Behavioral Health Agencies Training Video
I would like to thank the Ohio Department of Mental Health for partnering with us and for supporting this effort here today director Stevenson is with us this morning she is sitting in the very back so we appreciate her support and her leadership in this process today really does mark the dawning of a new decade it is a decade that offers some exciting opportunities and will challenge the way that we think about how we deliver services and document those services some of the things that are changing in this in this current environment include the federal parity legislation which as you know now will require coverage for behavioral health services on par with medical the medical benefits that most people have you have federal healthcare reform which includes a lot of opportunities for the delivery of behavioral health services again it’s a coverage issue in the behavioral health services are considered core benefits so that’s new and that’s different for those sort of folks that we serve there is a growing recognition and and data that demonstrates that in order for people to be truly healthy they must have good mental health as well and then of course there is momentum towards the delivery of integrated care where we are finally reconnecting the body and the brain so that we are treating hope people as whole persons and then the emphasis on the use of health information technology and electronic health records and electronic medical records all of these things are important is way opportunities as we move forward the title for today’s training is also includes aligning for the future and that is intentional because we must take advantage to take advantage of these opportunities we must really start to think and act differently we must to begin to align our practices with the standards of other health care practices we must begin to start thinking of ourselves as specialty healthcare providers and we need to start thinking in terms of data elements rather than paper forms today does mark a paradigm shift the information that you hear today will challenge information that has been shared before related to documentation in the concept of medical necessity our goal today is to show you that federal and state laws do not create barriers but really do allow providers to have the flexibility to document services in a way that is different and to still have we all of the required elements it is reducing the administrative burden and allowing your staff to have more time to spend working with the clients that you serve at the same time still ensuring that we’re documenting the quality and the clinical content of the information that we’re providing before we go into the actual presentation I do want to take care of a couple housekeeping things restrooms if you haven’t found them they are alcohol out in the hallway down the hall and to your left we will not be taking a break during this presentation so please use those two restrooms at your convenience if you have a cell phone please put your cell phone on silence so that we are not interrupted by those we are video recording this presentation today so we will be doing that and part of that is because at the end of this training we will be putting together a DVD and each agency will be provided with a DVD that includes a copy of this presentation as well as all of the training materials and that will be to each odium age certified agency and board CEU certificates will be available at the end of today’s presentation at the registration desk if you are a psychologist and you want CEUs please make sure you have signed in at the registration table in your training packets on the left hand side you will find a copy of today’s agenda you will find the PowerPoint presentation as well as information about each of our speakers on the right hand side you will find several things that we reference today on including letters from the Ohio Department of Mental Health the CM the rules from Centers for Medicare and Medicaid Services or CMS that are the federal definitions for documentation as well as the rules from OD JFS and OD MH that are being talked about today for the structure of today’s event we will be doing up we will have a panel presentation from the state agencies that will be followed by a question-and-answer session during the question and answer sessions we will be bringing around microphones so that if you have questions we ask that you speak into the microphone also included in your packet you have note cards we will also another way to get your questions asked just to fill out the note card and we will collect them and as time permits we will ask the questions that are on the cards I will tell you in the training that we did in Akron last week we did not get through all of the written questions we will also be compiling a QA document that will be included or sent out as well so we have about 30 to 45 minutes that we have allowed for questions so we’ll do as many as we can during that time after we finish with that question-and-answer session we will have a panel presentation from three providers who participated in a pilot using this the new progress note rule that we’ll share with you some of the lessons that they’ve learned and the experiences is that they’ve had as they’ve changed some of their documentation practices [Music] with that before I introduced the panels I would like to Stanton director Stevenson wanted to make sure that would that everyone and all the this is the fifth site that we’ve done had an opportunity to hear a message from her and she really wanted to be with us and she is physically with us today and I’m sure she’s going to love watching the video of herself but I do want to share her welcome message with you waiting’s I’m Sandi Stevenson director of the Ohio Department of Mental Health I want to welcome you to documentation and medical necessity aligning for the future I truly regret I can’t be with you because this issue has been near and dear to me for many years in Ohio and across the country behavioral health documentation has differed greatly from the general medical field all of you are aware of how much time you spend with your consumers here equally and perhaps more aware of the time you spend with paper when I joined the department and talked to staff we agreed to come together to look at regulatory reduction particularly in the area of documentation we’re very pleased today to be joining with all of you to discuss the culmination of that work and what we consider to be rational documentation regulatory reduction there should be several outputs from this work that you will notice immediately should you choose to implement this new opportunity one as you provide services to consumers you should gain efficiencies with regard to the actual documentation that is required and you should simply have more time to spend with the people you are serving in addition we all know today how much paper goes into our client medical records and we know if you are a physician a nurse a CPS T staff member a social worker or a counselor and you need critical information from that file how very difficult it can be to find that information with the documentation product that we have created the rules that support it it should be easier for any practitioner to go more quickly into any client record whether it be electronic or paper and find specific information that is critical regarding that patient or client of consumers care it is also important to note that as we move along with the new environment of health care reform and we look at the issue in the future of health information exchange that the process that we are putting in place today will allow if not encourage providers to participate much more successfully in the new world of exchanging information you will see that much of the documentation we’re suggesting is driven by pulldown list check boxes if you will information in the future can be more easily packaged in order to travel electronically to inform other providers of the care that you are your consumer I hope you enjoy the day today I hope you were excited about the opportunity this affords you your provider organization but most importantly the consumers you sir thank you in addition to her welcome director Stevenson wanted me to extend her sincere appreciation to the agencies that participated in the pilot project that was done when we when we were testing the what we were talking about or thinking about around the new progress note rule so with that I would like to welcome and thank our panelists from the state agencies for their participation first you will hear from Dan Arnold dan is with OD JFS from the office of ohio health plans which is otherwise known as the Medicaid office he will be followed by Janelle Pecha know who is with OD MH she is chief of standards development and administrative rules Janelle will be followed by Terry Jones who is also with OD MH the office of Medicaid as the Compliance Manager Dan good morning my role in the presentation session today is to give you a little general overview about the Medicaid program and also to tell you a little bit about the technical work that went into revising the oh six documentation rules and each FS is our role in that first a little bit about the Medicaid program as you’re aware it is a health care program is jointly funded by both state and the federal government with federal government picking up the majority share of the cost in Ohio the federal share is about 63 percent but currently with some enhanced funding that’s available the federal government’s picked up about 74% of the cost of course the states in Ohio using various means to make up the rest of that the Medicaid program provides an opportunity for individuals who may not have the ability of healthcare services otherwise to get those services and there are many eligibility groups and categories of consumers that can take part of that for most parts they’re low-income and it’s some of the groups are children pregnant women families and then some elderly individuals as well there’s many categories and caveats and restrictions on that but it is a fairly wide group of individuals that can participate in the program for those states that participate in the Medicaid program the federal government requires that certain medical services be provided and those are stated and listed and individual states don’t have any up options about where to provide those are not they are required to do so however each state can have an optional list of services that it which it wishes to provide and oh how has a pretty thorough list and as part of that optional list behavioral health service is that that you provide and are interested in are part of the of the optional list suppose the administration of the Medicaid program the states are able to measure the program the federal government gives them a pre wide latitude about how they may do that the federal level administration that’s responsible for doing that is CMS as the Centers for Medicare and Medicaid Services and they work with each of the states in various ways the CMS provides some of the rules and regulations that states have to follow they also provide technical assistance for states and setting up their programs administering their programs so they can they can provide those services and assistance the states whenever they request that also any changes that the for the most part that states would want to make in their Medicaid program has to receive approval from CMS each state is required to have a state-level agency that’s going to administer the Medicaid program and that’s called the single state agency it’s actually a formal term that’s used in a hope in Ohio that’s odj FS Department John family services and the way we do that is to have a very large document that all the categories of services the eligibility groups that can participate and the services that are going to be rendered in Ohio and that doctrine is called the state plan and Theresa was talking about them a little bit about paper earlier and the state plan has lots of paper in it was still on the paper format several binders and very large and anytime we make changes in that as I mentioned earlier we have to get CMS approval to do so first compliance in the Medicaid program there are several sources of rules and regulations as I mentioned CMS has some that they develop at the federal level and then also within Ohio and other states there are rules and regulations in Ohio we have the Ohio Revised Code that sets statutes that are going to govern the Medicaid program and then built on that are the rules the Ohio Revised Code rules that actually operationalize both the federal and the ORAC rules and regulations and hopefully the the OAC rules are a little more user-friendly for you as providers and stakeholders to have a better understanding about what you need to do on your day to day operation they’re carrying out your various services as your where Medicaid providers in Ohio are required to abide by both federal and state rules and regulations and that includes the OAC rules so we certain courage you to be familiar with the OAC rules and if you ever have any questions about those what you need to do is certainly feel free to to contact me or someone within ODM age and we can certainly help clarify for you now a little bit about the work that went into revising the O six documentation rule basically there were three sources of information that providers and other stakeholders are interested in when it comes to documentation requirements in a medicaid programs basically for behavioral health services and these are the Medicaid state handbook for two to one paragraph D and then an OD JFS administered rule which is 5101 327 zero to paragraph G and then of course the documentation rule suit that you’re familiar with 51:22 2706 that was recently revised now in developing the the revisions on the O six documentation rule what we wanted to make sure was that we captured all the both federal and state documentation rules and regulations and make sure when the o six rule was revised that there wasn’t any kind of conflict between these three sources of documentation requirements so LD j FS worked really closely with tho DM age to come up with a new rule and the way that we did that on the odj FS side was to come up with some legal language actually our legal office developed that we could put into a no DJ FS rule and that was the Oh DJ message role and developing and revising the O six rule our legal office developed the language and we wanted to actually put it in the three 2702 rule and that would kind of make sense because that’s the rule that currently has the documentation requirements as they applied for Medicaid providers however we weren’t able to do that because the o2 rule is currently under a temporary restraining order and of course you’re not prove allow us to make any kind of changes in him to rule so we had to look for another venue to be able to do that and so in consultation with our legal office we found another rule of 5101 320 705 that mean of you would be familiar with it as well and it makes sense to use this rule because it had to do with mental health services and it also had to do with reimbursement so it seemed too good vehicle for us to be able to insert the new language that we need to put in there to provide compatibility with the revisions in the old six real and little paragraph view that you see there is the language that our legal office came up with that was put into the old five