Wave 1
Additional areas of focus on the progress note outlines these key updates
Patient reports updates on recovery environment, changes in support, barriers to recovery, strengths
These patients need a relapse prevention plan
Everyone regardless of length in treatment or sobriety time.
The presenting problem should include the following:
CURRENT problems and any treatment needs
Clinical documentation requirements for OTP patients in the first 90 days.
-scheduled 60 minutes weekly (roster for group)
-document DNS
-memo to chart
-explain short sessions in progress note
These things are needed to be prepared for individual supervision
-counselor caseload report reviewed and prepared to share what caseload management you have done/plan to do
-patients that need to be discussed
You should coordinate with this team member for dimensions 1, 2, and part of 3
The medical provider (or medical note if the provider is unavailable)
This group note contains a brief, high-level summary of the group without patient-specific information
The main group note
"Patient will attend medical and behavioral health appointments to complete the induction process to address health and safety risks created by ______"
ITP goals and objectives should be in this format
*double the points if you can list the acronym*
SMART goals
-Specific
-Measurable
-Attainable/Achievable
-Relevant
-Timebound
Where you can find BH daily/weekly checklist
-Team BrightView Intranet
-Quick start guides--> Center quick reference guides
-Behavioral Health QRGs
Every ASAM dimension on the biopsychosocial needs to have this from a patient
We need this number of treatment provider referrals added to the discharge/transfer summary
What goals will be transferred from the old ITP to the new ITP?
ALL active/declined/deferred goals
These are the current BH KPIs
-Failed activities
-ITP capture
-Retention
-Encounters
This should be done if a patient no shows their appointment
Phone call and contact log
This is the process if you assessed for moderate or high risk to self or others
-Notify BHS, Center Director, and medical provider
-If this is a TH patient (not at your center), notify BHS and BHS will tag the correct people
-Complete safety plan
- Schedule a follow-up call within 48 hours from RA.
-Schedule a follow-up with onsite provider within 14 days of RA.
-If high risk, 911 will be called for immediate follow-up. Obtain ROI for hospital if able to.
These are times when a relapse prevention plan should be revisited
-At regular intervals during treatment
-After a significant life change or stressor
-Following any lapse or relapse
-As new coping skills are learned
These are reasons why a risk assessment is needed when completing the PHQ-9
-"Yes" to question 9
-Clinical judgement
Things required for all pregnant patients
-ROI for OBGYN (and hospital if separate from OB)
-pregnant patient letter
-providing education documented
-spreadsheet updated
-POSC
These tasks make up caseload management
-Review caseload for the following: expired/upcoming expired ITPs, unscheduled patients
-Call patients to schedule and follow up on DNS calls
-Review patients to add to individual supervision and/or MDT
This is the process if the patient either refuses to complete a safety plan or is unable to complete a safety plan.
Select "no" under "Is the patient able and willing to participate in the creation of a safety plan?" and document why.
This is the main change for discharge/transfer summaries
An updated ASAM to match the biopsychosocial ASAM
This needs done if we identify needs on the Outcomes, Reassessment, and Coordination of Care page
Provide a referral for identified need or schedule the patient for a follow-up to address the need
-Respect
-Inspiration
-Service
-Excellence
The person responsible and owns a patient chart