Person-Centered Plans & Documentation [Autosaved].pptx

Principles of writing person-centered service plans using People First language for NYS OMH residential settings. Are your goals measurable? Are people progressing on goals? How can you write goals in a way that people will be successful?

1. Person-Centered Plans & Documentation People First Language Presented by Jennifer Hatch, Corporate Compliance Officer July 21, 2021

2. Foundational Principles Strengths Based Person Centered Recovery Oriented Goal Oriented

3. Strengths-Based Strengths-based means recognizing and starting care with and individual's strengths, not with his or her deficits . While ELC   eligibility  is defined by deficits,  care  in ELC should be characterized by building on an individual's strengths, current resources, and resourcefulness.

4. Person-Centered Person-centered means assessment is conducted  with people , not at a desk apart from them . Person-centered means that the people we serve have control over their services, including the amount, duration, and scope of services, and choice of providers . Most importantly, person-centered services means that we exhibit  unconditional positive regard. 

5. Models of care Models of care have changed over time. A traditional/historical model of care focused on the diagnosis, disease, and deficits… Where as a person centered model of care focuses on the client’s abilities, preferences, and individual needs.

6. Models of care comparison Historical/Traditional Deficit-based model of care, using standardized assessments and treatments Care is focused on fixing problems . Professionals make decisions about treatment Person-Centered Strength-based model of care. Disability is only one of the characteristics considered in model of care . Care is focused on supporting them in learning skills . The person served makes decisions about care.

7. Models of Care Comparison (cont.) Historical/Traditional Control: professional judgement and decision making Goals decided for the client Stabilization is the desired result Fit person and treatment plan into the program parameters Person-Centered Partnership/shared decision making Driven by the individual's goals Quality of life is the desired result Individualized

8. Goals Developing Positive & Measurable Goals

9. Recovery Vision/Area of Growth The Recovery Vision is the big picture and the ultimate Treatment Goal Otherwise known as an Area of Growth or Area of Strength to Build Upon It paints a picture of how an individual would like his or her life to be different than it is now, where mental health symptoms have prevented them from living the life they desire. 

10. Treatment goals Break down the recovery vision as needed in to more detailed or focused areas of need . Example: Recovery Vision: Jane would like to live independently, successfully managing her mental health symptoms with coping skills and medication management. Treatment Goal: Jane will learn to utilize three coping skills 100% of the time that she displays symptoms of anger. Objective: Jane will practice deep breathing when she is upset

11. Personal Goals These are other goals a person might have that are not directly treated with services, but that give us insight into the bigger picture of the person and what they want out of life. Recording these is optional, up to each perso n. Example: Jane would like to learn how to sew. This is a skill that is important to Jane to give her a hobby.

12. Positive Goals / positive language Negative I don't want to be so depressed anymore . I don't want to lose my children . I don't want to be so lonely anymore . I want to stop hearing voices . I want to lose weight. Positive reframing I want to enjoy life . Be a better parent . Meet people and make friends . I want to learn how to cope when I am hearing voices . Get healthy/get in better shape.

13. Exercise What are 2-3 things you would like to be different in your life? Are the statements you wrote phrased positively? Describe each goal in more detail to help others understand it. What strengths and resources do you have that will help achieve the goals? What are the barriers to you achieving each goal? What help do you need from others to achieve them?

14. Objectives & Methods Core elements of objectives: The Goal with which the objective is associated; The Domain being treated (Symptom management, medication management, interpersonal skills, etc.); Rationale (Why are we providing treatment or services in this domain?); Desired Outcome statements (see next slide) Methods (how will services/treatment in this objective be delivered?); Frequency and duration of the services to be provided.

15. Desired Outcomes Desired Outcome statements are tangible, measurable steps toward goals . These statements are: Small Steps Toward the Goal Objectively Measurable or Reliably Reportable Measure Only One Thing Get To the Ultimate Goal

16. Service Plan or Progress Reviews Service Plan/Progress Reviews are completed at least every 90 days from the start of each plan, prior to updating a plan at any time, and upon discharge from services . Provides the plan developer, with the resident , the opportunity to: Celebrate success Check in on satisfaction with services whether or not a person's needs, priorities, goals and objectives remain the same or have changed engagement and satisfaction with other services to which the person has been referred or is receiving Identify new problems, needs, or barriers to success Change course in services or treatment if needed

17. Progress notes Using Person-Centered Language in Every Day Documentation

18. Progress notes are concurrent documentation Concurrent documentation means the following : Substantially drafting Progress Notes during the activity in which you are engaged, or the services you are providing, or immediately thereafter. Completing Progress Notes within 24 hours. Submitting Progress Notes for review and approval daily.

19. Why Concurrent documentation? Accuracy: Your progress notes are medical records. Your days are busy. Documenting concurrently using the previous guidelines will help to ensure the accuracy of your records and prevent inaccurate records that could constitute fraud . Efficiency: Documenting concurrently also saves time . It is much easier to remember and record accurately and efficiently what you have done and observed if you write it down when it occurs, or within minutes afterwards, and before other events occur and cloud your memory. Trying to get all of the facts straight hours or days later takes much more time.

20. Objective documentation Objective documentation can be easily understood as this: document only what you can detect with the five senses: sight, sound, smell, taste and touch . Judgements , opinions, and conclusions have no place in objective documentation .  SEE HANDOUT

21. Writing Good Progress Notes Avoid jargon and confusing abbreviations . Use proper spelling, grammar and punctuation . DO NOT COPY AND PASTE NOTES!!! This is NOT person-centered documentation at all!   Write in simple, plain language. Don't assume that rules you learned elsewhere apply here.

22. 3 Components of a Progress Note Intervention - describes what you did. How you gathered or presented information, taught skills, intervened to help with a problem, redirected, responded to requests for help, etc . Provide information here relevant to the service or treatment. It is not necessary to describe every moment of the session, or detail of dialog or interaction. Provide a concise synopsis that illustrates that you provided the service . Response - Provide a brief, objective synopsis of how the individual responded to the intervention . Plan - Plans should identify what you will do, and what the individual will do (and when)

23. Remember… As its name suggests, person-centered care puts the person at the heart of their care. You adapt your service to their expectations and preferences, not the other way around. Doing so enables residents to retain their dignity and autonomy during an already challenging time. Rather than leaving them feeling hindered by their mental illness or disability, or debilitated during their time as a resident, you help them live a fulfilling life . Not only does our care need to be person-centered, but so does our documentation. When we speak person-centered language on a regular basis, person-centered care becomes natural.