S02 - Attachment W MH SUITE TREATMENT PLANNING - VASH.pdf

How to access MH Suite through CPRS

GLA VA HUD-VASH Program

Mental Health Suite (MHS) Treatment Planning

Updated 11/1/2016

Treatment Planning Competency

DO write SMART goals, objectives, & interventions:

Specific

Measurable

Attainable

Relevant

Timely

DO:

• Use the Veteran’s own words

• Use recovery-oriented language

• Consider the treatment plan a “living document” that evolves throughout the course of treatment

• Problems addressed in treatment planning should be reflected in DAP notes

Treatment Planning Competency: DO’S &

DON’TS

Interdisciplinary Treatment Plans

DO:

• Document in MHS treatment planning software •Update as needed or every 6 months •Unlicensed Social Workers, Supervisor’s Co-signature required.*

DO NOT:

•Do not include medication list in MHS

•Do not “suspend” plans. It will create an encounter error.

Health Summary

How to access MH Suite through CPRS

•In the Progress Notes section, click on the TOOLS pull‐down menu and highlight CLINICAL

APPLICATIONS

•Click on MENTAL HEALTH SUITE ‐do NOT click on Mental Health Assistant

After you have clicked on "Mental Health Suite"

After you have clicked on "Mental Health Suite", you will be asked to log on to Mental Health Suite:

Log on with the same Access Code/Verify Code you use for

CPRS.

Please note the Mental Health Suite Icon

When you change your CPRS/VISTA verify code, your MH Suite verify code will automatically be changed to the same verify code.

Almost ready to begin the plan.

"NEW PLAN" button at the upper left of the screen is "grayed out", that is you cannot click on it to activate the new plan until you have selected the following:

1. Select the patient

2. Select the note title (TIU TITLE)-the note title for this plan should be:

MENTAL HEALTH

TREATMENT

PLAN/UPDATE

Please note that there is no trailing suffix as there is now for the inpatient and outpatient plans.

Select clinic location as a new visit to bill separately from other note (e.g. home/office visit).

NEW PLAN

In the screenshot below, the patient, note title, and visit location have been selected and the NEW PLAN is no longer "grayed out" and it can be clicked on and started.

NEW PLAN

Note that at the top of the plan that there are 8 different tabs:

Coversheet Profile Summary Participation Problems GAF/Meds Plan Priority Measures (this is an optional tab if you wish to include MH measures, e.g. BDI-II)

MHS date should match CPR Admission & HOMES Entry Form dates

Treatment Plan

Below the "Options" is a list of clinics or programs that can be checked to indicate the patient's involvement in different programs.

Immediately below the tabs is the "Options" section where you would click the "Treatment Plan" button and then indicate in the box to the right what type of treatment plan it is:

Initial, Comprehensive, or Update

Designate the Team Members

Designate the Team Members who are involved in the patient's care. If you create the plan, indicate HUD-VASH as the Primary Clinic or Program. If the Mental Health Treatment Coordinator is identified, you can include them in the plan. VASH should not be the MHTC. However, if Veteran is not connected with any other mental health clinics, VASH will be designated as the MHTC.

Set a Default list Add/remove Team Members

See what the plan looks like before it is complete Places a signed, permanent copy of the plan in the chart ;

allows no additional content

Saves work without the final signature. *Do not suspend plan as it can create encounter errors.

Setting Your Default Team

This screenshot shows the text box for ADDING team members in expanded form.

There are SEARCH , ADD, and REMOVE buttons.

Enter Team Members name

That name will appear here Use “Add” /”Remove” to change the names on the list; Repeat for all desired Team Members. Do NOT use the ENTER key.

When your list is complete click “OK”

A fully populated coversheet

Profile Tab

Profile tab without any contents: This tab needs to be completed to comply with Joint Commission and CARF requirements to record the following:

Patient STRENGTHS, NEEDS, ABILITIES, and PREFERENCES (SNAP!) as well as patient risks, restrictions, privileges, and limitations or barriers to care

Click “add” and choose from a list to populate

Restrictions – Select:

“No restrictions”

Privileges – Select: “Not applicable-outpatient status”

Enter individually or hold down the Ctrl button to elect more than one at a time.

Prioritize here*

Expanded section for the STRENGTHS section and some of the default choices that you can make by clicking on them. You can also add CUSTOM selections by choosing the "OTHER" option at the bottom and typing in the desired content.

Click “Add” for all highlighted options or Click “Add All” for entire list of options to Populate then:

Prioritize (if needed)* Click “Ok” when finished

Populating Profile Tab

Summary Tab

Must be completed:

Add detailed information that is relevant to the treatment plan.

