Revised 12/2009 1 Treatment Goals, Treatment Planning, and How to Write an Effective Treatment Plan

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Treatment Goals, Treatment Planning,and How to Write an Effective Treatment Plan

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What will you learn about Treatment Planning?

• How to prepare for treatment planning

• What treatment planning is and its purpose

• What the benefits are for treatment planning

• When treatment planning should occur

• Who should participate in treatment planning

• How to identify information needed for developing a well-written treatment plan

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Treatment Planning

Complies with rules for community-based behavioral health services: Texas Administrative Code, Chapter 412, Subchapter G; Texas Administrative Code, Chapter 419, Subchapter L;

and Texas Administrative Code, Chapter 448, Subchapter H.

Complies with Medicaid billing requirements, and prevents the facility from losing revenue.

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PreparationBefore writing a treatment plan speakwith the individual to:

Develop a relationship and gain trust.

Identify personal desires, goals and needs.

Identify functional needs.

Identify natural supports, and obtain the individual’s written permission to make contact with those natural supports.

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PreparationThe provider should keep treatment outcomes in mind to help the person, parents, family, Legally Authorized Representative (LAR), or other support systems identify the:

• nature of the problem

• options for intervention

• individual’s role in the treatment process

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What are the Purposes for Treatment Planning?

To engage the individual, parents, Legally Authorized Representative (LAR) and other natural supports in the treatment process

To establish a method for communication among the treatment team, individual, natural supports, advocates, and external reviewers.

To identify the presenting problem(s), symptomatology, and needs of the individual.

To identify treatment goals, objectives, interventions and strategies used to achieve a desired treatment outcome.

To document quality assurance efforts.

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What are the Benefits of Treatment Planning?

Provides a road map that guides the treatment process.

Forces critical thinking to develop methods and strategies for intervention.

Assists with ensuring accountability.

Assists in coordination of care with other healthcare professionals (e.g., primary care physicians), social workers, housing and employment counselors, etc.

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Treatment Planning vs. Writing a Treatment Plan?

Treatment Planning

Process that identifies

who, what, when, and how

treatment will be delivered

Treatment Plan

Written agreement that defines

who, what, when, and how

treatment outcomes will be achieved

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Writing the InitialTreatment Plan

The Treatment Plan includes a starting point or “baseline” measure prior to the onset of the treatment period. This will enable you

and the individual to know how far they have come (or how far they have gone astray) at

the end of the treatment period, thus producing a measurable outcome.

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What is included in a Treatment Plan?

“A Treatment Plan should provide all of the information necessary for a conscientious person to

deliver the correct treatment procedures, at the correct times, and with sufficient consistency to

produce the changes in behavior that are described in the Plan - reducing or eliminating undesirable

behavior and increasing or improving desired behavior, while providing a means to monitor progress on an ongoing basis that informs the

process of treatment.” Steven Kossor

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The Treatment Plan

Is developed in cooperation with the individual, parent, family, and other natural supports as appropriate

Is a living document that responds to changes over time outlining the progression of treatment

Focuses on recovery goals and realistic expectations including timeframes

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Lists the type(s) of services to be provided within each discipline of treatment

Includes (as applicable) co-occurring substance use or other substance abuse treatment services, and physical health disorders

Is a tool for treatment providers to reference when documenting services provided in a progress note

The Treatment Plan

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A “Strong” Treatment Plan

Is focused on recovery(e.g., what it takes to live independently in

the community)

Contains recovery-focused goals and

objectives

Contains goals and objectives that are clearly stated and

measurable

Is developed in genuine collaboration with the individual who is to

receive services

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When is a treatment plan required?

Texas Administrative Code, Chapter 412, Subchapter G §412.322(e)

Texas Administrative Code, Chapter 419, Subchapter L§419.456(a)(2)

The mental health treatment plan = within 10 days of the authorization

The substance abuse treatment plan = within 5 individual service days of admission Texas Administrative Code, Chapter 448, Subchapter H

§448.804(b-e)

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What is required in a treatment plan?

