How Do You Measure a Wish? - SCCMHA

How Do You Measure a Wish?

WRITING SMART GOALS IN THE IPOS

BY HEIDI WALE KNIZACKY, MS , MARY BAUKUS, LMSW ,

AND THE SCCMHA GOALS WORKGROUP

The “Golden Thread”A thorough assessment (1) - done while engaging - pulls easily and naturally into the plan of service (2), which then leads directly into service documentation (3). This not only leaves a clear trail that justifies necessity and provides evidence of accountability, but it provides a guide for service planning, from authorizations to each service encounter, and simplifies the approach to documentation.

IndividualPlan of Service

(2)

The IPOS is the centerpiece in holding the thread together

SMART Goals/Objectives Maintain the Golden ThreadSpecific

◦ Specific objectives help to create a framework that shows which steps need to be taken to complete the goal.

Measurable◦ Effective objectives are measurable so that individuals/natural supports and service providers are able to determine

if they have been accomplished.

Action-Oriented and Attainable◦ Actionable objectives provide clear, positive steps to take to support progress toward the goal. Actionable objectives

are future-focused on what is achievable and do not contain language about what the individual is to stop doing.

Relevant and Realistic◦ Objectives must be relevant and realistic, based on the needs, functional level, and stage of change of the individual.

Time-limited◦ The target dates need to vary based on individual needs/skills and should be specified for completion at various

points within the service authorization period.

The Goal▪ Goals emerge through meaningful conversation during the pre-planning phase.

▪ Conversations identifying potential goals are guided by the case holder and can draw from: 1. topics the person brings up on their own; 2. observations of the case holder based on assessment information; and, 3. the context of the program.

▪ Goals are always a change the person chooses for themselves.

▪ Goals become clear and specific when the person is able to:1. identify their reasons and/or needs for the change; 2. recognize their own strengths and abilities; 3. communicate a vision for what their life will be like when the goal is achieved; 4. decide when they want to make the change; and 5. envision a step they can take toward the goal.

▪ It is the clinician’s job to evoke this specific and future-oriented vision.

▪ Multiple goals should be developed individually and then prioritized by the consumer.

Special Circumstances What if the consumer is non-verbal? Or what if they are a minor child?

▪ The consumer is still central, the goals are their own. HOWEVER, parents and guardians should also be involved in the conversation of identifying goals and support decision-making. Goals should reflect the wishes and desires of the consumer and their caretakers.

What if there is disagreement between the consumer and their parent or guardians?

▪ If the consumer is a minor child, the plan should reflect the needs of the family. The clinician should facilitate the conversation toward a negotiation of core values and overlapping desires for harmony in the family. Usually there will be multiple goals, some of which will be solely what the minor child wants to achieve.

▪ If the consumer is an adult with a legal guardian, the goals should always be something the consumer wants for themselves. It is their plan.

Special Circumstances What if the consumer is court-ordered into treatment?

▪ The IPOS goals are still person-centered.

▪ The Michigan Mental Health Code specifies that being court-ordered into treatment does

not alter the individual’s right to determine their own goals:

(1) The receipt of mental health services, a determination that an individual meets the

criteria of a person requiring treatment or for judicial admission, or any form of admission

to a facility including by judicial order shall not be used to deprive an individual of his or

her rights, benefits, or privileges. 330.1702, Sec. 702.

Goals and SupportsAccording to the Michigan Mental Health Code:

▪ The individual plan of services shall address, as either desired or required by the recipient,

the recipient's need for food, shelter, clothing, health care, employment opportunities,

educational opportunities, legal services, transportation, and recreation. (330.1712, Section

712)

Supports for a goal come from four sources:

1. The consumer themselves

2. Unpaid individuals and groups known to the consumer (Natural Supports)

3. Paid individuals, resources, institutions, and groups available to the consumer (Community

Supports)

4. SCCMHA Funded Services (treatment services prescribed to alleviate symptoms and

suffering as established by clinical assessment)

What if a Goal Doesn’t Meet Criteria for Medical Necessity Support?“I want a new iPhone.”