For example, if one of Vets needs is employment, summarize employment history and current interests and referrals.

Summary Tab

Discharge Planning/Criteria – “Veteran is currently in the Reintegration/Maintenance/Supportive Phase of the HUD-VASH

Program. On-going discussion will be held with Veteran about positive discharge, which will be completed when he/she is living optimally in the community without need for case management.”

Indicate anticipated discharge date for 1 year.

However, be mindful of how you discuss the

“anticipated” discharge date with Vets.

Interdisciplinary Care: Veteran & Family

The Veteran must be involved in the creation of the treatment plan based on their identified goals, needs, strengths, abilities & preferences.

Family members or significant others of Veterans should be included in the treatment planning process with the Veteran’s consent. If these individuals are not available during regular appointment hours, accommodations should be made to include them by phone or by adjusting clinic hours.

The only exception is when the veteran specifically declines to have family members involved.

• Release of Information (ROI) needs to be completed for family member involvement.

• Include guardian or POA if the veteran has a guardian or an activated POA.

Participation Tab This is required for Joint Commission and CARF and allows you to document levels of participation in treatment planning by patients, their families and by staff. When patients do participate, both Joint Commission and CARF require that we quote the patient about their thoughts/feelings/reactions about and to the plan. You can also document family and provider comments as well as participation of others in the treatment planning process (e.g., the legal guardian or conservator, other VA providers, etc.).

Check appropriate boxes

Indicate level of participation from the family

Indicate Collaboration

Quote the Patient & VA/Community Providers

Problems Tab

WHODAS assessment can be added.

This area is populated with the list present in CPRS. Highlight only most current and relevant diagnoses.

Recently updated for DSM 5

This section allows you to add diagnoses from the current active Problem list. You can also add custom problems that are not on the pre-selected list by using the "OTHER" button.

If you are adding the diagnoses, include “Above list is from other VA providers. See CPRS file [Title of Note] dated [X].” to the bottom of the list.

Select “+Add” button to include this sentence.

GAF/MEDS Tab

Plan Tab The content in this section is defined by the Treatment Plan Discipline selected through the drop-down menu. The four required elements for a complete treatment plan are:

Problems, Goals, Objectives, Interventions (PGOI)

The 8 MH Disciplines

Once you have signed on to MH Suite, you will be asked to pick a Mental Health discipline. GLA has 8 different Mental Health Disciplines that have overlapping but different contents for the treatment plans.

For HUD-VASH, select “Recovery Based HUD VASH/GPD”

Click the drop-down menu to choose a Treatment Plan Category (For VASH, only selection available is “All Elements”)

Populate this area first: “Recovery Based HUD VASH/GPD”

Click on Problem(s), Goals, Objectives, and Interventions to be included in the Plan.

Double left click on each Problem, Goal, Objective and Intervention to add them to the plan OR highlight each and click on the “Add” button to transfer the selection to the Plan

As with previous menus, “Crtl” key will not populate multiple items at once; Click “Add” for each item to populate the Treatment Plan

Click on “Add Other” to individually add additional Problems, Goals, Objectives, and Interventions (PGOIs)

Click “Add All Elements” to create a complete PGOI

As you populate the Treatment Plan a RED arrow will appear where information remains missing.

It will disappear once the missing information is populated; in this case the Treatment Plan is still missing the Intervention. In order to be complete, there must be a Problem, a Goal, an Objective, and an Intervention.

Plan Tab Example for VASH Medical & Legal issues are listed as barriers.

If not addressed in the plan, note them in referred/deferred section in Priorities Tab. For example, this Vet could already be connected with VA medical providers and a probation officer.

Intervention

Interventions require additional data on a pop-up menu.

Select “Social Worker” from list

Frequency & Time Frame Ex. Problem/Need Housing Maintenance

- the Frequency of Occurrence depends on Phase of Treatment (Reintegration, Maintenance, or Supportive) & Intervention Time Frame should be 1 year.

Select yourself as the provider Click “Accept”

“Accept” will remain grayed out until menu is completely populated

Plan Tab Continue to populate until all Problems, Goals, Objectives, and Interventions are complete.

Click on “+” to expand options Or “-” to close options

On-going goal for HUD-VASH should be “Housing Access” or “Housing Maintenance.”

REMEMBER: If a need/preference is identified in the Profile section, it should be addressed in Plan and/or noted in Deferred/Referred section of the Priority tab (next slide)

FYI - This section does not automatically spell check.