rule and what might seem a little technical there basically what it’s saying is that you as providers and stakeholders when you satisfy the requirements that are in the O six rule then you will be in effect fulfilling the requirements that are in the O 2 rule paragraph G so you can rest assure that the the O six rule is capturing everything that’s in the paragraph G of the o2 rule as well as the federal requirements as well so the the O six rule can be sort of your one-stop source for us looking for your documentation requirements and really a quick overview over Medicaid and what we did I’m the only six rule there’s my contact information as I said if you ever have any questions on Jabez rule please feel free to contact me and I think we’ll have a little time a little later on we’ll would be taking some questions with some other well well thank you very much [Music] good morning everybody we want to thank everybody for coming it’s a beautiful morning I’m gonna do my presentation from to handout so obviously the PowerPoint everybody probably has that pulled out but on the right-hand side of your packet there is also a document I think it’s toward the back and it’s an says five one to two 2706 intent and explanation so basically it’s the rule each paragraph of the rule with some additional information that and so you’ll you can use that to sort of follow along or take notes while you’re looking for that I want to talk a little bit about the the process to this they’ve been over a year and a half ago several of us at the department we got an email from director Stevenson tasking us with looking at the progress no rule and finding ways to reduce the regulatory requirements and to move toward using checklist for documentation we did some internal work at the department consulted with CMS the accrediting bodies other relevant areas of the rule and then we took this outside its but in providers for trade representatives and I really do want to thank the pilot agencies when you participate in a pilot project a lot of times you get to do something different when you’re one of the pilot agencies well these agencies when they were doing their documentation because they still had to bill under the old rule they had to write to progress notes for every service session so they had to write the original one to support the billing they had to write a second one they had to do analysis you know here a lot more information from the from the panel representatives but we really do appreciate the time and the effort that those organizations made and helping us get to the rule that we developed today so let me tell you a little bit about that document the intent and explanation how many people are really excited about this new rule a lot of people and see some hands up and okay so it’s it’s a gift that we give to you but we’re going to we’re going to demand I’m going to demand because you know I’m the one up here on video tape demanding as a state official we’re going to ask demand forget about the old rule and during my presentation I’m going to talk a little bit there’s some slides up there it’ll say previous requirements please don’t make that the only things that you remember from the day it really is the previous requirements it’s been hard for some people to accept I mean we were asked at one of the trainings when the questions was is this true can we utilize checklist and yes it is it is true we also know and Terry will talk about his presentation oral tradition and sort of how things develop and over time and this is what you’re taught and this is what you’re learning and a lot of times we don’t even know why we’re doing something it’s just what we were taught and along with that a lot of times myths develop who’s asked at one of the trainings and documenting a progress note is it okay to use personal pronouns and that was probably one of the trickiest questions and for me to try to figure out what’s this about and when you think back and I used to document this way this writer and the client with blah blah blah we were taught you can’t use I it’s against the rules the department doesn’t allow it I assure you there’s there’s no rule we don’t address that in our regulatory requirements so really the reason for this intent and explanation document is to debunk the future myths that are going to develop about this rule it’s going to come you know there’s an audit whether it’s a board it’s a survey or whether it’s your clinical director at the agency so that’s something that people can always look back and reference to see what is okay what is allowed what might not be okay as we has been talked about we do anticipate less writing with this rule there might be times when long narrative is important that’s okay that’s it should always be based upon clinical need not a regulatory requirements of flexibility and another big area of reduction that we’ll go into more detail is that the option to do a daily note rather than a note for each service contact so I’m going to start with paragraph a and agency shall document progress or lack of progress the last line documentation of progress may be done through use of checklist and/or brief narrative flexible individual clinician agency gets to determine that and you can utilize both one of the important things also to know is it doesn’t have to be the same once a clinician sees a client and writes uses a checklist it doesn’t mean the next time they can’t utilize the narrative you can go back and forth I think agency protocol is going to determine it again it’s the individual judgment we know when we did the pilot we asked agencies to redact the agency name and client names and they sent us some of the pilot examples and I can tell you that for the most part it was the licensed individuals who had the hardest time being briefed so I know that’s kind of shocking but we see it and they were writing there they were writing in the margins they wrote on the back they were I think we’re writing on their arms but as you also know you can write a page and not say anything you can write two sentences and just tell the most wonderful story it might be times that long narrative is is important it we don’t want to limit we don’t want to prohibit but we want to allow the flexibility based upon the agency need previous requirements narrative description clinical observations description of the response both in ours and then JFS had their their requirements to some of it which mirrored ours they use the term behavior in response paragraph B is each individual staff providing services shall document progress or lack of progress each day that a service is provided I do want to point out it might seem obvious the requirement to document progress is not new when we sent the rule out for draft the draft roll from public comment there were a few people that felt this was a great new regulatory burden somehow the department was adding a significant new requirement I’m not sure how those people read the rule in what they thought was different but the expectation of just to document progress that concept is the same in this rule as it was in the previous rule and remember that previous rule is the one I asked you to forget about so hopefully it’s going what previously roll documentation has to be completed in the old rule for each service contact and the new rule each individual person shall document progress or lack each day that a service is provided so yes you if you have to see PST contacts to counseling if you have three are uniformed service where that’s most likely to occur you can do that in one daily note rather than a note after each contact okay the exception to that is the provision of group services when it’s a minimum of one staff person completes the progress note documentation agencies have some again some different protocols for group notes sometimes one person writes them on behalf of all the people if there’s more than one person providing group services one time sometimes one person writes everybody cosines I would suggest that people also reference their accrediting body requirements when multiple contacts like that are provided the staff may complete one progress note rather than for service contact so a little bit about rural writing may versus shall a lot of times the majority of times and rules you do see the terms shall shall or must that’s a mandatory requirement it’s something that has to be done may or should it’s a discretionary action one that the agency or the provider may or may not take it’s they can use their own discretion in doing that so when we’re talking about a daily progress note again it’s something that you can do in the same way checklist or narrative the flexibilities up to the person you can also go back and forth maybe you know you see the client and the sium two times and you write a daily note and three days later there’s three phone calls and or in-service contacts for CP St you write a daily note and the following week there’s something in a session that was so significant you want to write just one individual note you’re going to sort of document the other contacts in that day in their own note that’s perfectly that’s certainly permissible again it’s up to you and there’s no once you make you not make a commitment always going to do a daily note can never deviate from that or the same way that you’re always going to do it per session it is each individual staff person so if two people provide CPS tea to the same client in the same day then each person much must write his or her own note so you cannot write you cannot write one note to cover two individual sessions provided by two different providers again when the same staff person provides more than one service so if you have a person who provides a counseling service and they provide a CPS tea service all in the same day then they must complete two separate notes so again one note per service per staff per day the two paragraphs you talk about the documentation requirements it’s the date of the service contact the timing day in duration of each service contact and the location of each service contact and for c2 and c3 those elements when you’re writing a daily note that covers more than one session those elements must be documented for each contact if you want a example to look at if you look at Greater Cincinnati behavioral health there see PST note that’s on the right hand side of your packet you’ll see toward the top they have I think three or four lines and you can see I think it’s started start time and time and then there’s some modifiers and location codes and you can see where that is done for each contact you cannot if you provide a Co point from 11 to 11:30 in the morning and then from 12:15 to 1 o’clock you cannot combine all those times and make it in just one hour and 15 minutes you must document those two separate times and for duration it may seem obvious but we do get these questions over time and some sometimes when you talk about debunking those myths that you can do it start time end time or you can put start time twelve o’clock p.m. and that it was a 45-minute session both both ways get to the information that’s required see for documentation shall include a description of the services rendered and I would reference you back to paragraph a it can be done through checklist and/or brief documentation this is where I’m going to start talking about diagnostic assessment ISP and progress node and you’ll hear me talk about that a few times for the rest of my presentation you’ll hear Terry talk about it through his presentation that really is the key to understanding this node and understanding that the documentation and what needs to be put on a progress note so I don’t want to sound redundant about it but documentation should flow somebody can look at and be able to pick up the record and read these and understand what is going on conversely your progress note in and of itself doesn’t have to support everything the progress note doesn’t need to repeat the information that’s in the diagnostic assessment it doesn’t need to repeat the goals and objectives that are on the treatment plan it just needs to be reflective of those documents c-5 whether or not the intervention is specifically authorized by the service plan that was developed based on a mental health assessment this is probably the element that has brought up the most questions it would be if I asked you to go back and read the whole intent and explanation document twice it’s probably a good idea to read this session section three times but it’s really not as complicated as it seems in the in the outline there that I give you I try to give some different examples of ways that you would accomplishment this element documentation of this element is really going to reflect back to c4 so for example if you’re utilizing a narrative and that’s how you choose to document your session and it’s a route well-written narrative that might meet that that might meet that intended for an example you have a client who maybe is diagnosed with an anxiety disorder and that’s one of the goals on the treatment plans and objectives is to reduce the clients anxiety and in your and your narrative where you describe the service interventions you might have been describing utilize some relaxation therapy and guided imagery to assist the client but clearly the link is there it’s shown it’s a short statement you would have met the intent of that standard if you’re utilizing some checklist you’re probably going to need to go a little bit farther and this is one of the areas that the department when we looked at the regulatory reduction unless information for when people do need to either come back will get either do some audits or when staff are documenting we want the staff to think is this is this based upon the treatment plan is it based upon the diagnostic assessment sort of to ask each staff person ask him or herself that question when they’re doing if it’s not it might be every once in a while there are those sessions where something happens and it it’s just that you know maybe the client was driving a session in a way that’s not reflective but that was a one-time isolated incident or it might indicate it’s time to look at the treatment plan maybe update the treatment plan and add a new goal or objective sometimes you might meet this in your documentation by doing what I call sort of a yes/no prompt question and that might just be repeating that statement of c-5 and I try to give back but I don’t think I can do that properly I’m going to go forward here so to the yes/no prompt question you might say is the intervention specifically authorized by the ISP that’s based upon the diagnostic assessment and in essence you’re just repeating that element of c-5 and it would be yes or no some people you can again it’s not a requirement some agencies that indicated they like the term medically necessary so they might have on that a yes/no prompt statement that says is the intervention medically necessary based upon an ISP that was done developed based upon a mental health assessment again you would answer yes no and and it’s that simple to do that some might have client specific checklists I think this is more likely to be perhaps the wave of the future and electronic records but when you look at those checklists going back to the options on c4 that somebody could put what are the interventions that were provided if they’re individualized to a client they’re not generic to the agency but may be based upon diagnostic assessment treatment plan you’ve developed some client individualized checklist that may also