~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
TIPS & TOPICS from David Mee-Lee, M.D.
Volume 5, No.5
September 2007
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
In this issue
-- SAVVY and SUCCESS
-- SKILLS
-- SOUL
-- SHAMELESS SELLING
-- Until Next Time
Welcome
to the September edition of TIPS and TOPICS (TNT).
I hope your vacation time was as successful as mine.
Or if you didn't have a vacation, maybe this is
something to be learned from the Australians and
Europeans.
SAVVY
and SUCCESS
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
As I train and consult around the country, clinicians,
counselors, supervisors and administrative staff
frequently complain about paperwork demands that
often are more compliance-driven than clinically
useful. I hear of enormous amounts of time and resources
that are poured into preparing for accreditation,
licensure and other quality audits. For some time,
I have discussed with county and state quality auditors
whether there might be ways to make audits more
useful. Could they focus on whether standards actually
improve treatment and client involvement, rather
than just checking on paperwork? Look back at the
2006 September
issue where I raised this same issue.
Over lunch a few years ago, I was sharing ideas
with Carleen Jimenez, Quality Assurance (QA) Manager
for Salt Lake County Substance Abuse Services. She
and her QA team ran with these ideas and have done
some effective experimentation which I want to share
with you this month. So I asked Carleen to write
up her experience so far. By way of introduction
to her SUCCESS STORY in progress, here is what she
said:
"I
think it's important that the members of our audit
team are all licensed clinicians who have worked
in the field, and while staff may find it hard to
believe, we do understand the pressures and concerns
of direct services. I don't know if it is significant,
but our Division is a public system and serves approximately
6000 adults and 2000 adolescents per year."
Carleen
Jimenez' Report
* HERE COME THE AUDITORS!
Auditing
the client record for quality assurance has its
challenges. How can we judge a program from its
documentation? Is the quality of the writing relevant?
Do grammar and spelling matter? Should we adhere
to a checklist that demonstrates compliance with
the contract? Is it possible to deduce the quality
of service from what we read?
The
client record deserves respect - after all, documenting
appropriately gets us paid, protects us in court,
legitimizes us as a profession, preserves clinical
memory, and, perhaps, as we organize and write our
notes, it honors our client with a moment of quiet,
personal reflection on the quality of our therapeutic
relationship.
A
thousand-plus record reviews later, however, it
is clear to our audit team that documentation has
a way of defeating its own purposes - it's seldom
enough and it's often too much. Documentation alone
will never adequately represent the scope of service
we provide - as chart auditing alone will never
improve the quality of the service.
*
ON LOOKING GOOD
You
know that the spirit of documentation has been lost
when the focus of record keeping has become "looking
good" for the auditors. In our first years
of reviewing records, we began to realize how our
checklist-driven audits might contribute to contract-
compliant records that promote program-driven treatment
where clients do 90 days, four AA meetings a week
and start over if they violate a rule. "We
have to document if we want to get paid" is
a recipe for resentment and loss of clinical energy.
No wonder treatment providers view auditors as aliens
who are out of touch with the 'real world' of too
many clients, not enough time and too much paper
work. No wonder line staff feel frustrated and overwhelmed,
and look at audits as intrusive rather than as an
opportunity to evaluate and improve services.
*
ON GETTING BETTER
Getting
better is what treatment is about: improving successful
outcomes is a concern to us all - clinicians, stakeholders,
auditors and clients alike. An audit, while seldom
welcomed, is meant to improve, not stifle services.
Over the past four years, we've been experimenting
with the audit process in an attempt to improve
our effectiveness as one participant in this ever
changing culture comprised of multiple moving systems
all trying to get better.
*
ASK THE EXPERT
We've
found that including client feedback in our quality
assurance process is essential. In the past few
years we have conducted in-depth face-to-face interviews
with hundreds of individuals receiving services.
Clients appreciate the interest we take in their
concerns as customers and they welcome the opportunity
to improve a system in which they are invested,
and, quite frankly, hold expert status.
A
client satisfaction interview and a clinical interview
require the same skills: promoting trust, assuring
confidentiality, and creating an atmosphere where
the client is comfortable expressing his/her opinions
and offering suggestions.
