Using the RedesignedCMTS Care Plan

Rita Haverkamp, MSN, PMHCNS BC, CNSExpert Care Manager and AIMS Trainer

Objectives

• By the end of this training the participantswill be able to– Discuss value of using a care plan for patients– Discuss aspects of SMART goals and plans forpatients

– Learn to use the new CMTS care plan format– Make plans for doing concurrent documentation

Care Plan Benefits• Sets clear expectations for what improvementwill look like

• Helps patient set and achieve goals• Patient is more engaged in treatment andbecomes an active participant in their care

• Gives patient a way to monitor their progressand discuss their care in a systematic way

• Leads to better treatment by focusing onimproving and maintaining their health ratherthan just dealing with problems as they arise

Care Plan Benefits, Cont.

• Has all members of the team working on thesame goals

• Improvement in patients can be clearlydescribed

• Aids in knowing when to do the RelapsePrevention Plan and when DC is appropriate

• Improved documentation of goals and tasksimproves billing and/or documentation ofmedical necessity for treatments provided

Care Plans Improve Documentation

• Establish need for every single serviceprovided

• Documentation that clients were given theopportunity to identify their own goals fortreatment

• Goals are clearly related to assessed needs

Research• Summary of numerous research and journal articlesthat document using behavioral techniques willimprove self care in chronic illness– Setting goals– Checking the patient’s readiness for self care– Breaking self care tasks into small, manageable steps– Getting personalized feedback– Self monitoring– Checking patient commitment to key tasks

• Von Korff M, Gruman J, Schaefer J. et al. Collaborativemanagement of chronic illness. Ann Intern Med.1997;127:10971102.

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Patients involved in care planning have betteroutcomes at 12 weeks than control groups

– Diabetic patients identified relevant lifestyleissues that affected them

– Patient preferences in care were solicited– Negotiation skills and obstacles were discussedand rehearsed

– Prepared patients more effectively elicitedinformation from providers and had betterfunctional and physiologic outcomes at 12 weeks

• Greenfield S, Kaplan SH, Ware JE Jr, Yano EM, Frank HJ. Patients‘participation in medical care: effects on blood sugar control andquality of life in diabetes. J Gen Intern Med. 1988;3:448 57.

The Documentation Linkage

• Diagnoses• Strengths/Challenges• Assessed Needs/Personal Goals

Psychosocial

• Goals and Objectives• Should link to assessed needs andgoals from initial assessment

TreatmentPlan

• Interventions• Clinical Progress

ProgressNotes

Care Manager Role

Identify & Engage

Establish a Diagnosis

Initiate Treatment

Follow-up Care & Treat to Target

Complete Treatment & Relapse Prevention

System Level Supports

3 Critical Elements of Engagement:(care plans create this )

WorkingAlliance

Goals?

Tasks?

Bond?

Adding Care Plan Goals Identify the Category

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Identify the Tracking Tool Define a Target Score to Achieve

Describe the GoalThe desired outcome of patient’s efforts in this area as a result oftreatment.

Questions?

Writing SMART Goals andAction Plans

• Specific – detailed outcomes criteriaThe goal should state the level of performance expected.

• Measurable – measurement criteriaTo achieve objectives, people must be able to observe andmeasure their progress.

• Attainable – realistic criteriaGoals should challenge people to do their best, but they need alsobe achievable.

• Relevant – significance criteriaGoals need to pertain directly to the performance challenge beingmanaged.

• Timeframe – answers “by when?” criteriaDeadlines help people to work harder to get a task completed.

Suggested Words to Use When WritingSMART Goals or Patient Action Plans

• Choose a verb: increase, decrease, reduce,improve, deliver, grow

• Define the object: what you wish or will worktoward to get better at and for whom

• Identify how much: target goals and areference to the meeting of success

• Identify by when: time frame for completionof goal

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Add Action Steps Types of Action Steps

Example Depression Goal Example Anxiety Goal

Establishing Goals and Plans

• What brings you to see me? What are youexpecting in this visit today?

• What are you hoping to get from your care?• What expectations do I have for treatmentand how do I communicate this to thepatient?

Tracking Patient Goals

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Updating Patient Goals Adding Referrals within the Care Plan• Add a Referral Action Step without leaving the Care Plan by

clicking the blue “Referral” link

New Personalized 0 10 Scale

Closing Patient Goals

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Questions?

CollaborativeDocumentation:Good for you, Good for your patients!Essential for involving patient in care planning

The “Holy Grail” of Documentation?

• Fast and easy to perform• Completed in a timely manner• Preferred by clinicians and clients• Guides clinical activity and episodes of care in arational direction

• Improvement in note quality and patientengagement in care

Client SatisfactionCase Study: Health Center in Massachusetts (2009)Of 927 respondents whose clinician used the concurrent

documentation process:

Helpful - 83.9%Neutral - 13.7%Unhelpful - 2.3%

More than 97% of clientsfound this practice helpful!

Benefits

• Improves clinician quality of life– Avoid the chronic, “never caught up” model– Can leave work at work!– Higher staff morale, less “burnout” and cliniciansfeeling overwhelmed/anxious

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Benefits, Cont.

• Improved clinical care/outcomes:– Improved engagement – patients are excited about theirtreatment and more “empowered”

– More focus on treatment plan and goal achievement– Decrease length of treatment episodes– Complements use of solution focused, evidence basedmodels

– Patients get better!

Quality Factors

• Compliance Issues– Late documentation is poor documentation…rush to “justget it done”

– “Lost” notes– “Boiler plate” notes– Is the service being billed for justified by thedocumentation in the note? (Clinical Necessity)

• Documentation of exact symptoms, etc.

Questions?

Office Hours

• CHPW will be hosting office hours on June11th from 12:00 p.m. to 1:00 p.m. to addressadditional questions resulting from userexperience with the new Care Plan. Log ininformation for this event will be distributedafter the June 2nd webinar.

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