meet this element back of so c4 and c5 and understanding how this gets to some of the regulatory reduction if you look back at slide I think it’s 16 that talks about the previous requirements JFS rule you know behavior and response so you have a diagnostic assessment it’s been it’s it’s done the client came in very sort of difficult to engage client they’ve stated a commitment to participating in treatment but they’re not very verbal unwilling to talk about their childhood sexual abuse so on your diagnostic assessment so you develop some treatment plan goals about that for the client being able to engage in treatment also be able to discuss their childhood sexual abuse the client comes in difficult to engage but they come back the first session the third session the seventh 11th in the old rule you’d probably be writing child was difficult to engage answer it one or two word answers to open-ended questions got more information from yes/no so you would like that at each progress note same information nothing’s really changed but the old rule you’d have to be writing that down each time and the new rule we have that information you don’t have to do that you don’t have to document any of that you’re not be documenting you’re going to put your intervention but you’re not repeating yourself client difficult to engage answered one or two questions each time until maybe something changes and that’s the point where you’re going to be putting some more information in your documentation oh goody Oh let me I know I skipped apart well figure out how to go back there’s that exception to that where farm management and crisis intervention in the mental health assessment rule 501 to 220 904 it states that a mental health assessment has to be completed prior to the initiation of any mental health service and it gives the two exceptions in farm management as the least restrictive alternative prior to completing an assessment or crisis intervention when that’s not listed on the treatment plan so in those cases when you’re documenting or meeting this c5 element you would be putting the presenting problem and that’s just part of good clinical documentation it’s not something that really needs to be you know regulatory requirement and you would be putting the information when you meet the elements of documentation either the crisis intervention rule you’re documenting according to those standards or the farm management you should as long as you’re documenting appropriately meet this requirement of c5 presenting problem develop a plan and you know here’s the client agree agreed to it and it should just solve within that that note meet that c5 now go up to c6 the assessment of the clients progress or lack of progress and a brief description of progress made if any again this can be so sort of yes/no and then when the client has made progress we then want you to give that description of it you can do that by further utilizing checklist if that’s what your electronic record system or your record system supports or you would just give a brief description of it going back to the client who’s difficult to engage but comes every session and not willing to talk about their their childhood have used and so up till now you know we’re at the 15th session you’ve just been documenting your interventions that you provided but this comes up and the client comes in and kind of starts talking and pours everything out this is the time to write that down and some progress has been made so you cook you’ve checked yes and you’ve given some additional information that’s perfectly it’s not a diagnostic assessment of per se but it’s assessing updating the assessment and the functioning of the client c7 is significant changes or events in the life of the client if applicable if applicable means that that information has to be documented if it’s true if it’s present you don’t have to document anything if it’s not there the c6 always has to be documented c7 only if something’s occurred significant changes or events in the life of a client those are things that are important and maybe the focus of treatment during that session or in the future that’s sort of your guide you know what are significant events it is individualized there’s no magic list that the department’s going to post of these are all the significant changes and if that occurs it has to be written down if you have a client who comes in and the client says I got in a fight with my brother last night this client is always fighting with their brother that’s sort of their relationship that’s how they work it’s really kind of no big thing you wouldn’t write it down another client comes in and says I got in a fight with my brother last night this client their brother is their only support system it’s very unusual you’ve never heard of them having a fight you’re going to explore this what happened how’s a relationship were they able to mend it where’s it out right now and this might be a significant event that you would write down people need to utilize clinical judgment and yes I put it in writing on that intent and explanation common sense so sometimes it seems that common sense and regulatory requirements don’t always go hand-in-hand but we really want people to utilize that I think continuity of care the next person coming in picking up the clinical record and reading it are they going to understand what is going on and I can assure you when we talked with the accrediting bodies about our movement toward this new new rule that was one of the concerns expressed they just wanted to make sure continuity of care needs are met and the information is documented in the clinical record see a recommendation for modification to the ISP if applicable again if it’s not there you don’t need to write anything if there is a recommendation indicated and why it does not mean that there has to then be a modification to the ISP it means somebody needs to look at that again in accordance with the agency protocol this might be a situation where you have an independently lysed clinician providing the service that’s the only service that they’re getting from the agency they can discuss it with the client maybe make that modification to the ISP do it all in that session in other cases it might trigger trigger an agency just a clinical staffing or review we just want somebody to look at again it doesn’t mean there does have to be an update see 9 is the signature and credentials or initials of the provider of the service and the date of the signature so again to remind everybody in 5.2 to 29 30 of the administrative code it’s the new service matrix that we put forth last July first we also try to reemphasize in the wording of that rule when you sign your name you must always include your credentials and they do need to be the credentials either spelled out qualified mental health specialists or the abbreviations that we identify in the matrix q MHS for qualified mental health specialists if you want to utilize initials you can do that what you would do then is have in the clinical record I would write Janel and Pekka no lis WS and then I would have my initials that and that would be a signature sheet that needs to be copied and put in each client’s records so that we have that information and then I could just sign my name on utilizing my initials if I want to do that we did check with the accrediting bodies on that that is acceptable to them when you read the carved standards for example when they talk about signing progress notes they do have a notation that signature or initials are not acceptable but they did say in our conversation with a signature sheet located in the chart that is fine they just don’t want to see initials without any reference back to those initials certainly if you’re utilizing electronic record system you have to be in compliance with our security of clinical record systems rule that also references the Revised Code 2706 D documentation may included notation there is no change in the clients risk of harm to self or others or if there is a change the results of a review the clients ideation intent plan access and previous attempts again remember slide 20 may vs. shall you don’t have to do this this is something that the department felt was very important reflective of good clinical practice there were some concerns expressed by many of these the agencies in terms of how this is documented and where it’s documented and in the protocols so in the sphere to compromise we went with may it’s not something that ever has to be there I think agencies generally do a good job documenting this information anyway you do have to be mindful of what’s frequently referred to as the duty to warn or duty to protect it might be this might be information you put in a progress note it might be that you have a separate form you might have a protocol a staff person that depending upon their licensure credentials if they see if they have a concern they just put a little bit of this documentation and then they refer the client to be seen by somebody else within the agency or perhaps a crisis screening agency outside of the agency providing the service the accrediting bodies one of the big questions we talked with them at the beginning throughout they all have received a copy of the final rule and I’ve discussed set up a session to discuss it basically no concerns noted again continuity of care I think when you go back to checklist and/or a brief narrative there’s no requirement for this I think what you’re going to see is over time over the course of treatment for an individual client it’s probably a combination of both to get it the information the significant information that needs to be documented again it’s documenting based upon clinical need not regulatory requirements I also want to give you the so quick update and many of you may have heard this by now the department is not going to be updating the so quick forms based upon the new progress note rule or in the future the current forms they remain on our website agencies can make modifications to them if they’d like to when you go to the so quick website and you download a form if you download the form it is locked that the website also includes the instructions for how to unlock it so if you want to add the prompt like significant changes or events if you want to put that in the recommendation for modification to the ISP you can do that and then you can read lock it because you know what happens you send unprotected documents to your staff they make changes even though you have a policy this is the form nobody changes that we want everybody documenting the same way but if you’d like to do that you may do so at some point they will come off the website that is that’s not any time soon we’re not anticipating it we are getting together the official communication from the department that will go out and that will explain that further however when so quick was envisioned we weren’t anywhere near where we are today with electronic records the and as they talked about sort of transporting information back and forth among different service providers and so quick you know with what we can do with it isn’t really supportive of that initiative the last thing is we will also have some examples ourself from the department so when you check back because all of these the documents are going to be posted to our website and we’ll also have some examples of our own progress notes that will be there so now I want to you know introduce Terry Jones good morning everyone Thank You Janelle a couple of things that I wanted to begin with first and foremost thank you all for coming I think this is important information and certainly when you leave today you will leave with the ability to go back and document less and not worry about that the second piece and this is something that came up in the five other trainings the one question that we had repeatedly was did CMS approve of this and as Dan indicated in his opening CMS is the federal agency that regulates all states and we talked with CMS throughout this process and they were encouraging us to move forward so when you operationalize this back in your agencies you don’t have to worry about CMS coming into the state and taking back dollars as relates to our checklist format because the rumor was that other states that had utilized a checklist had huge paybacks and the reason for those cheats paybacks was not because of the checklist it was because they didn’t meet their own state plan requirements so and we’re safe and I think this is on video so the other point that I want to make is I’m not going to address any particular County on this videotape presentation all right this is where the fun begins okay Medicaid and clinical documentation in Ohio Medicaid funds behavioral healthcare services through the psychiatric rehab option and again many staff aren’t aware that our services are funded through an optional Medicaid service known as the psychiatric rehab option and again Medicaid is broad it’s very complex it has 30 or so mandatory requirements that must be met in Ohio we fund our health care services our behavioral health care services through a psychiatric rehab option and I think that’s important for staff to understand as it is important for staff to understand the concept of medical necessity that will talk about the MRO or the rehab option pays for services rather than programs and the last bullet are the six covered services that are currently reimbursed through Medicaid in Ohio we have services are defined in federal law at 42 CFR 441 30 because again we have to speak this way because we work for the state and I figured you guys would appreciate this since my predecessors talked in in code I need to repeat the code so it’s 42 CFR 440 point one three zero and what I want you to pay particular attention to is the restoration of the individual to the best possible functional level that’s what we are attempting to do through the rehab option is to restore the individual to the best possible functional level prior to the onset of the mental illness that is the whole concept behind rehab services providers bill for rehab services on a client by client basis the amount that a provider can bill is based on the clients assess needs as outlined in a mental health assessment treatment plan and the actual services that are that are delivered and the rehab option provides very clear guidance for delivering billing and documenting services services must be related to a mental health diagnosis that is identified in a mental health assessment with goals and objectives specified on an individualized service plan and again as we referred earlier services must be medically necessary you’re probably questioning yourself what is medical necessity segue this is the federal definition for medical necessity pay particular attention to the rehabilitative notion it’s provided for the symptoms diagnosis and treatment of a particular disease or condition and again when we diagnose someone with a mental health issue that then meets medical necessity for services to begin it doesn’t necessarily mean that all services that are then delivered are medically necessary and one of the questions that we always have to ask is why does it take a mental health professional to deliver the service this is odj fesses medicaid rule for medical necessity as you can see it’s very long and it also talks about at the end of the paragraph medically necessary services are defined as services that are necessary for the diagnosis or treatment of disease illness or injury and without which the patient can be expected