1. Take a closer look. Does the goal expressed by the consumer actually represent something less tangible?

◦ How will your life be different once you get a new iPhone?◦ The way you see it, how does getting a new iPhone connect to becoming healthier?◦ Use reflections to clarify. “You want to be more financially stable. One way you’ll know you’ve arrived is

that you will have enough money to buy a new iPhone.”

2. Look for the Golden Thread. Explore the connection to the assessment.◦ How will getting a new iPhone impact [need identified by assessment (e.g. “your involvement with the

legal system”)]?

3. Discuss types of support in connection to the goal. While the plan remains person-centered, it is possible that not every goal will benefit from behavioral health services.

◦ “One thing we want to do when coming up with the plan to support your goals is to look at all the resources, or tools, that are available and select the best tools for getting the job done. What ideas do you have for tools that could help you reach this goal?”

Examples of Person-Centered GoalsChild/Family: (Finlee)

Per foster mom, Sonya, Finlee "struggles with focus. I want him to be able to finish a task without constant supervision. I think it would help Finlee get better grades, feel better about what he can do on his own, and help us to get along better because I won’t have to be constantly correcting him." Finlee said he would like to not be distracted so much so that he has more time to play instead of doing schoolwork.

ID/D: (Tony)

Tony wants to learn skills to be more independent. His mother, who is his guardian, would like him to learn how to write as a skill to gain independence and Tony agrees.

SMI: (Ava)

I want to be not so depressed anymore.

Making Goals Measurable▪ Establishing measurable criteria for a goal helps turn it from a subjective desire (an experience

that lives inside the person) to an objective accomplishment (anyone involved in the plan can support and recognize it).

▪ The prompt “I will know I have met my goal when” is a helpful way to evoke the person’s specific vision for when they will know they have met their goal.

▪ Exploring an initial response can help make the vision more specific. An example of exploring for specificity is asking the miracle question:

▪ Imagine that while you were sleeping a miracle happened and your goal was achieved. When you wake up, how would you recognize the miracle had happened? How would someone else recognize the miracle had happened? What would be different in your life?

Making Goals Measurable▪ Another source of clarifying the goal vision is through sharing assessment information and

inviting the person to share their thoughts about what the results show. If important things were different in their life, what would the assessment look like instead?

Examples of Measurable GoalsChild/Family: (Finlee)

“I can play video games after dinner instead of doing more homework.” Sonya agreed that if Finlee was able to concentrate better, it would show the most by his bringing less unfinished assignments home from school and his homework being completed accurately within an average of an hour or less each evening. Also, his room would be clean before noon on Saturday mornings as is an expectation in their house. The School and Home subscales ratings on the CAFAS will reduce to a 10 (Mild) or less.

ID/D: (Tony)I have been able to write without assistance every letter of the alphabet in both lower and upper case, and I can print my first name 50% of the time when asked.

SMI: (Ava)I have energy, which would show by being out of bed before 8:30 AM on weekdays and remembering to take a shower, brush my hair and teeth, and change my clothes at least every other day. I leave my house at least once a week and do something other than buy groceries. I stop crying so often (no more than once a week). I go at least four weeks without thinking I'd be better off dead. ANSA assessment items for Depression and Suicide Risk will reduce to a “1,” Self Care will reduce to a “0,” and Optimism, Community Connection, and Resourcefulness will increase to 1’s or 0’s.

An AnalogyPutting the goal into measurable terms is like the cone to the ice-cream. It gives structure and transportability to the good stuff.

Consumer Goal (expressed in consumer actual words or in a way that the consumer may read or

comprehend)

Finlee and his foster parent would like for him to be able to cope with difficult emotions, especially anger. Per foster mom, Sonya, "I want him to not hurt himself or others when he his angry or upset. I want him to use words to express his emotions." Finlee would like “for people to not be mad at me so much.”

I will know I have met my goal when“I don’t get mad or in trouble so much.” Finlee and his foster mom agreed that they will be able to tell he is having less problems coping with difficult emotions if he has gone more than a month with no episodes of aggression where he tries to hit, punch, or bite someone, and also angry outbursts of yelling while throwing and slamming things will occur no more than once every two weeks (a 50% reduction). Finlee’s Behavior Toward Others score on the CAFAS will reduce from a 30 (Severe) to a 20 (Moderate) or below.

