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San Francisco Mental Health Plan (SFMHP)
Behavioral Health Services (BHS)
BHS Quality Management &
BHS Compliance
December 2017 (updated after 12/18/17 session)
Implementing Improvements in
Clinical Documentation &
Documentation Monitoring:
Follow-Up to Triennial Audit (2016)
AGENDA & OBJECTIVES
Mins Item Objective
60
Documentation Improvements:
• Best practices-implementation
• Best practices-quality improvement
• Efficiency in Documentation
• Read prompts
• Priority Domains
• Case Formulation
• Insights from DHCS
• Agencies must have a QA plan…is yours up to
date?
• Efficiency relies on “standard work”
processes…are yours documented?
• Name the three elements of CDIP’s case
formulation model!
60
Documentation Monitoring:
• BHS Desk Reference Guide
• BHS Chart Review Protocol
• Name two “source documents” that are the
basis for both the Desk Reference and Chart
Review Protocol?
• Name one method to obtain a copy of the
Reference Guide and Chart Review Protocol
60
Documentation Q/A + Practice:
• Client cases
• Your biggest implementation struggle
• How to recognize “problems” and take steps to
make improvements?
SFMHP-BHS Implementing Improvements in Clinical Documentation & Monitoring (Dec 2017) 2
MENTAL HEALTH MEDI-CAL
“Medi-Cal Insurance”
Physical Health
Medi-Cal
Mental Health
Medi-Cal
Drug Medi-Cal/
ODS
San
Francisco
Health
Plan
Blue
Cross
Partner.
Plan
BHS
(County
MHP)
BHS
(County
SUD Plan)
• Physical health care
• Mild/Moderate MH care
• Autism Spectrum/BHT
• SMHS
• Moderate
to severe
MH care
• SUD
Treatment
Services
SFMHP-BHS Implementing Improvements in Clinical Documentation & Monitoring (Dec 2017) 3
MENTAL HEALTH MEDI-CAL
Area Clinic Model Rehabilitation Model
Definition from
Federal Social
Security Act
§1905(a)(9): “Clinic services [are
those] furnished by or under the
direction of a physician, without
regard to whether the clinic itself is
administered by a physician,
including such services furnished
outside the clinic by clinic personnel
to an eligible individual who does
not reside in a permanent dwelling
or does not have a fixed home or
mailing address”
§1905(a)(13): “Other diagnostic, screening,
preventive, and rehabilitative services,
including any medical or remedial services
(provided in a facility, a home, or other setting)
recommended by a physician or other
licensed practitioner of the healing arts
[LPHA] within the scope of their practice under
State law, for the maximum reduction of
physical or mental disability and restoration
of an individual to the best possible functional
level”
Treatment
ModelMedical model Recovery model
Focus Stabilization Active treatment and participation
Locations Clinic-based Community-based
Type of StaffLicensed; higher degree
professionals
Professionals, mental health technicians and
peer specialists
Organizational
ModelOrganized clinics
Organizations that provide one or more
covered servicesSFMHP-BHS Implementing Improvements in Clinical Documentation & Monitoring (Dec 2017) 4
MENTAL HEALTH MEDI-CAL
Provide Treatment
Interventions
M-Cal
Logic
Conduct assessment Create treatment plan Provide interventionsClinical
Practice
“The Golden Thread” of Clinical Practice & Mental Health Medi-Cal
Establish Diagnosis &
Functional
Impairments
Create Treatment
Plan/Client Plan
“what is the problem?” “why problem exists” “how to address it”
SFMHP-BHS Implementing Improvements in Clinical Documentation & Monitoring (Dec 2017) 5
Best Practices: Implementation
• Your Roadmap to Implement Doc Improvements
• Your agency/program must have a plan for clinical documentation:
• Agency-level (e.g., as part of accreditation, like Joint Commission)
• Program-level (e.g., as part of BHS Contract, Appendix A, CQI description)
• What do you know about your agency’s plan?
• Is your plan up to date?SFMHP-BHS Implementing Improvements in Clinical Documentation & Monitoring (Dec 2017) 6
Best Practices: Implementation
• Implementation Science
Component In Vivo Use
Theory & Discussion Only 0%
+ Demonstration (in Training) 0%
+ Practice/Feedback (in Training) 5%
+ Coaching (in vivo) 95%
Source:
Fixsen, D. L., Naoom, S. F., Blase, K. A.,
Friedman, R. M. & Wallace, F. (2005).