to suffer prolonged increased or new morbidity impairment of function dysfunction of a body organ or part or significant pain and discomfort so if we withdraw our services will this happen it’s a question that we have to ask ourselves especially for those clients that we are seeing on our recovery teams or those we refer to as in a maintenance stage of treatment so again ask yourself the question if you withdraw these services what is going to happen to that individual a medically necessary service must need generally accepted standards of medical practice are you going to deliver the same service or a similar service at another agency that that client is receiving an agency B must be appropriate to the illness or injury for which it is performed as to the type of service and the expected outcome it must be appropriate to the intensity of service and the level of setting for example if you’re providing a community-based level of care is your level of care more restrictive than if that person was hospitalized are you seeing that individual more than they would be seen on an inpatient basis again it has to be appropriate to the level of care and the intensity and level of setting and provide unique essential and appropriate information when used for diagnostic purposes this is one of my favorites federal government it must be the lowest cost alternative that effectively addresses and treats the medical problem and six it must meet general principles regarding reimbursement from Medicaid coverage services found in rule five 101 : 3-1 – OH – of the Administrative Code you’re asking yourself medical necessity where does it begin well it begins with your agency at your point of intake and it begins with a qualified professional that is an eligible provider of that service and they can assess that individual in terms of what their needs are the assessment is both clinical and functional you drive a clinical formulation which is the support for the diagnosis and as we all know there must be a diagnosis in order for us to bill it also determines the level of care and we all know that it orders treatment so from the assessment we develop a treatment plan that becomes your order for treatment keep in mind scope of license issues and we’ve addressed this in the other trainings you’ll never believe how many phone calls I get from agencies that start the conversation with Terry you’ll never believe what happened as well try me because maybe I haven’t heard this one we had an LPC see that was delivering diagnostic assessment services and they allowed their license to lapse so for the last year we have build mental health assessment and as we build that with an ineligible provider what do we do and then the dreaded words payback so make sure that your staff are fully licensed and credentialed you must have an appropriately qualified clinician delivering clinically appropriate services and interventions delivered at the appropriate intensity and duration what this refers to as an individual is progressing through treatment and that person is well into their recovery are you delivering the same services at the same intensity and duration as you did previously or as that person recovers are you starting to titrate the services for example someone who’s been in service for five years or more and they are doing well are they receiving the same services that someone that is new to your agency and as a treatment plan reflect that again all of this is directed by an individualized treatment plan designed to improve functioning and symptoms or prevent their worsening which we talked about earlier as part of the medical necessity piece it’s based on assessed needs and an approved diagnosis documentation is required by all payers not just Medicaid and again the reference Ohio Administrative Code here all Medicaid providers required to keep such records as are necessary to establish medical necessity and to fully disclose the basis for the type extent and level of the services provided again your documentation is just simply reflecting in your progress the interventions that are being provided as Janelle indicated earlier they do not have to stand alone okay that’s where we talk about the golden threat I also like the fact that Jamaal woven debunk because she said that she was going to put that as part of her presentation and she used it twice today debunking documentation focuses on the interventions delivered to meet the goals and objectives and the consumers progress towards meeting those goals and objectives this is where the paradigm begins to shift and again for those of you who’ve been around long enough your number of Robert Wood Johnson and remember all the dollars that flowed in and basically the message was do whatever it takes it was from cradle to grave and we provided everything we move people out of the state hospitals we moved them into the community we took him shopping we took him to McDonald’s and we billed for all of it okay those times have changed and so now our service focus is on teaching not providing it’s on cueing reminding training and overcoming barriers medical necessity is based on functional criteria this is this is my own issue and that’s why it’s in red community psychotic sportive treatment is not case management okay see PST is one of the six covered services it is a direct clinical service case management has a very different definition federally and it is not a direct clinical service it is a referral it is a linkage it is a nation of care so when you write into your medical record that you’re delivering case management I really aren’t you’re delivering CPS tea because again that’s what medicaid reimburses us for in all situations the ultimate goal is to reduce the scope duration intensity of medical care to the least intrusive level possible which sustains health in other words is to put ourselves out of business to then move on to the next client who needs our service and again part of the recovery model is to move individuals from a dependent status to an independent status and the Medicaid goal is to deliver and pay for clinically appropriate Medicaid covered services that would contribute to the treatment goals within the rules the Medicaid rehab option encourages a focus on recovery and consumer centered services the consumers goals and needs will drive the priorities within the treatment plan consumers will be reviewing their services and their progress towards goals with providers on a regular basis the consumer must participate and work towards measurable goals with the right amount of provider support which means that the consumer needs to be a part of their treatment plan and I’ve worked in community mental health and I’ve had my staff come to me and say Terry the consumer said just write down whatever it is that you want and I will sign it and so they did but again keep in mind that this is the consumers treatment plan and as we engage the consumer hopefully they will become more committed to the development of their treatment plan and again signature does not necessitate that the client has been involved it just means that the client is signed [Music] rules that are incorporated into medical necessity for payment purposes consumer must be able to be an active participant in their treatment thus they must contribute to their treatment process the consumer must have the sufficient cognitive ability to benefit from the treatment now one of the questions that we got before was if we’re serving someone who has a dual disorder both mental health issues and MRDD issues are you going to say that they don’t have the sufficient cognitive ability to benefit and the answer is not we’re depending on your clinical judgment and we’re also depending on your clinical review to determine whether or not this individual is benefitting from your treatment and if they’re not benefiting are you looking at the treatment and are you changing the treatment to amend whatever needs to happen to address that treatment issue but again it’s your clinical opinion as to whether or not that individual is benefiting from the treatment the documentation must be clear about the consumers participation in treatment besides being present during the intervention what else occurred evidence that the plan has been developed with the active participation of the count at the client and progress notes must document the services that were provided and as Janelle indicated that can be a narrative or it can be in checklist format staff must empower the client toward goal completion we all must believe in recovery our clients do get better and again you know they may not get better within a day within a week and thus clot response to intervention and it was one of my favorite on the old requirements because I can’t tell you the number of times that I read client thanked me that was the clients response to intervention I got to know this as stop tapping on desk okay Michelle oh wow good good well role of community support this is the definition of CP s T this is what CP St provides and again pay particular attention to the restoration and what this says is restoring him or herself to the best possible functional level with the greatest degree of life quality enhancement self-efficacy and recovery resiliency illness self-management and symptom reduction possible again we’re moving those individuals that we provide care to to a dependent status to an independent status because our clients do get better and they don’t need as much support from us CP st requirements for billing a billable unit of service may include either face-to-face telephone contact or in the future video conferencing because currently as Dan had referenced earlier this morning with our CPS T rule and with the adjoining OD GFS role the coverage and limitation rule it’s currently involved in a federal lawsuit so even though video conferencing is in our CPS T rule you can deliver it you just can’t bill for it and we’re hoping that one day soon we’ll be able to bill for that well currently and cannot bill for CPS t visa V video conferencing it’s between the mental health professional and the client or an individual essential to the mental health treatment of the clients such as and again that’s where the client tells you who is essential in their life who is essential in their treatment and who do they want to be involved in their care the golden thread everyone’s heard about the golden thread it begins with a mental health assessment the mental health assessment determines and justifies the diagnosis it identifies the symptoms it identified where the consumers personal goals are what stressors strength skills and functional deficits the individuals facing it also establishes baselines so that we know and the client knows when they’re getting better [Music] it also justifies the type and in the intensity of services it also prioritizes areas of needs and recommended service the golden thread begins where the service plan goes the service plan objectives the interventions and the progress notes and we’ll talk about all four of these the service plan goals address the needs identified in the mental health assessment the objectives or measurable changes in the consumer behavior or symptoms that are steps to meeting the specified goals the interventions of the services or the modalities plus intensity appropriate to accomplish the objective and lastly the progress notes they’re tied to the ISP goals and objectives they describe the intervention that’s specified in the service plan they also describe the progress towards the specified goals and objectives and recommendations for modifications to the ISP as Janelle indicated earlier if applicable [Music] the documentation linkage should be viewed as a reflection of the golden thread not the golden thread itself the golden thread is the real connection between the assessed consumer needs strengths preferences and personal goals and the individual service plan and services provided the clinical needs are identified through the mental health assessment the clinical needs are transferred to the consumers individualized service plan and progress towards goals are reported than consumers progress notes we had referenced a paradigm shift and this is part of that paradigm shift we were not taught to document and bill in a medicaid environment we were taught to provide services by following what supervisors and colleagues modeled for us supervisors must know and teach the requirements associated with the Medicaid rehabilitation option as well as know and teach the clinical skills themselves it’s important to know and again we don’t have o6 any longer no.6 was a Medicaid compliance review we now have a utilization review through OD JFS through surveillance and utilization review and what they do is data mining and they look at outliers so again every year as a mental health provider you would prepare yourself for your Medicaid compliance review and three weeks before the review we would all scurry about tool records check them make sure that we signed them again if we did that throughout the year and if we instituted a a utilization management program within our agencies or a peer review process we wouldn’t have to worry about this and if we learn the skills of how to bill in a Medicaid environment we’re going to be safe from all audits too often we are accustomed to doing for and not teaching skills and move someone from dependence to independence if we change the way we are interacting to reflective teaching modality documentation of services have has never been easier but not without a major ideological shift in our approach to service delivery where do our agencies tell us that CPS T is and again earlier in our presentation we referred to CPS T as a direct clinical service the other point that I’ve always addressed in training is ask yourself as a mental health professional why are you providing the service is it medically necessary when I jug that my oldest daughter is now driving and has been driving for the last two years and sometimes I have her transport me places and as you know in Ohio transportation is not billable through Medicaid it’s the direct clinical intervention that you’re providing and sometimes she does provide a direct clinical intervention to me while she’s transporting me but I just don’t bill it to Medicaid so again what do our agencies tell us that CPS T is and what is it really traditional approaches to community mental health emphasized to anything the client needs you to do or do whatever is necessary for the client and we’re shifting from that which is inherently in calm in conflict with current regulatory requirements associated with Medicaid as a funder compared with block grants and other grant funding to serve this population it’s also in conflict with recovery model today’s supervisors and program directors are often teaching from a platform that is outdated and is not reflective of current regulatory and fiscal parameters also known as oral tradition because when we got into this field we learn some lessons that may not have been correct and we kind of mirrored what our supervisors told us and we also copied what our predecessors put in the record and we just drafted it forward and so what we’re suggesting is something very different let’s provide services based on client need let’s understand what our clients need and then let’s deliver those services and that’s it I think we’ve got us back on time look at that thank you I hope you don’t hurt some things that are different today I hope that they’ve heard some things that are exciting