Description of the presenting problem Description of the individual's strengths Description of the individual's needs arising from the

mental illness or serious emotional disturbance Description of the individual's co-occurring substance use

or physical health disorder (if any) Description of the recovery goals and objectives based

upon the assessment, and expected outcomes of the treatment

The expected date by which the recovery goals will be achieved

List of resources for recovery supports List of the type(s) of services within each discipline of

treatment that will be provided

Texas Administrative Code, Chapter 412, Subchapter G §412.322(e)

The mental health treatment plan shall include:

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What is required in a treatment plan?

Goals based on the client's problems/needs, strengths, and preferences

Objectives that are individualized, realistic, measurable, time specific, appropriate to the level of treatment, and clearly stated in behavioral terms

Strategies that describe the type and frequency of the specific services and interventions needed to achieve the identified goals

Discharge criteria and initial plans for discharge The projected length of stay The client's primary counselor Date and signature of the client, and the counselor

Texas Administrative Code, Chapter 448, Subchapter H §448.804(b-e)

The substance abuse treatment plan shall include:

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Goals

Objectives

Interventions& Strategies

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Goals

“Obtain permanent independent housing.”

Broad statements about what the individual plans to achieve throughout the course of treatment

Offer a simple method of measuring progress

Should be appropriate to the individual’s diagnosis, age, culture, strengths, abilities, preferences, and needs identified during the uniform assessment

Example Goal Statement:

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Objectives define the steps to be taken to achieve a goal

Objectives should be SMART:• Specific• Measurable• Attainable• Realistic• Time-Limited

Objectives

Example Objectives:

“Research five permanent independent housing options within 90 days.”

“Complete housing applications for the two best permanent independent housing options within 90 days.”

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Developing Goals and Objectives

Poorly developed treatment plans often state goals and objectives in ways that make

progress difficult to measure.

(See following example)

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“Jill will get along better with her mother.”


This statement “get along better” is unclear and therefore very difficult to use to develop clear objectives. How would one know if Jill was actually making progress toward

this goal? What does the term “get along better” mean and what counts as

“getting along better?” Would progress be shown if Jill reported that they were “getting

along better” but Jill’s mother said that they were not speaking at all?

How would the treatment team (or clinician) develop clear steps to reach this goal?

Any time that a goal is stated in such a way that it is vague or non-measurable or measured in a way where progress depends entirely on interpretation, the wording should be refined.

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How can we strengthen this goal:“Jill will get along better with her mother.”


“Jill will develop relationships that contain traits such as honesty, respect, and responsibility”

Honesty can be measured by sampling communication for openness and truthfulness.

Respect can be measured by sampling behavior for emotional affirmation and valuing other’s opinions.

Responsibility can be measured by assessing for accountability for one’s actions.

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Interventions and Strategies outline the role or the steps that the provider, as well as, the individual’s natural supports will take to assist in achieving goals and objectives.


Example Interventions & Strategies:

Skills Training and Development: “Provider will meet with client and collaterals every two weeks to teach client and collaterals how to research and navigate available housing ads via written and electronic media.”

Supported Housing: “Provider will meet with client and collaterals every two weeks to take client and collaterals to available housing locations, to assist client in choosing the best available option(s), and to complete the requisite paperwork for obtaining permanent independent housing.”

Interventions and Strategies outline:• Who• What• Where• When• Why

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Goals

Objectives


Outcomes

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Emotions, cognitions, or behaviors that are different as a result of achieving a goal

Increase the basic level of functioning and quality of life

Reduce positive and negative symptoms

Prevent recurrence or increase in symptoms

Outcomes

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Example Statements for the Treatment Plan

Goal ObjectivesInterventions/

Strategies

“Obtain permanent independent

housing.”

“Research five permanent independent housing

options within 90 days.”

“Complete housing applications for the two

best permanent independent housing

options within 90 days.”