Implementation Research: A Synthesis
of the Literature. Tampa, FL: University
of South Florida, Louis de la Parte
Florida Mental Health Institute, The
National Implementation Research
Network (FMHI Publication #231). 7
Best Practices: Implementation
• Your Roadmap to Implement Doc Improvements
• Pre-service training:
• General documentation curriculum
• In-service training:
• Specific tools/modules for program
• Live observation:
• Real-time reviews of documentation (e.g., self-review)
• Close-to-time reviews of documentation (e.g., supe review, UR review)
• Data feedback & monitoring:
• Staff- and program-level data are reported and monitoredSFMHP-BHS Implementing Improvements in Clinical Documentation & Monitoring (Dec 2017) 8
Best Practices: Quality Improvement
• Your Toolkit to Implement Doc Improvements
• Your agency/program must have a plan for quality improvement:
• Agency-level (e.g., as part of accreditation, like Council on Accreditation)
• Program-level (e.g., as part of BHS Contract, Appendix A, CQI description)
• What do you know about your agency’s plan?
• Is your plan up to date?SFMHP-BHS Implementing Improvements in Clinical Documentation & Monitoring (Dec 2017) 9
Best Practices: Quality Improvement
• Quality Improvement Approaches-A3
Source:
Shook, J.S. (2008). Managing to Learn.
Cambridge, MA: Lean Enterprise
Insititute.
A3 Element & Question
Background: What are you talking about and why?
Current Conditions/Problem Statement: Where do things
stand now, today/What is the problem?
Goals & Targets: What specific outcome is required?
Analysis: Why does the problem or the need exist?
Recommendations: What do you propose and why?
Plan: How will you implement?
Follow-up: How will you ensure ongoing PDCA/PDSA10
Best Practices: Quality Improvement
• Your Toolkit to Implement Doc Improvements
• Identify the “problem” and collect/analyze information to understand the it;
• Identify an improvement and conduct structured PDSA cycles to investigate the improvement;
• Based on insights, abandon the change, adopt the change or adapt with further PDSA;
• GOAL is standardizing processes that lead to quality and reducing variation away from those standard work processes
SFMHP-BHS Implementing Improvements in Clinical Documentation & Monitoring (Dec 2017) 11
Efficiency: Medical Necessity
• Medical Necessity In SMHS:
• Four general areas for medical necessity:
• Included diagnosis
• Impairments resulting from diagnosis
• Interventions to address impairment
• Not a health-based disorder
• Four “specials” of SMHS medical necessity:
• Special diagnosis (“on a list”)
• Special impairments (“today” vs. “tomorrow”)
• Special interventions (“today” vs. “tomorrow”)
• Special setting (“not general health clinic”)
SFMHP-BHS Implementing Improvements in Clinical Documentation & Monitoring (Dec 2017) 12
Efficiency: Medical Necessity
• Medical Necessity In SMHS: Pick a pathway and justify it!
13
Efficiency: Read the Prompts
• Answer the question being asked by reading the screen:
• Assessment documents vary across programs:
• Children 0-4 vs. 5-18
• Adults & Older Adults-Short vs. Long
• Psychiatric Assessments
• Prompts vary slightly across documents:
• Some documents “squish” symptoms and impairments together
• Stop copying/pasting—answer the question!
SFMHP-BHS Implementing Improvements in Clinical Documentation & Monitoring (Dec 2017) 14
Efficiency: Read the Prompts
• Disaggregate and directly address prompts: CYF 5-18 example…
15
Efficiency: Read the Prompts
• Disaggregate and directly address prompts: AOA example…
16
Efficiency: Priority Assessment Areas
• Never leave blanks in an assessment:
• Strategies if you don’t have the information:
• “not yet assessed” (RISK: but you will need to)
• “insufficient information” (RISK: is information attainable)
• “does not account for impairment” (RISK: how do you know?)
• Remember the purpose of SMHS Assessment:
• Is there medical necessity for SMHS (vs. problem due to drugs, health, etc.)