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Barriers to Effective IPOS’s1. Goals that remain the same year after year.

◦ An indication that the supports need to be different. We shouldn’t keep doing the same thing and expecting different results.

◦ Apply the SMART rubric. Is the goal time-sensitive? Discuss how lofty goals (e.g. “I want to be able to retire by the time I am 50”) can be broken into incremental steps. “One year from today, how will you know you are on track to this goal or not?”

2. The consumer says they don’t have any goals / don’t want to do a plan.

◦ Work on Engagement.

◦ Determine what Stage of Change they are in and stay in step.

◦ Evoke values. Consider using checklists and card sorts to assist learning about what is important to them.

◦ Starting “small” is okay.

ObjectivesUsing the SMART guidelines can help ensure that the objectives create an accurate map to the goal.

◦ What needs to be done? (Specific, Relevant, Action-oriented)

◦ Who will do these actions? (Action-oriented, Realistic)

◦ When will the work be done? (Time-sensitive, Realistic)

◦ Where will the work take place? (Specific, Realistic)

Objectives are developed through the collaboration of everyone involved in the planning process.

Recording ObjectivesSteps or Actions Consumer agrees to take to attain identified Goal/Outcome:

Steps or Actions provided by Natural Support to attain identified Goal/Outcome:

Steps or Actions provided by paid or funded Community Supports (funding not through SCCMHA) to attain identified Goal/Outcome:

Service or Support

Clinical Goals or Description of the Step(s)/Action(s)/Methodology of the Service or Support:

Amount of the Service or Support:

Scope of the Service or Support:

Duration of the Service or Support:

What needs to be done? (Specific, Relevant, Action-oriented)

◦ Steps or Actions Consumer agrees to take to attain identified Goal/Outcome:

◦ Steps or Actions provided by Natural Support to attain identified Goal/Outcome:

◦ Steps or Actions provided by paid or funded Community Supports (funding not through SCCMHA) to attain identified Goal/Outcome:

◦ Clinical Goals or Description of the Step(s)/Action(s)/Methodology of the Service or Support:

Who will do these actions? (Action-oriented, Realistic)

◦ Steps or Actions Consumer agrees to take to attain identified Goal/Outcome:

◦ Steps or Actions provided by Natural Support to attain identified Goal/Outcome:


◦ Service or Support:

When will the work be done? (Time-sensitive, Realistic)

◦ Implementation Date and Target Date

◦ Amount of the Service or Support:

◦ Duration of the Service or Support:

Where will the work take place? (Specific, Realistic)


◦ Scope of the Service or Support:

How will it be evident that the goal has been met? (Measurable)

◦ I will know I have met my goal when

◦ Clinical Goals

ExamplesPERSON-CENTERED, MEASURABLE GOALS AND SMART OBJECTIVES

Child & Family (Finlee) Consumer Goal Number: 1

Consumer Goal (expressed in consumer actual words or in a way that the consumer may read or comprehend)

Per foster mom, Sonya, Finlee "struggles with focus. I want him to be able to finish a task without constant supervision. I think it would help Finlee get better grades, feel better about what he can do on his own, and help us to get along better because I won’t have to be constantly correcting him." Finlee said he would like to not be distracted so much so that he has more time to play instead of doing schoolwork.

I will know I have met my goal when“I can play video games after dinner instead of doing more homework.” Sonya agreed that if Finlee was able to concentrate better, it would show the most by his bringing less unfinished assignments home from school and homework being completed accurately within an average of an hour or less each evening. Also, his room would be clean before noon on Saturday mornings asis an expectation in their house. The School and Home subscales ratings on the CAFAS will reduce to a 10 (Mild) or less.

Steps or Actions Consumer agrees to take to attain identified Goal/Outcome:Finlee thinks that if he puts things away in his room when he is done with them he won’t have so much to clean up later. He agreed to work on this plan. He also agrees to work with his foster parents on ideas they come up with to help him and to take any medications that are prescribed to him.