Supported Housing: “Provider will meet with client and

collaterals every two weeks to take client and collaterals to available housing

locations, to assist client in choosing the best available option(s), and to complete

the requisite paperwork for obtaining permanent independent housing.”

Skills Training and Development: “Provider will meet with client and

collaterals every two weeks to teach client and collaterals how to research and

navigate available housing ads via written and electronic media.”

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Treatment planning is part of the treatment process that helps people overcome barriers that prevent them from being able to live, work, learn and participate fully in their communities.

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The treatment process has been defined in many different contexts, but generally has the following components:

Problem Identification

Intervention

Evaluation of Effectiveness

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What have I learned so far?

For individuals with mental illness or substance use/abuse problems, a treatment plan is a document that:

1. Identifies barrier(s) to recovery (i.e., problem identification);2. Lists individual strengths that aid in recovery;3. Identifies goals that the individuals desires to achieve through

treatment;4. Identifies specific intervention(s) that will be used to overcome the

barrier(s);5. Includes criteria for how to evaluate the effectiveness of the

interventions;6. Records the responsibilities of the individual and treatment team

members; and7. Includes referrals to other supportive services.

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Case StudyThe homeless outreach team has referred John for diagnosis and

assessment after speaking with him at a local shelter, where he was attempting to “buy a room for the night.”

John’s initial complaint is, “I just need a little help ‘cause I got no place to live right now - and sometimes I think that somebody put a

curse of some kind on my head.”

John is age 24, has no history of previous hospitalizations, and is employed working 30 hours a week at a local car wash. The Licensed Professional Counselor (LPC) interviewed John and has given John a

preliminary diagnosis of schizophrenia.

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Case Study

In this example the screening that has been done by the outreach team has already identified John as a likely candidate for mental health services.

This has been confirmed by the preliminary diagnosis by the LPC. Even at this early stage it is clear that one or more significant barriers stand between John and meaningful participation in the community.

Addressing barriers to meaningful participation in the community will be the focus of treatment. Exactly how these barriers will be addressed will flow from a treatment plan.

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Case Study

Assessments Assessments occur at various levels. At the highest level, assessment is little more than problem identification (e.g. “John is currently homeless”).

While identifying basic barriers to recovery is absolutely necessary, effectively addressing the problem will usually require that a more refined and detailed psychosocial assessment be conducted.

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Case Study

AssessmentsOnce the basic problem has been identified, further assessment may indicate that there is more to the problem than a surface analysis identifies. With a bit more probing, additional details may emerge that could be critical in formulating an effective treatment plan.

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Case Study

AssessmentsA thorough psychosocial assessment will help to identify the causes of a problem and will provide the treatment team (or clinician) clues for developing intervention and strategies to be used to overcome barriers to recovery.

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Case Study

Assessments An assessment process would include identifying:

- Potential causes of the problem- Immediate need, and- Strengths and natural supports.

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Case Study

AssessmentsThe process would go through a series of ‘open ended questions’ or ‘probing statements’ that assist in:

- Gaining individual confidence and trust- Building a relationship with the individual, and- Identifying goals for recovery.

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Case StudyAssessments

Initial Assessment: John is currently homeless.

Further Assessment: John has had trouble maintaining housing for some time.

Further Assessment: John has been evicted from 5 different living situations in the past 15 months.

Further Assessment: John has a job and has always paid his rent on time, and keeps his apartment tidy, but still has multiple evictions.

Further Assessment: John’s neighbors’ complaints to management have resulted in his evictions.

Further Assessment: John makes loud noises and will not respond to neighbors’ requests to be quiet.

Further Assessment: John beats pots and pans in his living quarters, often late into the night in an attempt to drive the spirits out.

Further Assessment: John has a belief that evil spirits inhabited his apartment and he is self-medicating by abusing alcohol and “Benzos.”

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Case Study

AssessmentsAn assessment progresses as needs are identified.

Specific goals and objectives are developed with the individual which are effective in meeting his or her needs.