• Work smarter!SFMHP-BHS Implementing Improvements in Clinical Documentation & Monitoring (Dec 2017) 17
Efficiency: Priority Assessment Areas
• Prioritize the Assessment Domains:
• MUST HAVES for SMHS Medical Necessity:
• Presentation: behaviorally specific symptoms for DSM dx
• Functional Impairments: current/sig vs. risk of decline
• Risks/Strengths: context for impairments & interventions
• Mental Status Exam: evidence for assessment/diagnosis
• Case Formulation: pull clinical story together
18
Efficiency: Priority Assessment Areas
TWO
SETTINGS
TYPE OF FUNCTIONAL IMPAIRMENT
Home/Living School/Work Community
Traditional
Outpatient
• Client cannot maintain
housing due to cognitive
& behavioral impairments
from Schizophrenia
• Client cannot maintain
employment because he
is withdrawn & cannot
maintain hygiene due to
Schizophrenia
• Client cannot engage in
community activities
(support group) because
he is so confused &
disorganized
Outpatient
within
Residential
• Resident cannot
maintain roommate due
to paranoia & risk of
assault related to
Schizophrenia…risk of
losing placement
• Client cannot pursue
interests & hobbies
(e.g., listening to music)
because he is distracted
by hallucinations that
stem from
Schizophrenia…risk of
social isolation &
decreased quality of
life
• Client cannot engage in
community activities
(e.g., lunch; movie night)
because of the risk of
aggressiveness that
stems from
paranoia…risk of social
isolation & cognitive
decline
SFMHP-BHS Implementing Improvements in Clinical Documentation & Monitoring (Dec 2017) 19
Efficiency: Case Formulation
• Case Formulation: DHCS’ View
• “case conceptualization is your attempt to understand the
client’s predicament or to develop a comprehensive
conceptualization that would provide an understanding of
[the client’s] state of mind and the reasons for [the
client’s] behavior.”
Source:
DHCS (2015). Improving Documentation
for Acute Psychiatric Inpatient Hospital
Services (August/September 2015). 20
Efficiency: Case Formulation
• Case Formulation: CDIP’s View
1. Restate medical necessity criteria:• Client meets criteria for (diagnosis) as evidenced by
(behaviorally-specific symptoms) that lead to (impairment
area and severity)…
2. Formulate the case theoretically:• Client’s mental health needs and impairments appear to
stem from (your understanding of the core
problems/themes). There are related dynamics and
processes that (maintain/aggravate) these problems…
3. Outline a 12-month course of treatment:• The services and supports that best address the client’s
goals and impairments (as well as dynamics/processes)…SFMHP-BHS Implementing Improvements in Clinical Documentation & Monitoring (Dec 2017) 21
Efficiency: Case Formulation
• Case Formulation: CDIP’s View
22
Efficiency: Case Formulation
• Case Formulation: CDIP’s View
3 Most
Problematic
Symptoms
2 Domains
Of Life
Impairments
1 Hypothesis: How Do Symptoms Drive Impairments?
(aka “THEORY OF CHANGE”)
SFMHP-BHS Implementing Improvements in Clinical Documentation & Monitoring (Dec 2017) 23
Efficiency: Case Formulation
• Case Formulation: CDIP’s View
3 Most
Problematic
Symptoms
2 Domains
Of Life
Impairments
1 Hypothesis: How Do Symptoms Drive Impairments?
(aka “THEORY OF CHANGE”)
SFMHP-BHS Implementing Improvements in Clinical Documentation & Monitoring (Dec 2017) 24
Efficiency: Case Formulation
• Case Formulation: Example 1 with TPOC
1. Medical necessity: (a) Schizophrenia; (b) Home/Living impairment; (c) Meds & skills building services will help
2. Theoretical formulation: (a) Client hears auditory hallucinations, interacts with them & then becomes confused & agitated; (b) this leads to yelling & spitting; (c) client’s behavior creates problems maintaining a roommate & receiving care—risk of increased LOC.
3. Course of treatment: Plan is to reduce interactions with auditory hallucinations (meds & CBT) to decrease & manage confusion/agitation (calming skills).
SFMHP-BHS Implementing Improvements in Clinical Documentation & Monitoring (Dec 2017) 25
Efficiency: Case Formulation
• Case Formulation: Example 1 with TPOC
• Problem & Goal: Schizophrenia; Restore functioning in Living/Home
• Objective: Reduce the instance of interacting with auditory hallucinations. Initial step is helping client distinguish hallucinations from real voices (from a baseline of 0 times/day to 3 times/day per client’s report)
• Interventions: Medication support services (1/week/15mins for 12mos) to reduce hallucinations; CBT Therapy (1/week/15mins for 12mos) to increase reality orientation; Rehab (1/week/30mins for 12mos) to build distress tolerance & calming skills; Collateral with mother (1/month/30mins for 12mos) to teach her to implement reality orientation/calming skills.