We
developed - and are continuing to improve - a standardized
interview format. The interview includes a number
of close-ended questions such as "how many,
how much, how often" that make calculating
data for our stakeholders possible. We also ask
open- ended question that allow a conversation with
the client to develop. Questions like "What
brought you here?" "What would you suggest
that might improve our services?" "What
would you like to get out of treatment?" And,
"Is that on your treatment plan?"
*
WHAT TREATMENT PLAN?
It
became apparent from reading treatment plans across
a large system as well as from client interviews
that treatment planning, treatment plans, treatment
plan reviews are the most obscure feature on the
clinical landscape. Often repetitive, prescriptive,
and based on the program's offerings, they seldom
reflect the living process that the client and the
clinician are attempting to make. It's not unusual
to find goals and objectives such as "Accept
the need for recovery and establish abstinence;
attend AA meetings and find a sponsor; complete
all assignments; graduate from the program"
repeated for all clients. Nor is it unusual for
these objectives to remain the same at review. Interventions
or methods are often a list of standard clinical
services such as group, individual therapy, and
case management.
Treatment
plans by mandate have strangled our clinical process.
Fixed time lines, standardized formats, and drop-down
elements in most electronic records have further
cluttered the scenery and encouraged clients and
therapists to think in program- driven terms as
typified by "attend 36 groups; 10 aftercare
groups; 4 University lectures; and pass 26 UA's."
In
interviewing clients, we found them aware and/or
supportive of their treatment plan 51% of the time
- meaning that 49% of our clients either do not
agree with or do not have a treatment plan.
*
I'VE GOT A PLAN!
However,
the amazing discovery was that 100% of clients have
a plan! In interview, they tell us about their personal
expectations for treatment and recovery. And what
they tell us appears reasonable and would provide
a great beginning to a dynamic, individualized treatment
plan.
-->
"I don't have a treatment plan. What I want
is to stay clean and sober. I'm hoping that after
the year is up I won't have cravings any more."
-->"No,
not through here. My workforce services counselor
has helped me though."
-->"I
can't remember what's on the treatment plan. I think
I saw it when I was moving to the 2nd level. My
goal is to graduate, to maintain sobriety and healthy
living and live day by day without using."
-->"I
haven't got a treatment plan. I have a plan I made
for myself at home. I want to stay sober and not
do drugs. I want to be a responsible mom, get a
job and go to school."
-->"Five
years ago I would have sold everything to keep using.
I don't want to lose everything that's going on
now - I'm raising my grandson and that's my most
important thing. No, that's not on my treatment
plan."
-->"To
complete the program and get a job. I want to get
as much out of this as I can. I have a treatment
plan, but I don't know how to read it."
-->"I
think we did a treatment plan and that it was faxed
to my PO but it's been so long ago I can't remember
for sure."
-->"They
don't agree, but I want to use for pain management
only."
-->"Not
go through treatment centers no more."
-->"After
they have their meeting they will inform me."
-->"My
goals were established through writing an autobiography
and sharing it with the group and then the group
decided what I will work on."
-->"I
just got back into treatment. I left last week with
my friend so we could go use, but she died of an
overdose. When people come in now they start writing
plans. I just can't plan ahead right now. I'm just
going day-by-day, hour-by-hour. That's how the world's
going for me right now."
-->"Initially
I got to help create my treatment plan and then
my therapist changed last week. My new therapist
added another goal, but I had already chosen my
goals and I don't want to do both. My new therapist
said she would review it with her team and get back
to me with what they decide."
-->
"I don't have a treatment plan. I just want
to hurry and complete the program. I don't want
to have to involve my kids. My drug problem is my
problem, not theirs."
-->"My
plan is to lay low in here because if they knew
what I'm thinking they would make me start over."
-->"I
want to continue coming here. I want to find a treatment
solution for my needs and work on what I need to
work on. I know what I need but people need to listen
to me."
-->A
parolee shared his 6 point plan created while he
was incarcerated. It included completing all the
substance abuse courses offered by the prison and
earning his high school diploma before his release.
In his transition to parole he was assisted in making
contact with his family and repairing those relationships.
