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Documentation Best Practices for Family Peer Support Providers: Part 2 YVETTE KELLY, CTAC ANNE KUPPINGER, CTAC October 23, 2019
Documentation Best Practices for Family Peer Support Providers: Part 2YVETTE KELLY, CTACANNE KUPPINGER, CTAC
October 23, 2019
Please Note‣Refer to state guidance documents for official guidance.‣Providers should follow internal agency policy and
procedures in alignment with state issued guidance and manuals.‣ Information is current as of the date of the presentation.‣Slides and recording will be posted to the CTAC website.
Part 2: AgendaTreatment Plan Basics
Progress Notes
Goals and Objectives for FPSS
Putting it All Together
Q&A and Resources
State Guidance Documents
CFTSS Health Record Documentationhttps://www.health.ny.gov/health_care/medicaid/redesign/behavioral_health/children/docs/cftss_prov_guide_hlth_rec_doc.pdf
Child and Family Treatment and Support Services Provider Manualhttps://www.health.ny.gov/health_care/medicaid/redesign/behavioral_health/children/docs/updated_spa_manual.pdf
Multi-System
Community Based
Culturally Competent
Least Restrictive
Family Focused
Child Centered
CFTSS Core Principles
Trea
tmen
t Pla
n Ba
sics
Golden Thread TipsGoals and objectives are individualized based on assessment,
reassessment, or treatment plan review.Progress notes address issues identified in the assessment and
treatment plan. Treatment goals, objectives or overall strategy change when there
is no/limited progress.Treatment plans are updated when significant new issues are
identified, or current objectives are achieved.
The LPHA Recommendation
The sample LPHA Recommendation Form can be found here.
• Diagnoses and Symptoms• Areas of Functioning• Recommended CFTSS Services
and Needed Interventions• Reason for Recommendation
Initial Treatment PlanBy the 4th session or no more than 30 days after the first face-to-face with the parent/caregiver:
• An assessment of the parent/caregiver’s needs and strengths should be completed.
• A FPSS Treatment Plan is developed to outline the steps the parent will take with support from FPSS to help their child make progress on the needs outlined in the LHPA recommendation.
• Treatment Plan signed by the parent/caregiver, FPA and FPA’s supervisor.
• Parent involvement in treatment planning is required.
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Not Just a Piece of Paper‣ The process of writing and making updates and revisions to the plan should
engage families in defining their needs, strengths, goals and steps they want to take.
‣ The treatment plan is a touchstone for an ongoing conversation about what is working, what isn’t working and helps everyone know when goals have been met.
‣ It is an agreement between the provider and family about what changes need to occur and how they will work together to achieve those changes.
Parent Participation in Treatment Planning• Not just a signature!• Progress notes should reflect parent input, ideas, reactions that in turn
influence planning. • Assessment should include the parent’s perspective on their priorities,
needs and desired supports.• When possible, write treatment plans in using the words of the parent.• Support the parent to fully participate in the treatment planning process
and meetings.
Treatment plans must be updated and adapted as the needs, challenges, progress and priorities of children and their parents/caregivers change.
FPSS Treatment Plan is Grounded in the Child’s Goals and Objectives• In Medicaid, the child or youth is the
beneficiary.
• The parent/caregiver(s) are a critical resource for the child and the family well-being matters to child outcomes.
• The work you do with parents needs to be clearly related to the child’s goals and objectives.
FPSS Treatment Plan
GoalsBroad desired outcome for parent/caregiver to meet the child’s
identified need (as per the LPHA recommendation).
Objectives Specific steps parent/caregiver will take to meet identified goals.
Interventions/ServicesFPA interventions to support a parent/caregiver to meet
goals/objectives Must include scope, frequency and duration.
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Treatment Plan Building BlocksEngagement, Bridging and
Transition Support
Self-Advocacy, Self-Efficacy
and Empowerment
Parent Skill Development
Community Connections and Natural
Supports
Examples‣By the end of June, the parent will learn about and begin to
use two new parenting approaches that will help her foster-daughter who has a history of trauma indicate when she is feeling stressed. (Parent Skill Development)
‣Once a week for the next 8 weeks, the parent will visit her child at the RTF and participate in team meetings to develop a plan to help her son transition home in a way that works for everyone in the family. (Engagement, Bridging and Transition Support)
Examples‣Parent will take his son to playgroup at the community
center twice a month for the next two months so they can both meet some other families in the area. (Community Connections and Natural Supports)
‣Parent will learn about what happens at a CSE meeting and attend the December meeting to share her perspective on her daughter’s needs and learn more about support services. (Self-Advocacy, Self-Efficacy and Empowerment)
Treatment Plan Components1. Child’s behavioral health diagnosis, where required; or behavioral
health challenges/symptoms to be addressed2. Child’s needs and strengths3. Child’s treatment goals and objectives4. Services, service components and interventions (scope)5. Frequency and duration of services6. Service location(s)7. List of other service providers and individuals involved in the child’s
care
Treatment Plan Components (cont.)8. Safety Plan*9. Discharge criteria10.Name, title and signature of the staff providing the service11.Signature of the child and family/caregiver*12.Signature of licensed supervisor (or, for FPSS and YPST a licensed
supervisor or a supervisor with an FPA Credential)
* See Guidance Documents for additional information
Prog
ress
Not
es
The Progress Note‣Provides evidence of services to, or on behalf of a
individual and/or family and relates to one's progress in treatment. ‣Details areas of need, gains, and achievements made
by individual and their family.‣Contains the necessary details to support medical
necessity of each delivered and subsequently billed service.