Priority Tab Allows the user to Rank Problems entered in the Plan Tab:

Select “HUD- VASH” as the Clinic for each Problem

By order of priority by moving them “up” or “down”

Mark Problems, Goals, Objectives, and/or Interventions as Updated, Resolved, or Inactive.

User can document any Deferred or Referred Problems

INDICATE A

PLAN RENEWAL

DATE (6 months for VASH)

Measures Tab

Adding Additional Signers

Step 1: Select the plan you want to add signers

Step 2: Add Signers and/or Add Alerts to Team Members for treatment plans initially created as well as updates or changes.

Locating a Plan Once a Treatment Plan has been

Suspended, Closed, or made Pending it will populate the Home Screen. To access an existing Plan, click on the Plan you wish to review/update/ review/etc.

Or

Click on Plan Lookup

Or

Search by Author/Provider/dates

Then

Select your action

Updating Treatment Plans: Close & Renew

Step 1: Highlight the plan you want to update

Step 2: Close Plan

Step 3: Renew Plan

“Renew Plan” will automatically repopulate all previously captured information/goals. This allows you to add new goals (in the Plan Tab) and/or update/resolve goals (in the Priority Tab).

Treatment Plan Updates:

CHANGES IN LEVEL OF CARE

An updated treatment plan is required with all changes in the level of care the Veteran receives. These include:

Resolution of a goal

Referral to address problems/needs (ex: Unemployment and VCED Referral)

Discharge from VASH

Addition of new Team Member (ex: VASH SUD)

Treatment Plan Updates:

MULTIPLE PROVIDERS

When/If other Team Members want to add additional treatment goals or other information to the plan, the plan will have to “close” so the next author can “renew” plan and add updates.

Remember to add all team members as additional signers when making changes/updates to the treatment plan.

Treatment Planning: DISCHARGE When:

Upon completion of program goals

Veterans transferred to Aftercare (positive discharges)

Dropping out of treatment

Failure to engage in treatment

Veteran choice

Moving out of GLA service area

How:

Update/resolve all treatment plan goals in MHS using the “Update/Resolve” tab (Priorities tab).

If discharge date is known, you can document that in the “Anticipated Discharge Date” (Summary tab) as well as in the “Patient Input/Provider Comments” section (Participation tab)

If the veteran is continuing service with another program, only resolve the goals pertaining to VASH.

Close the MHS treatment plan.

Complete VASH Discharge Note in CPRS.

Add an Addendum to MHS Treatment Plan in CPRS noting discharge from VASH.

Add other team members as additional signers, so they are aware of VASH discharged. They can renew the plan for their program as needed.

Remember to update HOMES and SharePoint.

Treatment Planning: TRANSFER When:

Housed outside your SPA

Clinically appropriate to transfer care

How:

Transferring SW: Resolve/Update goals as needed. Ensure plan has been updated within last 6 months if nothing needs to be resolved/updated prior to transfer. Add addendum to most recent MHS treatment plan to note case transfer. Complete VASH Transfer Note in CPRS.

New SW: Close, Renew, and complete update of MHS Treatment Plan. Remove previous SW from Team Member List and add your name.

Continue to update/resolve treatment plan goals in MHS using the “Update/Resolve” tab (Priorities tab). Because Veteran is continuing with VASH, additional goals can be added with the new VASH Social Worker. Remember to change the “Selected Provider” for goals already in plan (e.g. Housing Maintenance).

Add other team members as additional signers, so they are aware of transfer.

A Flexible Tool

•Content is easily modifiable by the Super Duper Users Group

•Follow up with your Supervisor &/or Senior Social Worker for any questions/concerns.

•Michele Klocke 310-478-3711 x42835

•Michele.Klocke@va.gov

ENCOUNTER INFORMATION!!!

•Completing a MH Suite treatment plan will NOT generate a request for encounter information.

•To complete and close encounters for treatment planning, edit the encounter once the MHS treatment plan is populated in CPRS. [You can right click on the MHS treatment plan note in CPRS and select “Edit Encounter.”]

•VASH - Diagnosis codes: Z71.9 (housed) or Z59.0 (homeless)

•VASH - Procedure Code: T1016 for in-person contact or 98966/98967/98968 for telephone contact.

•VASH – For administrative updates, select “Historical Visit.”

Additional Information and Training Resources

MH Suite website http://vaww.sps.lrn.va.gov/ workspaces/MentalHealthSui teTraining/Mental%20Heath %20Suite%20Training%20R esources/Forms/AllItems.as px

TMS Training Modules- Mental Health Suite Overview