Since his parole he finished a vocational program
and earned certification allowing him to hold a
good job. Now he had that job and was working. Coming
to treatment however was interfering with his work
because his boss was not happy about letting him
off early to attend treatment and treatment was
not willing to compromise their program to support
his goals.
*
ARE THERE ANY QUESTIONS?
Reviewing
client comments raised questions. We questioned
if and how clients found treatment sensitive to
their needs, or if some clients just 'endure' treatment
while working to meet goals on their own - in spite
of our 'interventions.' As one client told us, "I
just want to complete treatment and endure the longevity
of sobriety."
We
questioned the mandatory nature of a treatment plan
that imposes timelines and formats that are burdensome
to clinicians, that don't follow clinical logic
and further encourage program-driven treatment.
*
ARE THERE ANY ANSWERS?
We've
responded to our findings with a number of changes
to our audit process beginning with a redesign of
our treatment plan/treatment plan reviews. Our new
ASAM guided treatment plan will be connected directly
to the progress notes, because, as our client record
auditing has shown, the progress note most closely
follows the clinical flow and represents the 'here
and now' of treatment. We will ask our programs
to think "dimensionally" as they partner
with their client in establishing a meaningful goal
(there will be no drop down or pre-cooked goals).
A progress note that incorporates the treatment
plan and ASAM PPC-2R to evaluate and track the client's
needs in each dimension and identify objectives
and interventions in the present rather than waiting
to meet an arbitrary timeline. It is our hope that
this change will promote the treatment plan/review
as a living document and the relationship between
clinician and the client as a dynamic, problem-solving
partnership.
Again,
documentation alone is not an adequate measure of
the quality of service. However, as a tool, documentation
will continue to serve us in all the usual ways
while provoking us with the questions it poses.
So, no, eliminating documentation is not the answer.
But we can set expectations that allow documentation
to become more meaningful to clinicians, payers,
auditors and clients, more supportive of the therapeutic
alliance and more encouraging of client-driven,
individualized treatment across a continuum of care.
"As
I've thought about what I've learned in the audit
process - especially in integrating the client's
voice and the clinical record, it greatly exceeds
what I've written here. What I've learned has given
me hope that, however slow, change is possible.
We
are continuing to make significant changes to our
audit process: making visits more often, making
them less intrusive (hopefully) and more consultative.
I think we are moving toward more interaction with
clients and encouraging providers to be more diligent
in their supervision of both the record and treatment."
Quality
Assurance Team for Salt Lake County Substance Abuse
Services:
Carleen Jimenez, LSAC, LPC, Quality Assurance Manager
Tracy Christensen, LCSW
Brian Currie, LCSW
and
Tim Whalen, LCSW, Division Director
SKILLS
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Whether you are a clinician working in a program;
a therapist in private practice; a clinical supervisor;
or a quality assurance auditor, the following client
survey can help focus on collaborative treatment
planning. What follows is the current version of
the survey Salt Lake County is using to assess client
involvement, and to consult with programs to improve
quality of care and outcomes.
Salt Lake County Division of Substance Abuse
CQI/UR Client Interview
Client
ID:
Treatment Provider/Program:
Date entered Tx:
ASAM Level: (How long at this level)
Date:
Interviewer:
1.
What's the single most important thing that brought
you to treatment?
Why
Now?
What
would happen if you hadn't come here?
Court
ordered: _____ Self-referred: _____ Other: ______
2.
Have you been in treatment before?
Yes:
_____ No: _____
(If yes, how many times?) 1-2:___ 3-4:__ 4- 6:___
7+:____
3.
What are you hoping to get out of treatment?
(What will make your time here worthwhile, etc.?)
4.
What will you need to make this happen?
5.
Using this scale, how well do you think treatment
is helping you make this happen?
Not at all ________________________________ Very
Well
6.
Are these things on your treatment plan?
Yes_____ No______
7.
Are you linked to other services?
Yes: ____ No: ____
If yes: list services/agencies
Did treatment connect you with services?Yes: ____
No: ____
8.
What have been barriers to your treatment?
