Insights from Behavioral Health Accreditation Expert: Treatment Planning Standards and Compliance
we have Peggy Lavin who’s joining us today she’s an lcsws and director of Behavioral Health for accreditation gurus I met Peggy many years ago at the Joint Commission and uh we really value her insight and her teams they have Representatives all throughout the country that help uh Behavioral Health as well as other facilities in their accreditation needs she’s going to provide insights into treatment planning standards and so let’s begin we’re going to start with myself and Peggy and then we’re going to move on to Maria Peggy so what are some of the current treatment planning standards that the accreditation agency have mandated well first thank you for asking me to join today’s webinar always happy to talk about accreditation um your question current treatment planning standards mandated by accrediting Body such as the Joint Commission carf International and also good practices such as Asam criteria consistently emphasize that a treatment plan needs to be individualized and person centered patient centered that means the plan needs to reflect information planning specific to each person served the current standards also mandate that the uh person served needs to participate in their entire treatment Pro uh experience a set assessment treatment planning treatment planning review discharge planning accreditation standards provide a framework for a treatment plan and there are required components needs what are the issues that’s preventing a person from reaching their desired functioning each identified need needs a goal and a goal is a highlevel outcome treatment outcome because it’s high level the standards require that each goal be broken down into objectives and they require that the objectives be measurable that they be indicators of progress and that there be an anticipated time frame for the person to achieve uh their uh goal another required component and an important component is uh a listing of interventions and services so this is any and all activities actions provided by the organization in which the person will participate to reach their goal individual family group therapy if it’s medication assisted uh treatment uh the uh prescription administration of a me of medication uh it also uh the standards also require that the interventions and services uh identify the frequency of each activity and action um I would mention that the standards required that the plan is uh relevant at all times so it always has to reflect the current uh circumstances and conditions of the person uh there’s the initial treatment plan and then as it’s implemented the treatment plan needs to uh indicate the person’s response to treatment their progress Joint Commission has a standard that says the use of a standardized tool or instrument to monitor the person’s progress in achieving their goals must be used so if some if it has to do with depression some standardized instrument that measures what uh is the level of depression at the beginning of treatment and how treatment impacts uh that measurement and finally I would say the treatment plan needs to clearly indicate that the person sered has participated in the planning and is in agreement with the plan clear indicator great well that’s a it’s quite a bit that you covered Peggy and one of the ones that you mentioned and and we’ve we get a lot of questions on and there were questions that came in was in regard to assessments which you mentioned and being a critical piece of effective care why are these tools being highlighted so prominently in the current standards is this a is this a change or is this something that has been evolving I would say it’s been evolving accreditation standards have always required that treatment plans be based on assess M findings so that process is a very critical component to uh effective care um a comprehensive assessment will accurately identify the needs of the person served and um it’s been evolving in the sense that are emphasizing one example is more the participation of the person served so um this and they’re using adjectives like active collaborative participation um which you know action uh type adjectives and um in the assessment process that is shown by the person being actively and collaboratively involved in identifying their own needs and also their strengths their abilities their preferences and that information as well as other assessment findings need to be reflected in the treatment plan um so and and uh uh evolving because uh carf and Joint Commission the accrediting bodies are looking for um outcome measurement you know it’s how effective is this treatment as I mentioned the Joint Commission is even asking that a standardized tool be used to measure the effectiveness of each person’s uh progress in treatment great thank you Peggy on that so you’re talk little bit deeper about the master treatment plans and engaging a care team as you mentioned in who needs to be engaged what are the expectations well the simple answer Cola is that everyone involved in the treatment process and the Treatment review process needs to be involved everyone that’s providing assessment interventions and services um you asked uh who needs to be involved so it does depend on the level of care so if you have a person who’s going maybe twice a month for outpatient counseling there’s the counsel there’s the therapist but once you go into more intensive levels of care the numbers start increasing so you may have multiple counselors or therapists doing individual family group therapy you may have someone involved in in like in a residential level of care the physical health care needs of the person uh if it’s medication assisted treatment someone prescribing administering medication residential may have a dietitian uh so um uh the standard say that when there is more than one that they’re all working together that they’re communicating they’re collaborating they’re coordinating treatment remember it’s person centered so everything needs to be directed directly to the person served for as the individual okay makes sense um Peggy standard seem to place a strong emphasis on that patient