Steps or Actions provided by Natural Support to attain identified Goal/Outcome:Finlee’s foster mother plans to talk to their foster worker about facilitating a medication consultation with Finlee’s pediatrician. She also agrees to participate in the Parenting Through Change program to explore techniques of issuing directions and followingup that may benefit Finlee. She will coordinate with Finlee’s school to ask for school-based support to help with this goal.


Finlee has a foster care worker, Jiminy Cricket, who facilitates legal releases for services and can secure some resources when needed. Finlee will have a medication consultation with his pediatrician, Dr. Geppetto. Finlee has an existing 504 plan with his school and a request will be made to expand the plan to assist with issues related to concentration.

Consumer Goal (expressed in consumer actual words or in a way that the consumer may read or comprehend)Per foster mom, Sonya, Finlee "struggles with focus. I want him to be able to finish a task without constant supervision. I think it would help Finlee get better grades, feel better about what he can do on his own, and help us to get along better because I won’t have to be constantly correcting him." Finlee said he would like to not be distracted so much so that he has more time to play instead of doing schoolwork.

Service or Support Indicate the discipline, provider, or natural support who will provide this Action. Note: This is part of the Scope: Who (e.g.:

discipline, professional, paraprofessional, aide supervised by a professional)

Parenting Through Change (PTC) Group with psychotherapist

Clinical Goals or Description of the Step(s)/Action(s)/Methodology of the Service or Support:Finlee will take action within 10 seconds to comply with at least 2 of every 3 parental requests and will be able to maintain action on longer tasks for a minimum of 10 consecutive minutes without direct adult supervision. The PTC group leader will meet individually with Finlee’s foster parents for orientation and program baseline assessment prior to the first group meeting, the group will meet weekly for twelve weeks, and additional individual follow-up assessment and coaching will be scheduled 30 and 90 days after group end.

Amount of the Service or Support: Procedure code and number of units

Sixteen (16) units of 90849 - Family therapy

Step/Service or Actions to Attain Identified Goal/Outcome Funded or Provider by SCCMHAStep Letter A

Duration of the Service or Support: Length of time it is expected service will be providedServices for this goal will be provided across eight months.

Scope of the Service or Support: Parameters including How and Where

Individual parenting sessions will be held in the foster family’s home; group PTC sessions will be held at SCCMHA Child, Family & Youth Services offices at 3875 Bay Road, Suite 7N.




Finlee and his foster parent would like for him to be able to cope with difficult emotions, especially anger. Per foster mom, Sonya, "I want him to not hurt himself or others when he his angry or upset. I want him to use words to express his emotions." Finlee would like “for people to not be mad at me so much.”

I will know I have met my goal when“I don’t get mad or in trouble so much.” Finlee and his foster mom agreed that they will be able to tell he is having less problems coping with difficult emotions if he has gone more than a month with no episodes of aggression where he tries to hit, punch, or bite someone, and also angry outbursts of yelling while throwing and slamming things will occur no more than once every two weeks (a 50% reduction). Finlee’s Behavior Toward Others score on the CAFAS will reduce from a 30 (Severe) to a 20 (Moderate) or below.

Steps or Actions Consumer agrees to take to attain identified Goal/Outcome:Finlee will work with his therapist to learn and practice words that describe his thoughts/feelings as well as coping strategies for identifying and responding to anger or other upset feelings. He agrees to take his daily vitamins and any medication as prescribed by his doctor. Finlee thinks it may help to punch a pillow when he is angry and agreed to try this.

Steps or Actions provided by Natural Support to attain identified Goal/Outcome:Sonya will help Finlee practice coping skills for emotional control as taught by therapist. Sonya will set up an appointment with Finlee’s pediatrician for a medical intervention evaluation. If medications are prescribed, Sonya will administer these and supervise as prescribed. Sonya will transport Finlee to therapy sessions as scheduled or provide 24-hour notice for cancellations and willreschedule when necessary. She agrees to function as a member of Finlee’s support team and will coordinate communication andprovide feedback to service team about progress and satisfaction.


Finlee has a 504 plan at his school which allows him to leave his classroom and go to the counselor’s office any time he feels the need to go calm down.