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Case Study

Planning, Identifying and Documenting Interventions

After completion of an in-depth psychosocial assessment, the treatment team (or clinician), working together with the individual, will need to plan how to overcome the barrier(s) to recovery.

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Case StudyPlanning, Identifying and

Documenting Interventions

In John’s case, he verbalizes and demonstrates a desire to live independently. He has a steady job, and a history of meeting his obligation to pay rent. He also maintains his dwelling. These are all clearly strengths that increase John’s likelihood of meeting a goal.

John’s inability to control or appropriately deal with his beliefs related to “evil spirits” in a manner that does not cause problems with his neighbors, as well as, his substance abuse problems are clear barriers to John’s recovery.

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Case Study


The treatment plan should identify the strengths and barriers that may help or hinder the individual in overcoming barriers to recovery.

The plan should leverage the individual’s strengths and address ways to overcome or offset barriers in order to achieve the goal.

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Case StudyPlanning, Identifying and

Documenting Interventions

Each goal can be achieved through the identification and successful completion of one or more objectives (or steps).

Each step toward a goal will require both a collaborative partnership with the individual being served, and expertise and creativity on the part of the treatment team members (or the clinician).

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Case Study


In John’s case, the treatment team will:

• Collaborate with him to identify the goal(s) that motivate him toward recovery.

• Develop a step-by-step plan that will assist him in actually achieving his goal(s).

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A Word About Content

John’s case example offers various points of entry for creation of clear objectives or steps to meet a goal. These points of entry include, but are not limited to:

Changing John’s beliefs; Changing John’s behaviors, which are based on

John’s beliefs; or Changing the environment in such a manner that

John’s actions do not create a barrier achieving the goal.

The particular approach should be up to John, his natural supports, and

the treatment professionals working with him.

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Although Bob understands how important it is to take his medication as prescribed, Bob has quit taking his medication on three occasions in the last 11 months due to severe side effects. Bob has subsequently been admitted to the local Crisis Stabilization Unit

each time he quit taking his medications.

Thinking Through a Treatment PlanCase Study

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Thinking Through a Treatment PlanCase Study

After some discussion, Bob stated:“It is like I have a choice to either be mentally ill or

physically miserable. I know the Doctor wants me to take my medication, but it makes me so uncomfortable that I

just can’t stand it. I sometimes wonder if some of this stuff will kill me if I keep taking it. I’m just not sure. I don’t want

to let the doctor down again, but she doesn’t know that this cure is as bad as the disease. I tried to tell the doc that the meds made me feel weird, but I don’t think she

wanted to hear that.”

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Thinking Through a Treatment PlanCase StudyWhile every treatment plan has some potential for improvement, it is important to try to make goals and objectives:

realistic,

simple, and

measurable.

Outcomes should measure the behaviors that indicate success.

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Thinking Through a Treatment Plan

GOAL STATEMENT – Attempt 1: (very weak)

“For the next six month period, Bob will not experience any side effects

from his medications.”

Developing Clear Goals

The following examples show a professional attempting to develop a simple and measurable

goal statement for Bob’s treatment plan:

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Negative Aspects of Attempt One:• The statement is unrealistic. If severe side

effects are a problem, they can rarely be completely eliminated.

• It is difficult to know whether or not Bob is “experiencing” a side effect.

Analysis of Developing Clear Goals

Positive Aspects of Attempt One:• It directly addresses the issue of side effects.• It specifies a specific time frame for addressing the

issue against which progress can be measured.

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GOAL STATEMENT - Attempt 2: (somewhat better)

“For the next six month period Bob will report 50% fewer side effects.”


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Positive Aspects of Attempt Two:• Directly addresses the issue of side effects.• Specifies a specific timeframe for addressing the

issue against which progress can be measured.• Recognizes that reduction of side effects is more

realistic than complete elimination of side effects.

Negative Aspects of Attempt Two:• Reporting few side effects can indicate an actual

reduction in side effects or can misinterpret failure to report a side effect as a success.