about some of the changes and I am a hundred percent sure that there are a lot of questions because the information presented today is drastically different than what you’ve heard in the past it really is creating a lot of flexibility in terms of how we document it’s allowing you the ability to utilize more effectively electronic records if you have them or if you’re looking at using them and it also is shifting the way we think about medical necessity from looking at the totality of the record rather than saying in every single note I have to justify every component of medical necessity so with that what we do want to do is open it up for questions we’ll be bringing microphones around because we are audio recording this this presentation today so if you do would like to ask a question we would ask that you speak into the microphone we are also have the note cards so if you would prefer to write your question down we will be having people to come around through the aisles to collect those cards and we will try to get through as many of those questions here today to get answers to them and like I said if we run out of time for the question-and-answer session we will be putting together a written frequently asked questions document I have a court-ordered client and custodial mother refuses to sign ISP I sent it to her attorney and have documented in my notes every week I have called the attorney asking what the status is this is a Medicaid child any suggestions I think you’re doing to be doing in terms of documenting your efforts to obtain parental signature it’s the attorney involved the Guardian over the mother the Guardian the mother as long as your document your efforts to obtain parental signature you satisfy the requirements of the rule my question is a round level of care issues you referenced in your presentation that the mental health assessment is to make recommendations for a level of care and I’m wondering if there is a process underway to operationalize that and I asked because my County is developing a level of care protocol system for non medicaid services and at some point they’re anticipating that they may need to merge that to a parallel system being developed at OD mhm well we are currently looking at statewide is not only levels of care but also consistent definitions as it comes as it pertains to SP mi s md sed and then corresponding service packages and we have a state committee that is comprised of both constituency groups OD made staff stakeholders that is working on that that process so stay tuned oh my Christian County hi Mike hi these all kind of bitty questions but they’re all related effective date habilitative and lastly and it’s not lastly balance just do stick with three on page twenty two you indicate that in the golden thread the client’s needs are identified through a mental health assessment and what if the client identifies thanks because you really emphasized client driven but if the client identifies things that they want to include in their treatment plan that you don’t aren’t in sync with your assessment of their mental health and in correspondence with that and again it’s their treatment plan if they want to include things in there then I encourage them to do so and when you said effective date is the effective date of the rule again one of the one of the caveats that CMS has not been clear on Mike is the whole issue of children and services delivered to children because again a lot of the services that are delivered under the psychiatric rehab option with kids can be construed as we as rehabilitative and can be construed as habilitative because again with habilitative services we’re teaching new skills and depending on where that individual is developmentally they may not have ever learned those skills so CMS has not been clear as it relates to kids and the whole issue of the billet ativ services that are delivered to kids versus rehabilitative services so am i within my realm of authority to say I’m going to stop paying for those and I’ll let you guys decide that and then I’ll if you decide against me I’ll pay them well I would have to confer with our legal staff on that one Mike well just for the record that’s what I want to do okay the rule went into effect February 15 I want to thank you first for the new progress note rule we love it and I want to ask if if you foresee the possibility of eliminating the treatment plan as we know it and including treatment planning on progress notes like we do in primary care if that’s the movement that we’re going to you know these don’t you in your primary care notes you’re writing the chief complaint for the day and this is the plan between now and our next visit is that something the department is looking at if the department currently is looking at the integration of behavioral health care as well as what is happening on a federal level and a lot remains unknown but again what we’re trying to do is simplify and reduce administrative burden whoever we wherever possible so again stay tuned because we’re not sure what we’re gonna be moving on next but again it makes sense to integrate services and to become as simple as as possible because one of the areas that I think have led to a lot of burnout with staff is the fact that behavioral health care especially with Medicaid has required so much more and most people became very distraught in our system because they’re here to deliver services and what they were finding is that they were spending much more time documenting the service than they were delivering the service so what we’re hoping is a process to where we’re going to simplify that and reduce that administrative burden to then be able to have providers deliver service so again that’s something that we will certainly look at at the department the definition of rehab services as you showed on the screen seems to integrate physical and mental health care it does and that’s based on the medical model okay it talks about the maximum reduction of physical or mental disability and restoration blah blah blah so 4c PST where do we draw the line I’m assuming if we use that model of rehab services a CPS tea worker could queue remind assist and teach a client that had physical problems with those physical problems if those physical problems impacted their mental health status which since they are closely aligned physical and mental seems like that that they could do that and bill for that is that a correct they could do that as long as those physical symptoms were impacting on their psychiatric symptomatic and again that is part of CPS too and again it’s part of the teaching so that that individual can then do that for themselves I work for a treatment foster care agency where we provide CPS TN counseling but we also provide just strictly case management so for instance following up on medical appointments and things like that that are required through the foster care system recently we were told that we need to separate our progress notes so that for instance if we’re providing CPS T in one visit but then also just doing some case management though we’d have to do two separate progress notes one for the CPS T and one for the case management and I don’t know if this would be a question for you Terry or him but it would medicate objects to having a side progress note about strictly case management or is that something that you think should be separated in a chart who is telling you to have separate notes and who are you billing for the case management piece we don’t bill anybody for the case management that’s strictly for foster care OD gfs standards and that kind of a thing well I’m going to defer to my colleague at OD JFS for that one okay you know I might have to actually go back because I don’t know enough about the specifics to address the specific concern like that so maybe maybe actually we could talk just a little bit more and a little bit till I may have to confer it back with some others to see before I give you a specific recommendation way or the other because I had seen where you know if a provider is providing two separate billable services like a case management or I’m sorry CPS tea and counseling but you would have to do two separate notes about that but I just wondered if that is also the case if one of the services isn’t billable so okay thank you well we’re in our role we obviously speak to the requirements for our certified services I know what some agencies have on their on their template that they use for their documentation as a place to put sort of billable time where they think I referred people as one example the Greater Cincinnati notes you have to start time and stop time and some create a way or format within the note itself to straight out that information so that you’re not billing for something that clearly isn’t billable I just have a comment about that question and it’s very similar to what Janelle you just said as far as for e-type reimbursable services and stuff that the county pays for in foster care it’s just very clear at how we document what time the billable service ends and then at the bottom of that note we just I’ve done an indentation of following this billable service these following issues were addressed and so it’s not in the billable time but you can see that we spent further doing some items so because it was all in the same timeframe I just had a question about how to document the start and end time let’s say you did a CPS tea service and provider from 9 to 9:30 and then later in the day that same provider provided a CPS tea service to the same client from 12:00 to 12:30 and then maybe again from 4:00 to 4:30 and our electronic record does not allow us to enter multiple start and end times for one entry so that would have to be a separate entry and what I’m wondering is is they on that time from 9:00 to 9:30 if you did your note that was inclusive of the day but then you had to do separate a separate actual billing entry could you reference back to the 9:00 to 9:30 note and basically just say in your narrative part see note with start time at 9:00 a.m. you need to have the ability to start and end time for each contact and you also need to have the location tied in to each start and end time and and I guess that’s what I’m saying is that there would be a separate sort of billing entry that had those things but in in terms of actually doing the checklist all the checklist sort of the note portion the progress note portion would just be on the one I guess I’m just trying to think of a way that we can incorporate the new rule of only doing one note for multiple contacts with our current with our electronic record system where there is no ability to do multiple start and end times fix you know I think now I get it yeah that would be fine I think as long as the information is there so yeah as I understand it now you’ve got 9:00 to 9:30 you put all the coding and then you just sort of handwriting narrative also so quiet from a lot 11:30 at the clients home and saw them from 4:00 to 4:30 at the client’s office so it’s kind of written within the body of the note that’s what you were those sort of except I’m saying we’re gonna have to actually for billing purposes we’d actually have to enter that as a separate time so there’s going to be something in the chart that also shows this 12:00 to 12:30 that’s and that’s where we’d write in the narrative to reference back to that nine am note and then yeah it’s like as I understand it it’s fine because you’re just you’re documenting the information and then your billing people will know how to enter the billing okay in those same lines we are in the same situation that she is we have an electronic record and you can just do one time and start time stop time so could we total all of our duration together eighty minutes and then in the narrative have the different times that we were with the client and then the start time to stop time and where they were what have have you been able to talk to your vendors about making changes to the system yes that we cannot afford the changes that yes so that’s uh and we do recognize I mean one of the questions while we were working on this role and having it you know go forward was sometimes sort of the cost of that and certainly if people you know continue to document usually you know the format’s there’s a couple of new elements like significant changes or events in the life of the client those are accrediting body requirements anyway so we so we did recognize that and this doesn’t require a change to that it certainly makes it easier if you can if you can do that all I can say is it then it needs to be clear of start and stop time and location so how that is done if if you need for billing purposes to have it but then have a way that it just separated out on the note but you just need to make sure that you you would have a policy about that that staff are trained that they’re following that and and that would be perhaps a concern but you might develop I think I said just well you’re not developing a template because you have that but as long as it’s clear in the documentation for each note that’s not a problem so we don’t want to make it again sort of flexible and how you show that so we don’t want the relief that this offers you know to conflict with sort of the reality your systems until the time you can get it changed and a quick question about this paradigm shift in thinking here – have been that you should be able to differentiate a time at the session like a 30 minute CPS tea to a 90 minute CPS tea it sounds like if we move to this checkbox system even in your narratives those notes will look relatively similar with different times is that correct that’s correct you might have liked on a checkbox system when the department gets their examples finished and posted you’ll see check all that apply so it might be two types of interventions three types of interventions again you know it’s combined if you’re documenting you know I think is it if you saw a client twice in a day does it really matter that the whatever significant you felt that you might do some narrative does it really matter that it happened during the 11 to 11:30 session or was it during the 1 to 2 session just making sure that the information that needs to be documented as documented is what’s key probably for charity then if I have four six minute CPSC interventions have I now met criteria for billable time or does each individual one have to meet the criteria and thank you for saying that once for Terry I said probably that a bit of service is eight minutes okay now without an access system we also know that it Sonny rounds that again a billable unit of service is eight minutes in duration so the being able to bill for all the service or do a note for all the services in a day does not equal being able to tally the minutes for that I think we’re talking about a billable note and what happens at the end of the day when those services are summoned and round because at the end of the day you get paid for 24 minutes but in order for those services to be billed it has to be eight minutes in duration to understand the distinction the system is going to bowl the four notes all right so the end of the day you’re going to get paid for 24 minutes and again that’s a disconnect between what is supposed to be billed and what exists does at the end of the day right and what exists does at the end of day is at summon rounds but the rule is it has to be eight minutes in duration so I thought and other questions if not I will start reading a few the first one 42 CFR 440 point 1 3 0 therefore habilitation