going on PC Web, clicking on the QA

tab, select Tutorials, and click on “Client Treatment Plan” (PDF version)o Reminder: This training is also available in the Ultipro Learning System –

AKA MyPCTI on UKG (with audio recording)

➢ In addition, for step-by-step instructions on how to develop a treatment plan in Welligent, please refer to the EHRS Training Manual.

➢ Information on the Client Treatment Plan may be found in the Quality Assurance Documentation Training Manual (please refer to the Table of Contents)o NOTE: LA County Training Manual will focus on the hard copy version only

➢ You may access our Training Manual by going to PC Web, clicking on the QA tab, select Manuals, then click on “LA County Training Manual”

Documents

Client Treatment Plan