collaboration component you mentioned um can you share more about how treatment planed has shifted to include the patient more actively in this process yeah yeah well that’s exactly right the active collaborative participation is emphasized by the accrediting bodies for sure Keta um I’ve mentioned the type of participation in the um assessment process I gave two examples in the treatment uh process the um standards say and this shows the participation that the person’s own words and ideas need to formulate the goals and objectives uh carf has a standard that if there is a need for a more clinical goal okay but it has to be understandable to the person served so people need to watch what clinical terminology they’re using it has to be very understandable to anyone reading the treatment plan but most importantly to the person that is being served the individual served interesting that is very interesting and it certainly makes sense so for centers aiming to implement these standards successfully challenges are bound to arise right Peggy yes what are some of the common obstacles and what advice would you give to help centers overcome them if you can think of any um well I have thought about this and um also uh uh asked our consultants and some of what they see when they’re working with organizations to prepare for accreditation or re accreditation um want it is that people seem to be challenged with the measurability of the objectives um and that is a requirement so perhaps an example might illustrate that well um the goal may be sobriety a measurable objective might be um the person identifies two or three triggers that lead them to drink or use drugs uh another example a person identifies two coping skills that they can start using to um when they’re triggered or to prevent a trigger uh might be a coping seill that’s worked well for them in the past it might be coping skill that they learn in an individual or group sessions uh provided by the provider um so so measurability is a challenge at times um um another example that we see is um the and I think I mentioned the treatment plan has to be reviewed periodically and it has to stay current and organizations seem to do very well in the periodic review so they have an initial treatment plan and maybe their policy says every month or every other month for halfway house they’re reviewing the treatment plan and um they’re doing pretty well at that that that’s happening pretty well it’s scheduled but sometimes our Consultants are seeing in progress notes that there has been a rather significant change in condition or circumstances of the person and it’s not considered in the treatment planning review there’s not a treatment plan review to say okay this might mean a different need it might mean that the treatment plan needs to be changed because it’s always it always has to reflect the current condition and circumstances of the person and the last challenge I would mention that our consultant see is that um uh I said uh in the assessment process there’s an identification of needs by the individual and by the uh help with the provider and all of those needs are expected to have a goal but sometimes we’re seeing that there’s a missing uh need a missing goal and um uh that can’t happen all the uh needs have to be mentioned or addressed but it could be that that need is being referred to an external provider uh for uh treatment during that episode or after discharge perfectly okay but it needs to say that in the plan it can’t be missing it needs to State this is being referred so so so are some of the challenges I thought about and thought worth mentioning today no that’s great Peggy and it it all circles completely around to that entire care team approach making sure that you’ve you’ve got the whole team involved so as your example highly emphasized if a clinician is seeing something and is documented in a progress note something that’s changed having them part of that care team and having that ability to in a review have them share that so a treatment plan can be updated invaluable and it really makes sense the the evolution towards a whole care team approach not just one individual um taking care of it I I think it’s great and thank you for those those insights uh Peggy and and updated St ards I’m sure there is more to come and um you know emphasizing as your team does on that patient centered you know the outcome driven care um it’s clear that these standards are not just for compliance it’s really about delivering a better outcome for the individuals exactly cleta um individualization engagement of the patient uh the person served uh means they’ll be more engaged they’ll they’ll have more ownership of their treatment and that contributes to better clinical outcomes yeah it’s wonderful I mean we have we have seen with the the many facilities that we serve you know the evidence-based assessments that they’re they’re discovering that are research based that they want to utilize whether they’re serving youth whether they’re serving substance use disorder or mental health there really are some wonderful evidence-based assessments out there and standards many of them very common and many are using the same ones but other ones that are being utilized as well so um it’s and evidence-based interventions and services yeah there you go hand in hand with assessment yeah of of great value for sure um Peggy one of the first questions was in regard to increased compliance in personalizing those treatment plans you know if you want to summarize you really hit upon it you know earlier on the the entire care team and engaging the patient I think um sure so some of the suggested ways to increase compliance um well let me start with personalizing the plan I hope I’ve emphasized that the active and collaborative participation of the person served throughout the exper their experience is critical and will certainly personalize a plan um I gave some examples how to do that in the assessment process how to do that in the treatment planning process say I would also say make sure that your procedures and protocols regarding treatment planning cover the applicable treatment planning standards that your sta that your staff know