is not billable is that true or false again the question is is rehabilitation versus habilitation the question that you have to ask yourself and a question that is not clarified by CMS as it relates to children and again is it a habilitative service that has been built through the psychiatric rehab option if the individual has never gained those skills the question that you have to ask yourself is where is that person developmentally and what are you providing that’s clinically appropriate for that child it’s a whole different ballgame with adults but with kids it’s less clear and CMS has not registered an opinion well put that opinion in writing and we’re still waiting for that for an utterly home-based class or refer clients that may have dementia how will this meet the rehabilitation model again with dementia you have to ask yourself does the person have the sufficient cognitive ability to be able to benefit from the service and if you can’t demonstrate that the person is benefiting from that treatment then I would not bill for it another question for you Terry can you explain the difference between CP ST and case management and since the comment was made that CPS T is not case management that case management is linkage and referral and not billable does this mean CPS T linkage and referral is now not billable let me answer the last piece first CPS T is available and a component of CPS T is linkage and referral the difference that I tried to expound in the presentation is that case management has a very different federal definition than CPS T and case management is not a direct clinical service whereas CPS T is a direct clinical service and again our rule there are ten activities that can be delivered visa BC PST that are available which include coordination linkage and referral but the difference is C PST is a direct clinical service and is one of the six covered Medicaid Services in Ohio Darrin lies the difference the question was do case notes need to specifically state which goal the therapist and client we’re working on for example therapist and client addressed goal one and used relaxation techniques to address anxiety issues the answer is no next question does everyone billing for services have to be on the ISP for example what if supervisor not on the ISP basically steps in for the regular clinician and provides a service is this billable that’s fine I have a follow-up question to that in terms of system-wide if you have more than one agency and more than one provider working with a client can you speak about integrated ISPs and what what the guidance would be on that more than one provider within the agency at the system-wide so two different agencies working with the same client on behalf of the client where each agency would need to have their own ISP for the client the day you know starting back with a diagnostic assessment you wouldn’t have to repeat it but there is a requirement that if if an agency gets an assessment that’s completed by somebody else that they review it so they would still want to be looking at it clinically each would develop an ISP certainly they can be sharing the information if you have the appropriate release of information that this is hopefully a coordinated coordination of care and not duplicate of care does that answer the question yeah in the past I believe the mandate was that you work together and try to develop one ISP even if it was across providers for that particular client I mean you could you could have the same ISP but are both agencies working on the same goals the same service working on the same goals is everything what what’s different I guess that would be my question what’s different about what the two agencies are each individually bringing to the table on behalf of the client I think probably the prime example would be medication management from a mental health center and more CPS tea home based services from an outreach an agency that does outreach both working on behalf of the client and it’s it’s fine if we can both have our ISPs and I think in the past it was a little cumbersome to try to develop one ISP across agencies because what I’m hearing you you have the two different services there so I would expect to see some some you know differences but again hopefully the agencies to work together on that but you know when it comes one of the things I’ll talk about is what is the rule and there’s no rule that says when two separate agencies work with the same client they must have the exact same ISP nor is there rule that says that there must be a completely different ISP so what you want to try to do is have your coordination to the benefit of the client and not duplicate services how best that is met really it’s flexible and up to the agencies involved I had a question about diagnostic assessments oftentimes we I work with children and oftentimes they would have had perhaps two or three in the duration of one year relative to where they’ve been placed in part of their different treatment plans is very cap on how many diagnostic assessments mental health assessments that you can build for within one year I know physicals for children there’s a cap on you will only pay I think it’s one a year and again what I would have you references a mental health assessment role that if there is a change in the clinical status or in the level of care certainly a diagnostic assessment can be updated however Medicaid does not have a limit on the number mental health assessments that it will reimburse an agency for within a year Medicare does and that is one every three years okay thank you you’re welcome next question is assessing screening for metabolic disorders which may be the result of psychotropic medication available as pharmacological management in the clinical documentation you have to be able to reflect how this is addressing the psychiatric symptom because again there is mainstream Medicaid that pays for physical healthcare and I recognize the federal reform and moving towards integration of care but also recognized that our pot of dollars is much more limited so again if it is affecting or having direct contributions to the mental health symptoms all the documentation reflects that then that’s something that you can bill for regarding the CPS T case management differentiation how does the square with the CoA they don’t recognize CPS t they accredit us as providing case management the department has a deem status crosswalk which identifies based upon what services that you’re certified for by the department which services or programs you have to be accredited in by your accrediting organization in that regard we look at the activities that comprise the different services not really the name is there a limit to the number of persons one staff clinician can have in a group no good at this overlapping services with multiple services multiple fires how do we build so that we do not overlap for services for example CPS tea from 9:00 to 9:45 pharmacological management from 946 to 10:15 and NC pasty from 10:30 to 11:30 how does this get billed if I if I understand it I mean you’re documenting each document in each session I’m going to presume it’s the same provider I think I heard to see PST sessions in that day on one farm management so you have a CPS tea note did a daily note and it shows the times from I think with 9:00 to 9:30 and 11:00 to 11:30 again differentiate you have on that note somehow the two different times in the location code and then the front management but that information good as I if I understand it correctly that information should go to whoever does your billing at your agency in the same way you would do now with two separate progress notes for it for the CPS tea and one note for the farm management and you’ve clearly showed that the times are not overlapping can you do one note for two different service codes for example CPS tea and individual counseling if provided by the same person yeah it has to be if the same person who provides two different services in the same day than it has to be two separate notes is there a limit to the amount of time you can have on a log for example our current form there’s a 100 minute limit per note no this email intervention of billable cpsc PST service if a copy of the email is required or placed in the progress note now can you build Medicaid for a provisional diagnosis and if so where is the rule you can use a provisional diagnosis and again what is important is that you’re assessing that individual and that you’re clarifying what the diagnosis is and as you engage that individual and gain more information then you should have an accurate diagnosis because again I can’t take the number of records that we’ve looked at where there is five or six different diagnoses and any record and they’re not provisional and again there may be a different diagnosis that’s described by the psychiatrist dennah from the C PST done from the clinician so again what’s important is that the treatment team gets together and arrives at one singular diagnosis can we get some clarification on the staff to client ratio in groups there is not one that’s prescribed in the role when you clarify on the development of the is P is it five sessions or 30 days whichever is more and what would you write on a progress note under the new world before an ISP is developed Thank You Gaius P as to be developed within five sessions or 30 days whichever comes last and you would document that the the same way that you’re documenting now I mean you know I would ask what are you doing within that within that note or within that session and what information needs to be written down I assume part of those sessions are working on in discussing the ISP and document the information that needs to be included there’s no there’s sort of no magic answer to it again I’ll go back to clinical you know documenting based upon clinical need if I’m utilizing a signature or signature sheet does the signature have to be the same as on state state licensure for example if the middle name is written out on the license does it have to also be written out on my signature that’s the first time for that question so now what is the state’s policy on electronic signatures we reference within our Administrative Code rule we reference the revised revised code it’s the section is under the Department of Health and I don’t know it off the top of my head it’s certainly with electronic records and signatures you have to meet those security requirements of access and I think they say it’s like a you can utilize a signature by a computer-generated pen a unique combination of letters and numbers that is unique to the individual provider in the intent and explanation documentation for that section of the rule the progress note rule I do give the revised the Revised Code section so you can look that up or you can email me and I can send you the link if we utilize the so quick format in our current electronic record system will we be able to continue to use this format and meet the requirements of this change yeah I would I would make sure and remind staff to clued in significant changes or events in the life of the client when you look at some of the different notes the cpsc or counseling a lot of them have they don’t use that terminology and that’s one of the things as you know to get away from looking at terminology and what’s the intent of the standard and even in looking at those so quick notes you’ll see things you know important updates on a progress I don’t have a copy of them in front of me so I think if that information is there that’s what’s key and recommendation for modification to the ISP you know a couple of agencies said there’s a they’re just going to add a little checkbox I think in the section that talks about there’s some checkboxes for diagnostic assessment update and they thought they were going to add a checkbox there for themselves and I thought in a similar vein do I understand that they will no longer be a so quick progress note and that agencies are free to develop their own well agencies have always been free to develop their own so so quick was never a mandatory requirement we’re just accept not going to continue to update it based upon this rule change and and there are there are other rule changes that we’re looking at and we hopefully now have some now that we’ve got this one finished some more time to also offer some regulatory relief to agencies John I mentioned one note per service per day per staff per day is this regardless of the modifier yes and I’m gonna wrap this up because we do want to get to our provider panel and I do still have a stack of questions so please know that we are doing a frequently asked question if your question did not get specifically addressed we will be including that in our in our frequently asked questions document never need to indicate if transportation was provided in the note and if so must you indicate the specific intervention in the drive miss Terry talked about during his presentation you know transportation is not an intervention it’s not the intervention that goes back to do you need a mental health person to provide that service and no you don’t need to have a mental health person provide transportation the rule requires that you document the interventions so if why you’re transporting the person there is other and mental health services being delivered during part of that time then certainly that’s the intervention that you would be documenting there is no requirement in and of itself that transportation is listed on your progress note and I think – this is an artifact of six reviews then we were told don’t the transportation and they became very clever about using technology such as access to community resources compliance reviews okay to just include the invention that you’re billing for as a part of that note it doesn’t matter whether or not you put transportation in a note with that I do want to move into kind of the next part of this session which is to actually give you the opportunity to hear some from some provider organizations that have already begun to implement this process and change their way that they document based on the flexibility that’s allowed in this rule the three providers have all participated in the pilot process and they’re here today to just share with you kind of the less that they’ve learned and the experiences that they’ve had and to share with you the examples you do have copies of their progress notes that they are currently using in your packets on the right-hand side towards the very back they have included them in the PowerPoint presentation they are very hard to read on the overhead so you might want to go ahead and pull those out for references and with that I’d like to introduce our three presenters first you will hear from Michael Kaufman he has the clinical director for Appleseed community mental health center he will be followed by Amy Fletcher who is the QA director and compliance officer for Greater Cincinnati behavioral health and she will be followed by Lee Johnson he was the director of risk management for wingspan Care Group and with that I’d like to welcome Michael I would like to thank Daniel Arnold from Ohio jobs and Family Services Janelle Pagano and Terry Jones from OD MH and Theresa my fall from the Ohio Council I’m a relatively new clinical director at Appleseed just past my two-year anniversary in April but I consider myself fortunate to be considered in this project likewise I’m grateful that you allowed me to learn a little bit of what you do of speaking to the panel itself over here am