Consumer Goal (expressed in consumer actual words or in a way that the consumer may read or comprehend)Finlee and his foster parent would like for him to be able to cope with difficult emotions, especially anger. Per foster mom, Sonya, "I want him to not hurt himself or others when he his angry or upset. I want him to use words to express his emotions." Finlee would like “for people to not be mad at me so much.”



Individual and family psychotherapy

Clinical Goals or Description of the Step(s)/Action(s)/Methodology of the Service or Support:Finlee will be able to recognize that he is feeling angry before he acts in anger. This will be evident by no incidents of targeted physical aggression toward himself or others for at least 90 days. Therapist will utilize cognitive-behavioral therapy (CBT) to help Finlee identify his emotions and the circumstances that cause them as well as gain coping skills of new thoughts and actions he can implement to reduce the impact of negative emotions on his functioning. Therapist will meet with foster parents to review skills taught in sessions and teach how parents can coach and support skill implementation within the home.

Amount of the Service or Support: Procedure code and number of units

Ten (10) 60 minute units of 90837 Individual therapy; Ten (10) 45 minute units of 90834 Individual therapy; Twelve (12) units of90846 family therapy

Step/Service or Actions to Attain Identified Goal/Outcome Funded or Provider by SCCMHAStep Letter A

Duration of the Service or Support: Length of time it is expected service will be providedIndividual therapy sessions will begin weekly and titrate to alternating weeks when behavioral changes are observed. Expectationis that services will no longer be needed for this goal after six months.

Scope of the Service or Support: Parameters including How and Where

Therapy sessions will be face-to-face in Finlee’s foster home or at other community locations of his and foster parents’ choosing.


ID/D (Tony) Consumer Goal Number: 1


Tony wants to learn skills to be more independent. His mother, who is his guardian, would like him to learn how to write as a skill to gain independence and Tony agrees.

I will know I have met my goal whenI have been able to write without assistance every letter of the alphabet in both lower and upper case, and I can print my firstname 50% of the time when asked.

Steps or Actions Consumer agrees to take to attain identified Goal/Outcome:Tony chooses to learn to hold the pencil, pen, chalk (writing utensil) in his hand, in the proper position to write with three or lessprompts.Tony chooses to (with the help of staff) copy letters of the alphabet both Capital and small letters 1-2 times, twice a week.Tony chooses to copy the letters to print out his name three times, twice a week.Tony chooses to complete writing work sheets once a week, copying the words and letters.Tony chooses to print his first name on the paper when requested with no more than three prompts for each letter.Tony chooses to go to the store with staff to get activity books for writing or lined paper to practice writing.

Steps or Actions provided by Natural Support to attain identified Goal/Outcome:Tony’s mother will provide envelopes and stamps for Tony to write and send notes (a word or two and his signature) to her. Eachtime she receives a letter from Tony, she agrees to send him one in return to help provide him with reasons and motivation tocontinue practicing writing.


SSI/SSA; Medicaid/Medicare; Internet program to print out worksheets for practice writing skills; public library for books and literacy materials

Consumer Goal (expressed in consumer actual words or in a way that the consumer may read or comprehend)Tony wants to learn skills to be more independent. His mother, who is his guardian, would like him to learn how to write as a skill to gain independence and Tony agrees.



Specialized Residential Placement

Clinical Goals or Description of the Step(s)/Action(s)/Methodology of the Service or Support:Specialized Residential placement - home staffStaff will help Tony learn to hold the pencil, pen, chalk (writing utensil) in his hand, in the proper position to write with three or less prompts.Staff will teach Tony copy letters of the alphabet both Capital and small letters 1-2 times, twice a week.Staff will teach Tony copy the letters to print out his name three times, twice a week.Staff will assist Tony to complete writing work sheets once a week, copying the words and letters.Staff will teach Tony print his first name on the paper when requested with three prompts for each letter. - Can you make a “T",“O", “N" and “Y.” Praising Tony after each letter is completed.Staff will take Tony to get activity books for writing or lined paper to practice writing at the dollar store.

