Of Person-Centered Service/Care Planning

Download 339.75 Kb.
NameOf Person-Centered Service/Care Planning
A typeDocumentation
manual-guide.com > manual > Documentation
  1   2   3   4   5   6   7   8   9

The Role


Person-Centered Service/Care Planning


Mental Health Recovery

White Paper and Literature Review

Prepared for

The Center for Mental Health Services

Substance Abuse and Mental Health Services Administration

Neal Adams MD MPH

Diane Grieder M Ed
January 18, 2005


There is a considerable and growing literature about the importance of resiliency and recovery values and practice in the mental health service delivery system. There is also a clear consensus about how person-centered treatment plans are critical to making resiliency and recovery a reality for children, families and adults established in the literature. Yet today’s practice often falls considerably short of this vision. The need for change and the role of treatment planning in overall systems change was made explicit in the President’s New Freedom Commission Report and is affirmed by numerous other sources. While there are abundant standards and regulations that describe what should be done, there is little published about how best to train providers and effect practice change. Much of what is written focuses on the administrative requirements that are attached to treatment planning rather than on the clinical utility and relevance of the plan. In addition there is a lack of consensus about models, no science base to help determine best-practice, and few if any established curricula and/or competencies to assure quality services that promote resilience and recovery. It is incumbent upon policy makers, regulators, payers, administrators, providers, consumers and family members to address these issues in a consensus process and to promote resiliency/recovery oriented practice at all levels of the mental health service delivery system.

The mental health and addictive disorders fields have found a common language and mission in their now shared commitment to recovery and resiliency as the primary goal of treatment services. But exactly how to implement this vision in the mental health field remains unclear. There is much to suggest that treatment planning has the potential to play an essential role in making recovery and resilience real for consumers and family members.
There is perhaps no more powerful and effective approach to ensuring recovery-oriented services than a commitment to creating and actually using person-centered treatment plans in everyday practice1. The President’s New Freedom Commission on Mental Health report of July 2003 made explicit the central role of a plan of care.
In a transformed mental health system, a diagnosis of a serious mental illness or a serious emotional disturbance will set in motion a well-planned, coordinated array of services and treatments defined in a single plan of care. This detailed roadmap — a personalized, highly individualized health management program — will help lead the way to appropriate treatment and supports that are oriented toward recovery and resilience. Consumers, along with service providers, will actively participate in designing and developing the systems of care in which they are involved. An individualized plan of care will give consumers, families of children with serious emotional disturbances, clinicians, and other providers a valid opportunity to construct and maintain meaningful, productive, and healing relationships. Opportunities for updates — based on changing needs across the stages of life and the requirement to review treatment plans regularly — will be an integral part of the approach. The plan of care will be at the core of the consumer -centered, recovery-oriented mental health system. The plan will include treatment, supports, and other assistance to enable consumers to better integrate into their communities; it will allow consumers to realize improved mental health and quality of life.2

But translating these principles and values into actual person-centered services and outcomes remains a challenge in many settings. Two important questions remain: How can providers/organizations ensure that their clients are in fact receiving recovery and resiliency-oriented services? How can consumer sand family members assure that their recovery is self-directed and that needed services and supports are organized and provided consistent with a plan that is developed in a meaningful partnership and collaboration with the provider and services team/system?
Addressing individual and family concerns in describing goals and objectives, as well as the services and supports needed to enhance resiliency and achieve recovery, is essential. Creating plans that are meaningful and relevant — and at the same time meet the administrative and regulatory obligations while supporting the documentation of medical necessity required for billable services — gives providers an opportunity to demonstrate their commitment to the vision of recovery and wellness. At the same time this assures that services are individualized, person-centered and are driven by individual choice and preference.
All too often past and current practice leads to the creation of provider-driven plans that emphasize problems and diagnoses merely to satisfy bureaucratic and administrative requirements. Instead, both consumers and providers must seize the opportunity to make recovery real by working to develop service plans that:

  • forge an alliance between consumers and providers

  • are developed in partnership with the consumer (and family as appropriate) and the provider/treatment team

  • are individualized and based on consumer input regarding preferences, abilities, strengths, goals and cultural identity

  • are written in language readily understandable for the consumer

  • immediately directs the service delivery and recovery process

  • result in improved person-centered and individually defined recovery goals and outcomes

Yet, in a consumer focus group at a peer-support center3 about experiences with the Santa Cruz CA. county mental health system, a discussion amongst nine consumers revealed the following:
Q. Do you feel involved in your treatment planning?  What is your role in determining the specific services you receive?
A. 3 people did not have a plan/ did not know about a plan. 6 people had a plan.