i right the experience of talking with Terry Jones and Teresa and lambo in particular has helped me to see in part the necessary work they do in struggling with rules regulations and mandates I’ve learned much from this panel over the past a few months and I have seen your passion for the field of counseling and more specifically your belief in reducing documentation Lowe’s for the people that do the grunt work in the trenches so thank you very much likewise also thanks to Lee Johnson and Amy Fletcher for processing the past few seminars with me I appreciate your dialogue in the next 15 minutes I’m going to share with you what our experience has been like in implementing this rule to our internal processes at Appleseed you will note our forms in your packet or at work of progress as is our process in reorganizing ourselves to assimilate and accommodate this move and not so new information a proceed is a small rural community mental health center located in what is considered Northeast Ohio Appleseed is about 70 miles north of Columbus and is located in Ashland Ohio we started out in 1991 way back in 1991 with two psychologists to see teas counselor trainees I was one of those three csps now if you can remember CSP you’re dating yourself two secretaries and one part-time psychiatrist we have now a staff of over 60 employees and we serve a population base of about 55,000 in Ashland County for all of Ashland County now that might be small potatoes in comparison to some of the larger agencies represented here today but like I’ve told people before we like to think of ourselves as a little giant when it comes to offering the services that we have for a small agency the bar and clinical excellence is set high as you can see the number of services and the type of services that we provide you can refer to the PowerPoint handout regarding our services the progress note project we became interested in the project in early 2009 as we finish a sixth month project retooling our ISP we work real hard for six months researching and talking with Terry Jones about what it means to produce a really good ISP we’re not changing up for nothing that was an arduous process and we’re proud that we’ve got something that we think is going to help us into the future and also help us with the new progress note role we also participated in the brief project with the CPS team note project with OD MH and this gave me an opportunity to personally express an interest in understanding and making documentation more meaningful to the clinician to the members of that committee while waiting to hear about the upcoming project those of us on the ISP project decided to formulate a committee and dedicated our work to looking at efficiencies within the agency there are four to six of us on that committee and we are on the OCD side and we make up that group we’re lovingly known as the tweakers now for this group of people the project note project seemed like the next logical step I notified Dana Harlow of our interest who then notified Teresa lamb Paul from the Ohio Council and that’s how we became involved because the note was new we’ll want it to be at the forefront of learning about these changes so that we can ready ourselves to understand and adapt quickly to new mandates and be prepared for those awful audits to come we don’t know what’s happening so we want to be prepared we want to be ready I think that we’re ready or becoming so so the reaction I got to tell you about the reaction as we understood this rule we created the forms you see and they are in your packet some of those are still in process and then we took a few councilors in case excuse me CPS tea workers and when a pilot for a couple of weeks like many of you we discovered that we interpreted the old rule in a distorted way when we obtained the correct understanding of the old rule with the paradigm of the new rule we had some very unusual experiences so much so that I could describe it to you being clinically oriented in four distinct stages that occurs with such frequency that I’ve come up with a name for the phenomena DSS documentation shock syndrome I’ve even thought about a whole approach to this DD T is the approach which stands for don’t do that followed by an intervention TBF the TBF approaches to before and we’re still in the midst of evaluating that but the first phase I got to share with you the first phase was confusion there’s a slow recognition that something had changed among the clinicians you might experience that yourself this is not right that’s not how it was done we’re used to making bricks without straw you don’t understand we used to document everything now you’re telling us to be brief and focus on progress or lack thereof and tie the documentation to the treatment plan what do you mean be brief when are we to make of this and then the second phase this is the shortest live phase by the way so you’ll see it and then you won’t see it euphoria a lifting of effect an intermittent relief but no one wants to admit or talk about it because this feeling in the work setting is somewhat uncomfortable so back to mistrust the third phase we must go back to our old religion that God’s will not be pleased if we do not offer the sacrifice of verbage in our documentation and then the fourth phase which I consider the hardest phase slow acceptance acknowledgment that this is real this is a little freeing the clinicians admit that they still lack the skill of knowing what and how to document in this new way because before they documented everything there covered the proverbial rear in the back door there you get the picture the slow acceptance is now leading to the acknowledgment of change of the second order long term and significant change and clinically that’s the kind of change that you want first order change you attempt to rectify a problem by looking at the solution and and the first order change almost never works it’s the definition of an definition of insanity doing the same thing over and over and over and expecting something different to happen it just doesn’t work as for sort of change second-order change is where the change is long-term and sustainable in our pilot we recognize the need to rethink how and why we document if we can understand the basis for good documentation and of course the rule supports this we can position ourselves to focus more clearly on treatment outcomes based on documentation that reflects progress not process such a difference progress towards clients goals wishes and preferences our biggest hurdle is learning how to be brief I teach a class on brief therapy and I tell my students you can be brief if you slow down if you do it slowly you can be brief so it means that we have to retool ourselves at the agency to slow down in our thinking to be brief and save ourselves some time and headaches in the future now I have to tell you that some of the clinicians are going back to documenting everything to justify time spent with the client simply because of habit and I have to admit the lack of accountability to move in a different direction so as an administrator I have to hold my people accountable to this new paradigm but old paradigms die hard we found the rule provides us with a format that is flexible enough to permit us to individualize our forms to suit our own needs we’re now concentrating on connecting treatment through the golden thread and we are emphasizing this with less paperwork demanded I believe we can discourage it or we can discourse in a more thoughtful manner of how we will take care of the client imagine that and while – well that will work especially paperwork significantly contributes to burnout decrease quality of care and affects productivity we’ve taken a look at our thorns they’re still in process remember we’re a small agency we are not electronic your electronic only in the sense that we have these forms on msword two thousand three and we’re operating on XP if that gives you any kind of idea of where we’re at a little bit behind the game on some of you other service providers but we have a chance to individualize our forms and the advantage of this is that we’re really not spending a lot of money at this time on software so in the two forms presented we wanted to provide the basics for what we felt we needed for the form under the rule and make it easy on the eyes there’s something to be said for face validity so we think not being electronic that we’ve provided a form that the clinicians can look at and and say oh okay that looks simple that looks easy to fill out rather than fainting when they see complex forms like we used to provide for our clinicians and of course you can’t see these up here the counseling notes you’ll see two supervisor signatures we’ve axed one of those supervisor signatures and put client signature as optional it still needs some discussion but basically tweaked for our own internal purposes for the so the format will not change much and on some of the notes that have provided the examples you’ll see that our clinicians and I think Janelle was right the licensed clinicians are having the hardest time that’s what we found out and you’ll see that they’re still process oriented so it’s going to take some time and some dedication now briefly anticipated efficiencies and changes that have been a result of this new rule some of those changes are happening now some of these efficiencies are happening now not all of them but these efficiencies our our our goals if we’re not meeting them then this is something that we want to strive to meet in the short future April 5th was our official start date using the new notes based on the rule to supplement the new notes in our ISP we have implemented an open forum every Tuesday at 8:30 to discuss treatment plan creation and progress note writing in those meetings we are emphasizing the use of the treatment plan more specifically in the part and also tying it to the progress note with the clients goal in mind so we’re really dovetailing treatment and we’re really having good dialogue about what it takes to honor the client in the documentation and also to reflect good quality care and it can be done I’m convinced too that our QA progress our process is also being redesigned to pick up those people who need to be recommended to that team meeting or that meeting sometimes maybe being mandated to come to that meeting because of the review of the charts so we’re changing the format of the QA process another shift in QA when we review charts we’re not looking to see if it is there just to cover medical necessity but we’re seeing if it’s connect if it’s connected if their progress is connected and if there is movement and in the short future if there’s no movement I’m going to want to know why we anticipated reduce time in completing documentation and that is now happening almost across the board you have some people getting it some people not getting it for those who have gotten it one of our supported employment is specialists I asked him how the documentation was going and he said he just looked at me and his jaw dropped and he said oh my and I thought oh my because I didn’t know what Arlen was was saying was as good or was this bad and he told me that the documentation cut his time in half with the normal time it took for him to fill out paperwork you’ve got some people who I checked on last week and the caseworker said you know I’m still struggling with it so reduce time and the clinicians also like the new rule in how to document so those are a few of the efficiencies and how does this position us then for the future well the rule helps us to be more aware of the relevance of the golden thread and also what I call the Goldilocks treatment not too much not too little but just the right amount of treatment we think that with clarity in the progress note the treatment is going to show in our outcomes in the documentation then we can utilize brief outcomes to measure not the best practice but the individual clinician we want to know or I want to know if that individual clinician is making a difference and that’s where we’re headed and I think the reduction in the paperwork demands is going to help us to do that they think the new rule in wrestling with this process has helped us to appreciate how documentation can truly honor the client and their hope in us to move them forward the record while being a legal document should also be a very brief reflection of that journey on behalf of Appleseed we want to thank ot MH OD JFS and the Ohio Council for hearing those who work in the trenches and do the grunt work of providing mental health treatment thanks for being responsive to our needs and thank you again for letting me personally ride the bus with you these past few months thank you hello everyone my name is Amy Fletcher I’m the Quality Assurance director and compliance officer for Greater Cincinnati behavioral health services also known as GCB I’m here today with my CEO Tony to tell Oh some of you know him he wrote up here with me I also would like to thank the Ohio Council and Teresa for pulling this training together and including us and just all their efforts to support agencies outside of this particular effort also and to OD mhm and odj FS for implementing these rules that will help us reduce administrative burdens so that we can spend more time doing what we do obviously from our title we’re located in Cincinnati not stretch there we are in Hamilton County or a large urban SMD provider we serve about 3,400 SMD adults were adult only agency and that is about 400 different individuals throughout the year we have eight or nine traditional case management teams sorry teri we still use that term we haven’t come up with a better name yet we have several act teams including some specialty act teams mental health court a forensic act I DDT team and we also have 13 psychiatrists on staff we have psychiatric nursing payee services we have counseling day programming vocational services the full array of different vocational services we have about a hundred and forty direct service staff 75% of our services are field based and our we primarily provide CPS tea and farm management services a current status of our electronic health record or electronic medical record is that we don’t have one we have things on paper we have an electronic document management system so we instead of trying to make our field based services fit into a facility based software which most of them in the behavioral health field we still do everything on paper and we scan it and and some they’re available electronic all of our paper images are available electronically now and we just started doing this in December and part of our plan is to start to automate the extraction of some of these data elements to be incorporated into a database and then available again and some electronic format either through reporting or back on to another form or that kind of thing so that’s that’s what we look like down in Cincinnati right now at GCB where we stand with this the progress note rule change is that we did participate in the OD MH pilot last year and we have not implemented the draft note that you’ll find in your packet that is a draft version we came together and and pulled that together pretty quickly that was our interpretation of the rule at the time but having gone through this training now five times I think I understand it a little bit better and we might be willing and able to incorporate even some more efficiencies into that draft note we’re hoping that we can roll this out so that our staff can begin benefiting from these