• Assumes there will be an “immediate” drop in side effects.

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GOAL STATEMENT - Attempt 3: (improved)

“By December 30th Bob will effectively manage his medication side effects

by taking both his antipsychotic medication and his side effect

management medication as prescribed 95% of the time.”


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Positive Aspects of Attempt Three:• Addresses the management of side effects in a

realistic manner.• Specifies a timeframe for addressing and measuring

the management of the side effects.• Establishes an objective measure of success that ties

directly to the issue(s) that is creating the barrier torecovery that can be reported objectively.


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Negative Aspects of Attempt Three:• The measurement of success in managing the side

the effects uses only one indicator (i.e., taking medications). While this may be considered by many clinicians inadequate, it may be necessary to meet the most immediate need. Once stabilized, development of goals and objectives for other problems identified can become the focus of treatment.

• The way the measure is worded could be stated in terms of days per month (e.g., …at least 28 days per month) instead of a percentage.


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Reaching a goal often requires a number of sequential steps or objectives. Objectives should also be realistic, clear, simple, and actually measure the element that they are intended to address.


GO

A L

OBJECTIVES

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Exercise

Here are some of the objectives selected by Bob and his provider over a period of time. Notice how the plan progresses. Generally, 2 or 3 objectives are selected at a time.

Objective – By an agreed upon date, Bob will be able to accurately identify the side effects of any of his medications that might require immediate medical attention.

Objective – By an agreed upon date, Bob will be able to accurately identify each medication that he is taking and accurately list the 3 most common side effects of each medication.

Objective – By an agreed upon date, Bob will be able to accurately explain the reason(s) why reporting side effects to his physician is important.


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Exercise

Cont’d…

Objective – By an agreed upon date, Bob will be able to accurately identify any medications that have been prescribed to manage or alleviate the side effects of his other medications.

Objective – By an agreed upon date, Bob will be able to identify any foods or beverages that may make side effects more intense.

Objective – By an agreed upon date, Bob will start keeping a daily written log identifying all medications taken and any potential side effects that he experiences. He will note the date and approximate time that the potential side effect was experienced and its duration in the log.


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Exercise

Cont’d…

Objective – Bob will discuss his written medication log with his case manager prior to each scheduled physician visit to help identify the particular side effects that need to be discussed with the physician.

Objective – At the time of each physician’s visit, Bob will discuss any medication side effects that he believes he has experienced with his physician.

Objective – Bob will take medications that assist in managing or alleviating the side effects of other medications at a conformity rate of at least 95 percent as prescribed.


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Treatment Planningand Writing a Treatment Plan Treatment Planning and Writing a Treatment Plan

require clinical skill, knowledge and the ability to: Think Plan Develop Deliver, and Treat for recovery.

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Helpful Hints

Intervention: Activity to bring about change. For example: work as an advocate, cause change, or interrupt a process (mental, behavioral or

physical).

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Helpful Hints

Symptoms are typically divided into positive and negative symptoms because of their impact on

diagnosis and treatment.

Positive Symptoms are those that appear to reflect an excess or distortion of normal functions. Positive symptoms may include delusions, hallucinations, disorganized speech and catatonia.

Negative symptoms are those that appear to reflect an absence or decreased amount and may include lack of emotion, low energy, lack of interest in life, low motivation, flat affect. are difficult to evaluate because they are not as grossly abnormal as positives ones and may be caused by a variety of other factors as well (e.g., as an adaptation to a persecutory delusion).

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Helpful Hints

“Open ended” questions begin with the words: How long has “this” (whatever the presenting

situation) been occurring? When did “this” become apparent to you? What are you doing when “this” happens to you? Why do you think “this” happens to you?

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Helpful Hints

“Open ended” questions allow people to reveal information in a free narrative style response that assists with identifying:

Strengths

Weaknesses

Problems

Causes or possible triggers

Solutions for recovery

Documents

Revised 12/2009 1 Treatment Goals, Treatment Planning, and How to Write an Effective Treatment Plan