Step/Service or Actions to Attain Identified Goal/Outcome Funded or Provider by SCCMHA

Step Letter A


Amount of theService or SupportH2016 & T1020

Duration of theService or Supportone year or duration of the IPOS

Scope of the Service or Supportface to face in the home or community




Supports Coordination

Clinical Goals or Description of the Step(s)/Action(s)/Methodology of the Service or Support:Support Coordination- Support Coordinator- will link and coordinate services within the agency and community to support Tony with this goal, including update paperwork, complete authorizations and communicate with others involved with Tony. SC will meet with Tony via phone, video, or in person at the Supported Residential home on a monthly basis - more as needed. SC will monitor progress toward this goal at least every 6 months and provided in-service to the home staff as needed or requested. SC will review monthly progress notes and speak with home staff during routine home visits to assess Tony's progress


Step Letter B


Amount of the Service or SupportT1016 - 80 units of 15 minutes annually with monthly visits likely at AFC home of 45 minutes or telehealth when/if allowed

Duration of the Service or Supportone year or duration of the IPOS

Scope of the Service or SupportFace to face, at home, community or office, telehealth (phone or video).




Occupational Therapy

Clinical Goals or Description of the Step(s)/Action(s)/Methodology of the Service or Support:See Occupational Therapist assessment. OT recommends weekly therapy session of 30 minutes to address hand coordination and sensory issues. OT will also make suggestion for the AFC home of activities for Tony. OT will provide recommendations for supplies the home may use to also meet Tony’s fine motor and sensory needs. OT to in-services home staff on Tony's needs and any treatment as well as durable medical goods that may be ordered.


Step Letter C


Amount of the Service or SupportCPT Code H0032 TS 24 units/every 6 months CPT Code 97533 96 units/every 6 months

Duration of the Service or Supportone year or duration of the IPOS

Scope of the Service or SupportFace to face at the AFC home



Tony wants to have better sleep. He struggles with staying up late and then not wanting to get up in the morning every day. His mother, who is his guardian, would like him to develop a regular bedtime routine and have a more consistent bedtime and waketime.

I will know I have met my goal whenI go to bed between 10-11 PM and wake up by 8 AM at least 5/7 days.

Steps or Actions Consumer agrees to take to attain identified Goal/Outcome:Tony agrees to try to gradually change his bedtime from 2 AM, which is typical, to 10 PM, by going to bed a little earlier each night over the course of several weeks. Tony agrees to try to engage in quiet activities like listening to books or watching a quiet movie in the two hours before he goes to bed. Tony agrees to keep his room darker and cooler to help promote sleep. Tony agrees to work toward reducing daytime naps to no more than 30 minutes each day in order to promote going to bed earlier.

Steps or Actions provided by Natural Support to attain identified Goal/Outcome:Tony’s mother agrees to provide a “white noise” application that can be added to his tablet to help promote the sleep process and will provide “blue light blocking glasses” that Tony can choose to wear if he watches TV or uses his tablet in the two hours before bedtime. She agrees to set up a medication consultation with Tony’s primary care physician.


Tony has a primary care physician, Dr. Johnson, who will be consulted to determine if any of his current non-CMH medications could be contributing to his sleep difficulties.

Consumer Goal (expressed in consumer actual words or in a way that the consumer may read or comprehend)Tony wants to have better sleep. He struggles with staying up late and then not wanting to get up in the morning every day. His mother, who is his guardian, would like him to develop a regular bedtime routine and have a more consistent bedtime and waketime.



Supports Coordination

Clinical Goals or Description of the Step(s)/Action(s)/Methodology of the Service or Support:Support Coordination- Support Coordinator- will link and coordinate services within the agency and community. SC will monitor Tony at the Supported Residential home on a monthly basis - more as needed. SC to update paperwork, complete authorizations and communicate with others involved with Tony, including his mother and primary care physician. SC will monitor plan/services at least every 6 months and provided in-service to the home staff as needed or requested. SC will attend medication reviews with the psychiatrist if available and inquire about any medications that may impact sleep. SC will review monthly progress notes and speak with home staff during routine home visits to assess Tony's progress. SC will monitor progress on Tony’s sleep schedule by asking about his sleep and wake times during contacts and documenting his progress.


Step Letter A


Amount of the Service or SupportT1016 - 40 units of 15 minutes annually with monthly visits likely at AFC home of 45 minutes or telehealth when/if allowed

Duration of the Service or Support6 months

Scope of the Service or SupportFace to face, at home, community or office, telehealth (phone or video).