efficiencies by no later than July 1st but our draft note as you’ll see in the packet is now one-sided we are CPSC progress note was two sides front and back it was twelve separate sections it was a lot of writing and that meant whether it’s an eighth service phone call or an eight-minute cell phone call service or two hours of of CPSC in the field so you had to do the same amount of documentation for all that we’re anticipating with the number of actions that you saw that that we have that we will really see some big savings in time through the hoops that people have to jump to jump through and write and filling out front and back for each of those services we’re estimating from that pilot and from some focus groups that we did run this draft through that we’re going to be able to shave anywhere from five to ten minutes off of each progress note and what that means for us at at JCB we we provide on a slow month twelve thousand see PST services on a busy month and that can be as high as 18 thousand see PST services so times that into front and back that’s that’s how many pages of writing our staff are doing so if we on the low end take twelve thousand notes a month and shave five minutes off that gives us a thousand hours of time that we’ll be saving in one month and again that’s a conservative estimate that’s not incorporating the the ability to put more than one service in in a day into one note which we don’t even know what that’s going to look like for us yet but it’s going to be big and we know that we’re minimally going to probably cut our time in half we are also excited about the checkbox format that will allow us to extract more data with our software that that I described earlier and and we’re real big saving for us and for me as a compliance officer is the the understanding that we will not have to document and each progress note the need for services so really our front and back pay to page progress note isn’t what I call a mini assessment right now so if we really can focus that on being just a progress note and not having to go through all of those mental hurdles that’s going to have a huge impact on on documentation time for it for us to and our staff our challenges we’re expecting is that this is going to require a huge amount of training as Michael said it’s just we have so many processes in place right now where we’re coaching staff back about things to include and how do you describe client response it’s not thank you for the services Terry mentioned earlier what does client response me what client response isn’t even there anymore we’ve got rid of that section so and the other piece that we have in our note that we got rid of is the functional impairment section which we called the mini assessment the why does this person need a mental health professional to for this service so that’s gone so people won’t have to go through that anymore and I think that that’s going to take a long time for people to really believe that because we spend so much time coaching staff on how to do that and and the struggle from the management level with this rule was yeah we’re we’re liking the less documentation but we’re still struggling with it you have to have enough in the right stuff to to provide the information that you need for care coordination liability issues and utilization management we’re anticipating some other changes because it’s just such a part of our culture we have progress note reviews we have peer reviews that are going to be impacted by this so we want to do a really formal pilot and be able to anticipate all those changes and be really progressive so that are with our staff so that we’re kind of addressing their concerns and getting their questions answered upfront before we even roll this new form out it is so much more than just a new form it’s really a new way of thinking about the way they do their job every day and we want to make sure that we’re supporting that in that so even though this is exciting we’re still going to be faced with our 75% field based services and we’re not anticipating a lot of benefit in that area for efficiencies related to our EHR the staff feedback that did participate in the pilot of this draft that you have in your packet was that we loved it can we start using it now and we’re like no hold on we got a lot more to do the next question is there going to be more space if I need it as I said we’re going to have to go through a lot of training and provide a lot of support to staff that they feel comfortable writing less all the staff and especially the supervisors felt that the it’s a much more much better flow and much more clear to read a summary of progress for one day versus all of these piecemeal notes front and back that may happen within an hour of each other and trying to go through each of those hoops for each specific intervention everybody’s looking forward to that and the the ability to roll multiple services into one day staff just can’t believe that it’s a reality one of the other questions that staff had a frequently it was when is an event significant and I think Janelle has put together a lot of really helpful information in the intent document that’s in your packet also that we’ll be able to use in our training of staff now and again here is that our sample note is in the packet but this is just an example of what our our first interpretation of the rule and you’ll see some of the things at the top how we we we only had enough room for three I I don’t think we have a lot of times where we’re doing more than three services in one day of any given type but that that’s what we built in for the the sample and that might be something that we change if we find out there are more if there’s a need for more than that but when I was talking about our scanning software that’s why we have those weird little comb shapes and things in there that’s for our data extraction but um this is what we’ve come up with right now I as I said I already expect there to be some changes as a result of going through these trainings but if you have any questions about how we came up with this feel free to contact me and again thanks to everybody for the opportunity to participate in this these events name is Lee Johnson I’m the director of risk management and a group in the Cleveland area I wanted to say thank you to the Ohio Council OD MH and OD JFS for allowing the wingspan affiliate agencies both Applewood and Belfair the opportunity to participate in the pilot and also in this series of trainings and also for taking the lead in moving the mental health community in this positive direction that will allow us that will allow the field the opportunity to improve crying access to care staff retention and morale and to align mental health with the rest of healthcare just to give you a sense of the line wingspan and the affiliate agencies are are the result of the affiliation of a couple of behavioral health care agencies with wingspan Applewood and both Applewood and Belfair have deep roots in the in the Cleveland area Apple is the result of a merger of three agencies Children’s Aid Society Child Guidance in the Jones home and you can see from the slide here along those agencies were have been around and Belfair was founded in 1868 as an orphanage for children orphaned in the Civil War wingspan is a nonprofit that was born out of Belfair and o2 and we affiliated with Apple wouldn’t no eight both Belfair and Apple would deliver services where kids were kids agencies children and families to over 18,000 children and families annually from nearly all 88 counties in Ohio and other states we have residential treatment we have foster care and adoption we do firm illogical management services school based services and pH services Belfair is dually certified in aod and mental health and both Bellefleur ample would each have school programs to facilitate education for children Belfair targets specifically children with autism and the gerson school at Applewood works with kids with mental health issues that prevent them from being able to achieve success in their traditional school settings and they both have independent and transitional living programs and homeless youth outreach programs as well alright so in terms of the rule we participated in the pilot and we implemented the CPS T note in March and very happy to report that the efficiency gain that we saw in the pilot we also saw that continued when we implemented the progress note of people reporting about a 50% reduction in the time it takes to document the service so that’s certainly the upside and then the related upsides with that in terms of the positive staff feedback people feeling very good about good about the change in terms of the staff we have to balance that with the potential challenges but we welcome those challenges and basically the way that we think about this rule change is that it’s taken the it’s it’s empowered us to be able to think clinically about how we document the services and decide how we want to create our rules and processes to most appropriately document the care that we deliver to clients instead of really just thinking about how to deal with the elements of rule of the rule and meeting the rule so the the challenges that we have to think about in terms of how far to go in terms of gaining efficiency would be the ability to clinically supervise staff because all of our staff are not independently licensed compliance oversight you know to ensure that people are appropriately delivering the documenting services and with that flexibility for creating check boxes given the rule that we provide you we see that risk management has more of a challenge of creating multiple templates before this rule we basically had one progress note that you could deliver any service on and now with with developing check backs as a basic they make special specialized documents for each service type will have more templates we welcome that challenge as well in terms of rolling out the new progress note especially with the CPS T note and just in general educating staff about the rule just as with my peers here who have also talked about the changes at their agency or the rolling it out at their respective agencies you know the yes you can yes you can use check boxes now at our agencies we had already begun the use of check boxes we had implemented a check box diagnostic assessment so it wasn’t we didn’t have quite as big a hurdle there but you know using check boxes more thoroughly and completely throughout the documentation was welcomed and yes you can write more than one content on a note that certainly went over well with staff who deliver CPS T services and other programs in which there are multiple contacts in a day and yes you can refer to the mental health assessment and ISP to demonstrate medical necessity and that is you know we were very much trained and training in the justify the need for service and every note write to document and to prove that you spent the amount of time that you spent in the session and so those two pieces were very well received and you know we’re still trying to help staff understand that that really is true that you don’t have to you know write a page if you spent a lot of time with a client so write less generally the CPS t note implementation went over very well relatively easily and we I’ve given you example in the packet of the CPSU note and then we had a truck the trauma-focused behavioral counseling note we actually already had just how to tweak it with the rule change or we already using that with one specific program that we’re running in Lorain County and so we’re working on now the spice notes for the different counseling programs that we have and the different types of services that we have in terms of electronic record we have an almost complete electronic intake process the exception is some of our school-based services that that do not participate with the centralized intake because it doesn’t make sense for it to happen in that way they’re not as they’re not electronic but all of the other the residential in the foster care and some many of the other programs use electronic intake and we have a pilot happening right now on the Belfair side with an electronic isp and so this real change happened at a really nice time for us so that hopefully we can just continue to move forward as we work towards the achievement of that electronic record after I get into the notes I wanted some of the questions I was wanting to respond to that people asked just from you know an agency perspective in terms of documenting and you can see with our CPS T note we have client time and we have staff time on that note the staff time is the non billable time so that we can capture both on one nights note so that we as an agency have decided not to have staff write two notes for that but instead to capture the the non billable time with the staff time we also here’s that so that we can track how much it costed a little reservist because as we all know the cost is more than just the face-to-face you know intervention time with a client and then in terms of documenting the start and end times you know generally this this rule the the efficiency gained is supposed to be on the documentation and not necessarily on the billing or data entry and so even though you cannot do can document multiple service contacts on each note you still want at least from our perspective we still want to capture what time each of those interventions happen first of all to make sure that you don’t get I know in our billing system if there are two services delivered at the same time to a client that’s a red flag and then what services get kicked out for that so you don’t want to roll them all up you know at the beginning of the day because you might get into a conflict with double billing if other services happen that day and also you want to be able to have that pure documentation time so that you can you can avoid that and then in terms of the staff to client ratios and people were like what do you mean there’s no staff to client ratio you probably want to check with your accreditation requirements because they often have requirements on staff to client ratio so that might be where your agencies are coming from there in limiting that but going on to the CPS to you know I guess I think it’s pretty self-explanatory you’ve seen a couple of other examples we have three contacts on the CPS keynote this was the easiest note to do obviously because of the defined interventions that CPS T the prescribed interventions at CPS t has and so it was easiest to roll out first we do ask that people tie the intervention to the some of the activity that day because we see that that that justifies the golden thread so to speak and and the medical necessity we put the additional requirements and the new note to to document significant life changes or recommended modifications the ISP we put those at the end of the note so that you could you could document that there and I think that’s pretty much it in terms of that note and then the counseling note you can’t get the full benefit on it just with the printout with it with the hardcopy because there are drop-down boxes under each of those different intervention areas in addition to the check boxes at the bottom so staff have the ability to not have to document the whole
From 2010 regional trainings conducted by the Ohio Department of Mental Health & Addiction Services on the topic of Ohio Administrative Code rule 5122-27-06 Progress Notes, and Documentation and Medical Necessity.
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