4 Rs & 2 Ss for Strengthening Families: Effective and Efficient Documentation

Kara Dean-Assael, MSW Lydia Franco, LMSWNichol Moses, Psy.D., NCSP

Objective for Today

• Participants will understand concepts of writing a treatment plan and progress note for families attending the 4Rs & 2Ss for Strengthening Families program.

4Rs & 2Ss for Strengthening Families- An Overview for Documentation Development• The 4Rs and 2Ss (Rules, Relationships, Responsibilities, Respectful

Communication, Stress, Social Support) Program is a research informed treatment approach designed to improve parent-child interactions resulting in positive improvements in the child’s social behavior and the caregivers parenting behaviors.

• The program focuses on parts of family life that have been empirically linked to youth conduct difficulties.

• Program details:• A multiple family group format• Children with disruptive behavior disorders (ages 7-11) and their

families• Recommended group size = 6-8 families• Meets at least once a week for 16 weeks• 60 minute sessions• Co-facilitated (preferably a clinician and a parent advocate)

Identifying Strengths• Abilities, Talents, Competencies, Accomplishments• Values and Traditions• Interests, Hopes, Dreams, Aspirations and Motivation• Resources and Assets (ability to seek help)• Unique individual attributes (physical, psychological,

performance capacities, sense of humor)• Circumstances at home, school, work, or community that

have worked well in the past• Family members, relatives, friends, other “natural supports”

in the community• Cultural Influences• Previous successful experiences

Examples of Strengths- 4Rs & 2Ss

Tammy and her family are very close and enjoy spending time together.Tammy and her family recognize that they sometimes have difficulty communicating.Tammy enjoys reading and writing.Tammy does well in school.Tammy’s family is invested in improving their communication.

BarriersWhat is keeping the person from their goals?• Environment• Areas needed for skill development• Intrusive or burdensome symptoms• Lack of resources• Self defeating strategies/interests• Cultural factors• Threats to basic health and safety• Crisis or crisis is over• Feeling ‘unhelped’• Challenges/needs as a result of a mental/alcohol

and/or drug disorder

Examples of Barriers- 4Rs & 2Ss

Tammy’s parents were recently divorced.Tammy’s family does not have reliable transportation.Tammy’s mom does not feel that the family is linked to the community.

Goal for Individualized Planning:

Individual planning will become a manageable task for providers, a meaningful process for individuals and families receiving services, and a resource tool to ensure optimal outcomes, while satisfying the expectations and requirements for payers and oversight authorities.

A Child- and Family-Centered Approach to Service Planning• Collaborative process resulting in an

individualized, family-focused treatment plan• Directed by families and produced in partnership

with care providers • Supports family preferences and focuses on

strengths

Overall Treatment Planning Improvement

• “Golden thread” is carried throughout care and documentation

• Plans are child- and family-centered and individualized• Plans are developed collaboratively with the family and

their supports• Desired outcomes are written in the person’s words

(quotations)and goals are those outcomes transformed into clinical view

• Objectives are behavioral and measurable

Treatment Plan

• A treatment plan document, which is co-created by the child and family receiving services and the provider, outlines the steps needed to achieve a particular goal or outcome.• The plan is a key tool–NOT PAPERWORK. • A well-done plan is a source of motivation, recognition

for progress and cause for celebration. • It is not a document gathering dust in a chart, only to be

reviewed at the next required update. The plan is a living, up-to-date document that guides the everyday work that the provider and individual/family do together.

Writing a Plan

• Acquired skill / art form• Not often taught in professional training• Often viewed as administrative burden and paper

exercise• Requires flexibility

• Opportunity for creative thinking• Integrates information about person served• Derived from formulation and prioritization• Information transformed to understanding

TIPS for Treatment Planning Conversations

What do you want to see different in your life? What do you want as a result of services?

What is preventing you in accomplishing this goal tomorrow?

Have you had a time when things were going well?

How would you know that you were making progress toward accomplishing your goal?

What services/supports/resources are needed to help you accomplish these steps?

→This becomes the “desired outcome /goal”

→These become the “barriers”

→These become the “strengths”

→These become the “objectives”

→These become the “interventions”

Definition of Goal

The goal is:• a broad, general statement • that expresses the individual’s and family’s

desires for change and improvement in their lives• ideally captured in their own words.

Common Mistakes in Goal Development

• Goal doesn’t reflect person’s dreams/goals• Too many goals/too complicated• Not consistent with other provider

treatment goals

Examples of Goals

Tammy will communicate with her sister without being physically aggressive.

“I will reduce the number and intensity of anger episodes at home.”

Doug will communicate with his mom about his feelings without his aggression getting in the way.

Tommy will have a 50% reduction of negative behaviors.

Example of a Goal- 4Rs & 2SsDesired Outcomes/Goal :“I want everyone in my family to be happier.”TAMMY WILL DEMONSTRATE POSITIVE SOCIAL BEHAVIOR WITH FAMILY MEMBERS.

• Goal should address behavioral problems

ObjectivesObjectives are:• observable, measurable, changes• in the individual’s behavior, functioning, symptoms,

skills, and/or support level • that relate to achievement of the goal and • are expected to result from planned interventions.

• A maximum of two or three objectives per goal is recommended to create focus and reduce the chances of feeling overwhelmed.

How to Write an ObjectiveFormat 4Rs & 2Ss Example

Subject Tammy and her mother

Verb/Action Word will demonstrate

What respectful communication at home without yelling, cursing, or threatening

When will it be done/timeframe? upon plan review

How will it be measured? as evidenced by weekly child and family reports.

Examples of Objectives Tom will identify unhappy feelings.

Tammy and her mother will use respectful communication at home without yelling, cursing or threatening as evidence by weekly child and family reports within 16 weeks.