CONSUMER GOAL (EXPRESSED IN CONSUMER ACTUAL WORDS OR IN A WAY THAT THE CONSUMER MAY READ OR COMPREHEND)

I want people to stop saying I am acting grouchy. I want to get along with everyone.

I WILL KNOW I HAVE MET MY GOAL WHEN

I can get along with everyone at my home most of the time. Getting along with people means that I am in the same room as them or

talking to them without swearing at them, calling them a mean name, throwing things, hitting or pushing them, or yelling at them to do

something that I want right away when it is not an emergency. This goal will be met when Sally verbally gets along with people (no

swearing, calling them names, or demanding) an average of 6 out of every 7 days (86% of the time) for three months and physically gets

along with people (no throwing things, hitting or pushing) 97% of the time (average of all but one day per month) for three months.

STEPS OR ACTIONS CONSUMER AGREES TO TAKE TO ATTAIN IDENTIFIED GOAL/OUTCOME:

Sally says that she is better able to get along with people when she is happy. Some things that make her happy are coloring with gel pens,

watching television, going for walks, swinging on swings at the park, eating snacks, taking a hot shower, cuddling up in a blanket, looking at

pictures of kittens, painting her fingernails, and using her tablet. Sally is often less happy in the afternoon, so at lunch time she will make a

plan to do something she enjoys. Sally also says that one way to get along with people is to say something nice to them. She is going to

practice giving someone a compliment every day.

STEPS OR ACTIONS PROVIDED BY NATURAL SUPPORT TO ATTAIN IDENTIFIED GOAL/OUTCOME:

Sally’s friend, Shelby, likes to go for walks and swing on swings with Sally. Shelby will try to go to the park with Sally once a week if the

weather isn’t too bad. Sally’s brother, Jeremiah, invited Sally to call him after 5 PM to talk about anything she wants. Whenever Sally goes

15 days (they do not need to be consecutive) of getting along with people, Jeremiah will either take her out to dinner at a restaurant of her

choosing, buy her a magazine, or buy her a new color of nail polish (Sally’s choice).

STEPS OR ACTIONS PROVIDED BY PAID OR FUNDED COMMUNITY SUPPORTS (FUNDING NOT THROUGH SCCMHA) TO ATTAIN IDENTIFIED GOAL/OUTCOME:

Sally has a guardian who will ask Sally how she is doing with being happy and getting along with people each time they have contact. He will

affirm her efforts and compliment her progress.

Consumer Goal Number: 1 ID/D (Sally)

STEP/SERVICE OR ACTIONS TO ATTAIN IDENTIFIED GOAL/OUTCOME FUNDED OR PROVIDED BY SCCMHA ID/D (Sally) Goal 1

Step Letter A

Service or Support Indicate the discipline, provider, or natural support who will provide this Action. Note: This is part of the Scope: Who (e.g.: discipline, professional,

paraprofessional, aide supervised by a professional)

Specialized Residential Placement

Clinical Goals or Description of the Step(s)/Action(s)/Methodology of the Service or Support:• Every day, between 10 AM and 1 PM, a staff member will invite Sally to do an activity with them. Activities should be planned by

partnering with Sally to identify and choose activities she enjoys.

• At the beginning of each shift, staff members will spend a few minutes visiting with Sally to give her one-on-one positive attention.

• When in the same room as Sally, staff should invite her into conversations and activities.

• Invite Sally to help with specific tasks that she would enjoy (e.g. help with meal planning, bringing reusable shopping bags to van). Beneutral in response if Sally declines by saying something like “No problem” or “Okay.” Be sure to thank her and acknowledge her effortsif she does help (e.g. “It’s so nice to have help! I really appreciate it.”)

• Use Reflections to help Sally identify her feelings. Examples: “You’re feeling left out.” “You’re having a crummy day.”

• When Sally displays “grouchy” behavior, invite her into problem-solving (e.g. “If you could have a do-over, what would be a better wayof saying that?”) rather than directing solutions.