(What's made it hard for you to be here? Probes:
how long did it take to get into treatment, fees,
transportation, hours, conflict with employment,
child care, etc.)
9.
What is your drug of choice?
10.
Since you have been in treatment, have you been
abstinent? (Date of last use? Probe how
the client reduced use; what worked or didn't work)
Yes: ____ No: ____
If
no: have you reduced your use? (What's the program's
reaction to use?) Yes:____ No:____
11.
Since you have been in treatment, have you had fewer
problems with the police and/or courts?
N/A____ Yes: ____ No: ____
12.
Do you have children?
Yes: ____ No: ____
If yes, how many_____
13.
Since you've been in treatment have you had fewer
family problems?
N/A____ Yes: ____ No: ____
14.
How do you know when you have completed this phase
of your treatment?
15.
How will you know when you're ready to complete
treatment? (Probes: is it time driven [court
or program driven] or when treatment individual
goals are met [client driven?] Does client have
a sense of the treatment continuum of care or do
they think they "graduate"?)
16.
What are the strengths of this program?
(Probes: what have you learned; what do you like;
what has helped?)
17.
Using this scale, how would you rate this program?
Not Helpful ______________________________ Very
Helpful
18.
What would you suggest to make your treatment even
more helpful? (Ask client to suggest something
we can do to bring the mark up just a little)
19.
How likely is it that you would recommend this program
to others?
Definitely Would Not_______________________________________
Definitely Would
What
would make you more likely to recommend
this program to others?
SOUL
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Because I travel so much on
United Airlines, I frequently get free upgrades
to First Class; get to board the plane first ahead
of most; and even receive personal notes occasionally
from the pilot thanking me for being a faithful
customer. I don't have any illusions that United
treats me well because I am anyone special other
than that they want my business. Yet it is interesting
to see what happens when I have to take another
airline due to schedule or cost reasons.
Now at this airline, I am a nobody. Just one of
the crowd. My seat assignment is up the back instead
of in the premium seats up front with more legroom.
I have to wait my turn to board; and don't get first
pick of the overhead baggage space anymore. "Don't
they know I'm a million-mile flyer on United who
deserves the best?" "What happened to
all my special privileges?" "I deserve
much better than this" "Don't they know
who I am?" Well I don't really say any of those
things. But the taste of my United First Class treatment
easily fosters a sense of entitlement and expectation
that somehow I deserve special treatment everywhere.
The
other day, courtesy of a paparazzi video, I saw
Britney Spears create a fender bender with a parked
car as she pulled into a parking spot at a mall.
I was sort of stunned that she got out of her car;
inspected any damage to her own car; and then walked
off without the slightest concern to check what
she had done to the parked car she hit. Perhaps
it is naïve to think that no matter what celebrity
she might have, you think she would at least be
curious, if not remorseful, as to what damage she
had done to the other car. But no, she just walked
away.
As
my judgmental juices got active watching this display
of selfishness and elitism, I remembered how subtly
an entitled attitude can blossom. And it's not just
rich people, pop stars, actors, politicians and
frequent-flyers. It could be the multi-generational
welfare recipient who feels the government owes
them; the MD-eity or CEO who is used to getting
their way; the indulged child who thinks the world
revolves around them; or whatever your self-evaluation
reveals about your sense of entitlement.
"There
but for the grace of God go I."
SHAMELESS
SELLING
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
In
case you missed the announcement last edition of
TNT, here is the latest offering from Hazelden in
their Clinical Innovators Series.
"Applying ASAM Placement Criteria"
DVD and 104 page Manual with more detail
based on the DVD with Continuing Education test
(10 CE hrs), 75 minute DVD
David Mee-Lee (DVD) and Kathyleen M. Tomlin (DVD
manual)
Don't
miss out---just like the iPhone---rush to get yours.
Click
here for Hazelden DVD
Until
Next Time
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Thanks to all who write to express your appreciation
for TNT. See you in October.
David
Contact Information
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
email: info@dmlmd.com
phone: 530-753-4300 PACIFIC
web: http://www.dmlmd.com
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Copyright
2006 DML Training & Consulting | 4228 Boxelder
Place | Davis | CA | 95616