John will use his humor to improve relations with his family.

In the next 3 months, Sam will successfully use 3-4 identified coping strategies to express his feelings of anger, as reported by his mother.

Common Mistakes in Objective Development•Don’t support the goal•Not measurable or behavioral•Not time framed• Too many simultaneous objectives• Interventions become objectives

Objectives Are Not Interventions• Objectives are the WHAT

• What will we see different as a result of intervention/services/supports?• What is the next significant milestone?

• Interventions are the HOW

• How are we going to accomplish the objective?• Interventions are the action steps taken to

achieve the objective.

Examples of Objectives- 4Rs & 2Ss

There are 5 specific objectives that correlate with the 4Rs & 2Ss: Respectful Communication, Responsibilities, Relationships, Rules, and Stress/Support.

• 1: Tammy and her mother will use respectful communication at home without yelling, cursing or threatening as evidence by weekly child and family reports .

• 2: Tammy and her mother will report improved relationships with each other as evidenced by participating in at least one new family activity together outside of the group over the period of four months.

• 3: Tammy’s mother will establish and Tammy will follow at least 1 family rule over the period of four months as evidence by mother’s description of the rule and number of times Tammy complied.

• 4: Tammy and her mother will list and successfully follow roles and responsibilities (e.g., chores, school homework, curfews, dinner time activities, cleaning one’s room) as evidenced by verbal reports by Tammy and her mother on a monthly basis.

• 5: Tammy’s mother and Tammy will report less stress and more social support as evidenced by completion of three family outcome surveys included in the program manual.

The 5 Ws of Interventions• Who: Which member of the team or support system will provide it.

• What: Specifically, what service will be provided.

• When: How often, how much time and duration.

• Where: Identify the location of service delivery.

• Why: Identify the purpose of doing the actions. Link the intervention back to the desired outcome/goal.

Examples of Interventions

Tom will attend weekly 4Rs & 2Ss for Strengthening Families Group.

Susan & Greg, parent partner and therapist, will meet with Doug and his family once a week for 60 minutes for the next 16 weeks using the 4Rs & 2Ss for Strengthening Families curriculum, to focus on respectful communication.

John and his parents will spend 60 minutes each week doing a community activity to practice/improve communication strategies.

Sam will meet with a therapist each week and attend group.

Common Mistakes - Interventions

• Frequency, intensity, duration and purpose not documented•Method of intervention not included• Too few•Non-billable interventions are not

reflected/considered

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Example of Intervention- 4Rs & 2Ss

Susan & Greg, parent partner and therapist, will meet with Tammy and her family once a week for 60 minutes for the next 16 weeks, utilizing the 4Rs and 2Ss for Strengthening Families curriculum in a Multiple Family Group, to focus on family functioning.

Discharge Criteria

• Specific, reasonable and attainable

• Written in positive terms to address the individual’s goal

• Indicates what will be different for the individual and when the individual no longer needs this support

Examples of Discharge Criteria

Doug will be working towards his identified goal of making honor roll without his anger getting in the way for 2 consistent months.

John will have satisfactory relationships with family members.

Sam will remain living at home with his parents while proactively expressing his feelings of anger for a six month period of time.

Tom will have improved mood.

Discharge Criteria Example: 4Rs & 2Ss

Tammy and her mother will report reduced stress and increased social support in the family after 16 sessions of the 4Rs & 2Ss program.

Summary: Putting it all TogetherHave I…• Written the desired outcome in the person’s words and written the

goal from clinical view?• Reflected strengths and barriers that are associated with the goal?

Included natural supports in the plan?• Written objectives that reflect improvement and are observable

and measurable? • Written interventions that contain all 5 Ws?• Provided a copy of the plan to the individual/family?

Progress Notes• THE PROGRESS NOTE FOR EACH SESSION WILL RELATE TO THE

OBJECTIVE OF THE DAY.• Indicate what interventions are used and how they are working

towards achieving mutually agreed upon objectives/goal (as reflected in plan);

• Reflect strengths individual uses towards goal attainment and identifies barriers that interfere;

• Justify the frequency and intensity of services based on risk factors, mental status, symptoms, relevant history, perceived needs;

• Reflect the individual’s/family’s view on their progress;• Reflect changes/updates in the plan;• Include date, duration of visit, signature (and other agency-

specific requirements).

Common Mistakes - Progress Notes• Recording the actual dialogue • Recording detailed reports of what occurred in

the session• Writing the same note repeatedly• Not addressing medical necessity (interventions

utilized and their applicability to the presenting problem(s) & need for ongoing treatment)

Progress Note Breakdown

Attendance & Content:Therapist and co-facilitator (Parent Partner) met with Tammy, Tammy’s mom, and others for the 4 Rs and 2 Ss for Strengthening Families Group Session #4: “Problem-Solving Broken Rules”. The focus of today's session was on examining rules in more depth and utilizing tools to fix rules that are not working by addressing issues of clarity, consequences, rewards, and consistency. Tie it to the Plan:Effective communication was reinforced through the family 'tool box' activity which addresses Objective #1 in the Treatment Plan. Assessment and Progress:Tammy and her mother actively participated in today's session. Tammy’s mother reported some improved communication at home, but that Tammy still experiences great difficulty in expressing her anger without yelling or hitting others. Tammy reported that she found the session helpful and that it, “helped me see why mom has rules at home.” Plan for Future:Tammy and her mother will attend Session #5 next week to continue addressing their goals.

Resources• Adams, N. and Grieder, D. (2005) Treatment

Planning for Person-Centered Care. Elsevier Academic Press.• New York State Clinical Records Initiative

(NYSCRI)• www.omh.state.ny.us

Q & A

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