TIPS & TOPICS
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