your approved protocols and and uh procedures and they’re using them um and that you’re getting the results that you intended um at you mentioned Colin this is excellent evidence-based tools during the assessment process and during the um treatment process uh certainly increased compliance and because you’re monitoring an individual’s progress it adds to the individualization of the plan and as Maria just demonstrated leverage technology to assist you for efficiency and compliance um sometimes um the people doing the interventions say I don’t have time so you have to leverage technology to assist them to be efficient with their time um so those are some suggestions I would have great thank you Peggy um you mentioned terminology interdisciplinary team IDT that meeting approach and and I think Peggy with the whole care team approach as well the the master treatment plan seems to allow for that seamless collaboration now what if they have an external provider and I think Peggy you mentioned you there there are some external providers or consultants if if they were auor I to access asley could they document in this master treatment plan as well if they were to use an external provider they would actually have the flexibility of either situation Keta so if they if the external provider were authorized to view the entire treatment plan to view all needs then they would absolutely be able to however they would also be able to create their own treatment plan if needed for that author or for that external provider so that if that external provider needed to create their own set of needs and goals that for that patient then they would be able to do so as well okay great um Peggy you made mention of I think living document and the importance of a living document to treat an individual during their episode of of care how important is that quote unquote living document um well if you want to be in compliance with accreditation standards it’s critical um you can’t create a cre a treatment plan after the assessment and then let it stand uh without any changes um or updating or revision for the whole treatment episode because it it’s required that it reflects the current circumstances and conditions and it has to at a minimum show the response and progress of a person so even if there’s no significant changes in condition or uh circumstance es there is either progress or lack of progress as Marie mentioned um so it’s a living document it’s a realtime document it it just isn’t a stagnant um initial treatment plan that sits there it’s it’s got to be relevant and it’s got to maintain relevancy to uh the current condition and circumstances Peggy this one’s uh in regard to the differences between goals objectives and needs is there is can you distinguish those um sure I think I mentioned this a little bit when I was talking needs are um the issues that’s preventing the person from uh achieving their desired functioning so it it could be you know I’m drinking too much I um I’ve uh have problems with relationships family relationships significant others um and I don’t want to be like that I want to have friends I want to have a girlfriend I want to have a job I want my to invite me to Thanksgiving dinner um so needs are you know what the person identifies as the reasons for seeking treatment goals are very broad high level and Maria has done a great job at showing us some that she’s put into the system um very high level and because they’re high level outcomes a a a treatment plan should give the person specific steps to take to reach that goal so the objectives break down the goal into specific steps and I gave you an example I hope that was helpful and um I do want I did State and I want to emphasize this um interventions and services it’s any and all intervention and services so if the um person um is uh has some kind of physical health need and their blood pressure is going to monitored daily um if they have some type of special dietary need and I’m using nonbehavioral Healthcare uh examples because um sometimes the organizations are doing a great job with the Behavioral Health Care needs goals objectives interventions and but not putting in the other uh activities and uh actions that they’re taking uh in regards to the person uh particularly their physical health needs okay great thank you Peggy great detail um Mar
We were so excited to have Accreditation Guru’s Director of Behavioral Health, Peggy Lavin, LCSW, join us for our webinar on AZZLY’s new Master Treatment Plan module. Enjoy this highlight reel made up of excerpts from Peggy’s contributions to the full webinar discussion.
Get expert insights from Peggy as she shares valuable strategies for creating effective, person-centered treatment plans in behavioral health and mental health care settings. Drawing from her extensive experience in accreditation and compliance, Peggy highlights the importance of individualized care, active patient participation, and the role of measurable outcomes in treatment planning.
Explore key standards set by organizations like the Joint Commission and CARF and how to overcome common challenges in maintaining compliance. Hear Peggy discuss the critical role of collaboration among care teams and leveraging technology to streamline workflows and ensure accountability.
Want to see the full conversation, including additional insights from Coletta Dorado and Maria Gray, as well as a demonstration of AZZLY’s new Master Treatment Plan feature? 🔗 Watch the full webinar here: https://youtu.be/evVwqevR69U
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Meet the Panel:
• Peggy Lavin, LCSW
Director of Behavioral Health for Accreditation Guru, Peggy has deep expertise in accreditation and compliance. Her background includes managing The Joint Commission’s cadre of behavioral health care accreditation surveyors and clinical work across various behavioral health care settings.
• Coletta Dorado
Founder of AZZLY, Coletta is passionate about increasing access to mental health services at the community level. Since 2009, she’s led AZZLY with a focus on creating technology-driven solutions that empower treatment programs to grow and thrive.
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