There were varying opinions on involvement in treatment planning.  One consumer reported “I play a big role in it.”  Another reported “No.  I just tell them how I feel and what I do and they write it down.”  Family members felt uninvolved though they would like to be more involved. Some participants indicated that their treatment plans did not contain positive or clear goals other than to “stay stable.”

  1. Were you asked to sign your treatment plan after it was completed?

All who had a plan were asked to sign it. Not much follow-up was reported on the plans.  One consumer felt his plan was basic and easy to follow.  Another consumer feared not knowing who had access to her plan.
Q. How did your family members and persons who help you in the community participate with you in your treatment plan?
Family members did not know about the treatment plans.  Some family members offered general support, but no one said their family was involved with their treatment plan per se. One family member stated “If I was not actively involved pursuing the treatment I feel that I would not be consulted.” 
Q. Did you receive a copy of your treatment plan?
Two people received copies, one didn’t know, one didn’t want one and two did not receive one.  One parent stated “As my son’s conservator, no, I have never seen his treatment plan.”

While these experiences are entirely anecdotal, they are not at all uncommon. Clearly there is a gap between the vision and the reality of current practice. The concerns expressed by these consumers and family members are consistent with the finding and recommendations of the President’s New Freedom Mental Health Commission report which stated:

Nearly every consumer of mental health services…expressed the need to fully participate in his or her plan for recovery.

As noted earlier, the treatment plan has multiple functions and satisfies multiple administrative and regulatory requirements in addition to its primary clinical purpose as described above. These include:

  • identifying and establishing criteria for expected outcomes and transitions or discharge

  • documenting medical necessity and anticipation of frequency, intensity, and duration of services

  • supporting service documentation and billing

  • considering and including alternatives, natural supports, and community resources

  • identifying responsibilities of team members—including the individual and the family seeking services

  • increasing coordination, collaboration, and multidisciplinary interventions within the team

  • promoting the use of evidence-based practices

  • decreasing fragmentation and duplication

  • prompting analysis of available time and resources

  • establishing the role of the individual and family in their own recovery and rehabilitation

  1   2   3   4   5   6   7   8   9

Share in:


Of Person-Centered Service/Care Planning iconAdvance Directives Planning for Medical Care in the Event of Loss...

Of Person-Centered Service/Care Planning iconThere r two person each having same amount of marbles in the begining...

Of Person-Centered Service/Care Planning iconThe Virginia Health Care Foundation seeks a Deputy Director. The...

Of Person-Centered Service/Care Planning iconSection 9 Assessment and Service Planning

Of Person-Centered Service/Care Planning iconService users in residential care

Of Person-Centered Service/Care Planning iconPp ( Phoenix, Tempe, Tucson) Acacia Women’s Center, Old Pueblo Family...

Of Person-Centered Service/Care Planning iconUser Centered Design

Of Person-Centered Service/Care Planning iconUser-Centered Design Process

Of Person-Centered Service/Care Planning iconUser-Centered Design, Inc., Ashburn, va 20147

Of Person-Centered Service/Care Planning iconA person who by mutual asset acts on behalf and subject to the control...

Of Person-Centered Service/Care Planning iconA. Definition of tort: is (1) a civil wrong committed by one person...

Of Person-Centered Service/Care Planning iconName two books that describe raindrop technique in detail. Give titles...

Of Person-Centered Service/Care Planning iconThis Special Care Organization Record (scor) has been developed just...

Of Person-Centered Service/Care Planning iconAbstract Child-care subsidies (ccdf) were expanded after welfare...

Of Person-Centered Service/Care Planning iconTo request for product service and order replacement parts, please...

Of Person-Centered Service/Care Planning icon11 Internet Denial of Service (DoS) Service blocking 49

Of Person-Centered Service/Care Planning iconFirst of all create a service account. This Service account should...

Of Person-Centered Service/Care Planning iconPerson Name Description

Of Person-Centered Service/Care Planning iconI wish every eloquent person had something to say

Of Person-Centered Service/Care Planning iconPpp= only used about Person or Personality


When copying material provide a link © 2017