SFMHP-BHS Implementing Improvements in Clinical Documentation & Monitoring (Dec 2017) 26
Efficiency: Case Formulation
• Case Formulation: Example 2 with TPOC
1. Medical necessity: (a) Schizoaffective Disorder; (b) Physical/Medical; (c) Meds & stress/anger management therapy will help
2. Theoretical formulation: (a) Client becomes stressed & then angry & then refuses meds; (b) this leads to increased paranoia & confusion; (c) client believes staff are out to get him & he refuses his medications; (d) the refusal behavior is angry outbursts & physically hitting staff
3. Course of treatment: Plan is to reduce client’s stress (CBT skills) & anger (calming skills) & decrease paranoia (Medication Support Services)
SFMHP-BHS Implementing Improvements in Clinical Documentation & Monitoring (Dec 2017) 27
Efficiency: Case Formulation
• Case Formulation: Example 2 with TPOC
• Problem & Goal: Schizoaffective Disorder; Restore functioning in Medical/Physical
• Objective: Reduce client’s level of unmanaged stress & anger to baseline, one year ago. Initial steps are to reduce stress-levels from a current Subjective Units of Distress/SUDS rating of 100 to 80 (per client report)
• Interventions: Medication support services (1/week/15mins for 12mos) to reduce paranoia; CBT Therapy (1/week/15mins for 12mos) to increase reality orientation; Rehab (1/week/30mins for 12mos) to build anger management & calming skills
SFMHP-BHS Implementing Improvements in Clinical Documentation & Monitoring (Dec 2017) 28
Efficiency: Standard Work
• You cannot manage 50 different flows:
• “Standard work” is the key to efficient clinical documentation programs;
• Everyone documents in the same framework:
• diagnosis, impairments, interventions….
• claim your pathway and justify
• Supervisors, Utilization Review & Audits follow same framework:
• Stop “hunting and pecking” for information
• Mandate structure formats (e.g., P-I-R-P)
SFMHP-BHS Implementing Improvements in Clinical Documentation & Monitoring (Dec 2017) 29
Parting Thoughts….
• Implementing Clinical Documentation Improvements:
• Have a plan for clinical documentation (i.e., a plan for implementation strategies of improvements);
• Standardize the work so you can manage the work
• Make sure “efficiencies” fit with your agency’s risk appetite and risk management stance.
SFMHP-BHS Implementing Improvements in Clinical Documentation & Monitoring (Dec 2017) 30
Parting Thoughts….
Joseph A Turner, PhD, PSY22453
Clinical Documentation Specialist
Clinical Documentation Improvement Program (CDIP)
Phone: 415-255-3723
Fax: 415-255-3567
Email: [email protected]
San Francisco Department of Public Health
Behavioral Health Services, Quality Management
1380 Howard Street, 4th Floor, #428e
San Francisco, CA 94103
Clinical Documentation Resources
0. CDIP Homepage: https://www.sfdph.org/dph/comupg/oservices/mentalHlth/CBHS/CBHSQualityMgmt.asp
1. BHS Documentation Manual (2017 Ed.): https://www.sfdph.org/dph/comupg/oservices/mentalHlth/CBHS/
2. BHS Policies/Procedures: https://www.sfdph.org/dph/comupg/oservices/mentalHlth/CBHS/default.asp
3. BHS Contract Performance Objectives (FY17-18):
https://www.sfdph.org/dph/comupg/aboutdph/insideDept/CDTA/documents.asp
4. Organizational Provider Manual (FY15-16): https://www.sfdph.org/dph/files/CBHSdocs/2015-2016-ProviderManual.pdf
5. BHS Outpatient Billing Codes (eff. 7/1/15): https://www.sfdph.org/dph/comupg/oservices/mentalHlth/BHIS/avatarUserDocs.asp
6. Outpatient MH Service Codes Definitions (eff. 7/1/15):
https://www.sfdph.org/dph/comupg/oservices/mentalHlth/BHIS/avatarUserDocs.asp
7. Mental Health & Substance Abuse Staffing Qualifications for Service and Billing Privileges (7/1/2017-MHRS, MHW, Peers):
https://www.sfdph.org/dph/files/CBHSdocs/BHISdocs/Forms/Service-Billing-Privileges-Matrix.pdf31