• Do not ignore Sally when she is “being grouchy,” instead keeping voice and affect neutral and calm, ask Sally what it is that she wants.

• If Sally answers with an non-grouchy response, smile, thank her for sharing her question/perspective/etc. with you and continue toengage her in conversation. Fulfill requests if practical or make a plan together for fulfilling when possible.

• If Sally continues to “be grouchy”, offer another reflection identifying her feelings. Then tell her you are going to be going to do[something else] (tell her specifically what that is like “I’m going to go take the towels out of the dryer now”) and that she is welcometo come find you there to talk when she would like to have a conversation.

Scope of the Service or Support:Parameters including How and WhereSix months or duration of the IPOS

Duration of the Service or Support:Length of time it is expected service will be providedFace to face in the home or community

Amount of the Service or Support:Procedure code and number of unitsH2016 & T1020

SMI (Ava) Consumer Goal Number: 1


I want to be not so depressed anymore.

I will know I have met my goal whenI have energy, which would show by being out of bed before 8:30 AM on weekdays and remembering to take a shower,

brush my hair and teeth, and change my clothes at least every other day. I will leave my house at least once a week

and do something other than buy groceries. I will stop crying so often (no more than once a week). I will go at least four

weeks without thinking I'd be better off dead.

ANSA assessment items for Depression and Suicide Risk will reduce to a “1,” Self Care will reduce to a “0,” and

Optimism, Community Connection, and Resourcefulness will increase to 1’s or 0’s. Score on the PHQ-9 will be reduced

from 20 currently to 10 or less.

Steps or Actions Consumer agrees to take to attain identified Goal/Outcome:I will try to go to bed on time and to exercise. I plan to walk 3 miles in the next annual CAC Walk for Warmth event. I will

work with my therapist to learn strategies to stop thinking so many hopeless thoughts. I will talk to my primary care

physician about medication options.

Steps or Actions provided by Natural Support to attain identified Goal/Outcome:Ava's friend, Beth, will invite Ava to accompany her to the gym (where Beth has guest passes) and will participate in the

Walk for Warmth event with Ava. Beth will also invite Ava to go on bike rides on the rail trail.


Ava receives primary care services from Dr. Fauci and plans to coordinate psychopharmacological options with him.

Consumer Goal (expressed in consumer actual words or in a way that the consumer may read or comprehend)I want to be not so depressed anymore.



Psychotherapy

Clinical Goals or Description of the Step(s)/Action(s)/Methodology of the Service or Support:Psychotherapy - Therapist will provide individual, weekly psychotherapy sessions up to 60 minutes each, reducing to biweekly with notable progress. Therapist will use mindfulness, motivational interviewing and cognitive behavioral therapy to help Ava establish a daily routine where she will go to bed on time and exercise, working toward her goal of walking three miles. The therapist will work with Ava to help develop strategies to gain insight into her negative thoughts and develop healthy coping skills to positively impact her thought processes. Therapist will monitor medication adherence and communicate with the physician and case holder as needed.


Step Letter A


Amount of the Service or Support9083X, Individual Psychotherapy, weekly, 52 units, up to 60 minutes

Duration of the Service or SupportOne year duration of the IPOS

Scope of the Service or Supportface to face, telehealth or office

Consumer Goal (expressed in consumer actual words or in a way that the consumer may read or comprehend)I want to be not so depressed anymore.



Case Management

Clinical Goals or Description of the Step(s)/Action(s)/Methodology of the Service or Support:Case Management – Case holder will link and coordinate services and referrals within the agency and community. CH to update paperwork, complete authorizations and communicate with others involved with Ava, including her therapist and primary care physician. CH will monitor Ava’s progress by asking at minimum of monthly, for a self-scaling (1 to 10) toward reducing her depression and discuss what has gone well and what would help increase her confidence and ability to meet her goal. A formal review and assessment will be completed at least every 6 months. CH will communicate with Ava about medication adherence and document any changes with medication.


Step Letter B


Amount of the Service or SupportT1017 - 80 units of 15 minutes annually

Duration of the Service or SupportOne year duration of the IPOS

Scope of the Service or Supportface to face, telehealth, at home, community or office

Documents

How Do You Measure a Wish? - SCCMHA