When are Progress Notes Needed?A progress note must be completed for:• Services delivered
- Direct service to child and/or family- Coordination or Collaborative Contact on behalf of child/family
• Significant or unexpected events • Relevant unbillable events
Medicaid requires that progress notes be written contemporaneous with service provision
Progress Note Elements
i.e. DOB, participants, ID
.
i.e. modality, duration, location, provider name &
credentials
Is the service appropriate and
necessary?
How are you planning on working
with the family moving forward?
What has the family identified as their
priorities
Any new and/or significant issues that need to be
addressed? Is the family benefiting
from Tx?
STANDARD DEMOGRAPHIC INFORMATION
SERVICE PROVISION
DETAILS
MEDICAL NECESSITY
INDIVIDUAL PREFERENCES
& INPUT
CONCERNS, PROGRESS,
INTERVENTIONS
RECOMMEN-DATIONS &
NEXT STEPS
Progress Notes for Groups‣ In addition to components mentioned, Group progress notes must clearly◦ Indicate “group” as the service modality provided◦ Detail number of participants (including any non-CFTSS children present in
the group) ◦ Identify number of service providers present
‣ Group service must be clearly identified as an intervention in the treatment plan and associated with the specific objectives.
‣ A group progress note must be written for each group session and each participant.
Putti
ng it
Tog
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School Social worker referral to FPS who obtained recommendation from LPHA Medical Necessity Form - LPHA Recommendation for Children & Family Treatment & Support Services
(NOT A REQUIRED FORM. This form is NOT required to be used, but a sample template to capture the information necessary to demonstrate medical necessity.)
Instructions: This form can only be completed and signed by a Licensed Practitioner of the Healing Arts (Individual currently licensed as a Registered Professional Nurse, Nurse Practitioner, Psychiatrist, Licensed Psychologist, Licensed Psychoanalyst, Licensed Master Social Worker, Licensed Clinical Social Worker, Licensed Marriage & Family Therapist, Licensed Mental Health Counselor, or Licensed Creative Arts Therapist, or Physician).
Recommendation for Rehabilitative Service(s)
Participant Name: Joey Date of Birth 6/12/09 Parent/Caregiver: Kathy Relationship: Address: Phone: County of Residence: Medicaid CIN #:
Behavioral Health Information: (*A MH/SUD diagnosis is only required for a recommendation of PSR) Check all that apply:
List Diagnosis Category Specific Diagnosis or Symptoms of Mental Illness (MH)/Substance Use (SUD)
DX Code
Primary Axis 1 Depressive Disorder (unspecficed) Secondary Other
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Areas of Functioning
Recommended CFTSS Services
FPSS AssessmentFANS Assessment identified four areas in which the Kathey needs support to help Joey:
‣ Caregiver Involvement
‣ Knowledge of service options
‣ Satisfaction with school placement
‣ Satisfaction with school participation
FPSS Treatment Plan for Parent/Caregiver
GoalsBroad desired outcome for parent/caregiver to meet the child’s
identified need (as per the LPHA recommendation).
Objectives Specific steps parent/caregiver will take to meet identified goals.
Interventions/ServicesFPA interventions to support a parent/caregiver to meet
goals/objectives Must include scope, frequency and duration.
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Child’s needs/goals Joey is withdrawing from his peers in school. He has had physical altercations with his peers and suspended twice because of these altercations.
Goal Objectives Intervention/Services
Kathy will meet with Joey’s teacher and school social worker within the next two months to discuss Joey’s needs and develop a plan meet these needs.
FPA will meet with Kathy twice a week for one hour from 10/1/2019–12/30/2019 to assist Kathy to:• Craft a list of questions specific
to Joey’s school needs.• Support Kathy to arrange a
meeting with Joey’s teacher and school social worker.
• Support Kathy during the meeting.
• Debrief and determine next steps.
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1. Kathy will become familiar with available supports to assist Joey with school challenges
Child’s needs/goals Joey is withdrawing from his peers in school. He has had physical altercations with his peers and suspended twice because of these altercations.
Goal Objectives Intervention/Services
Kathy will identify and connect Joey with 1 new social opportunity within the next two months.
Family Peer Advocate will meet with Kathy once a week for one hour from 10/1/2019 –12/30/2019 to: • Explore natural supports
available to the family. • Identify recreational resources
for Joey within community. • Assist Kathy to develop
strategies to assist Joey with challenging behaviors.
• Assist Kathy to collaborate with PSR provider as they each support Joey.
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2. Kathy will assist Joey in enhancing his social skills.
Child’s needs/goals Joey is withdrawing from his peers in school. He has had physical altercations with his peers and suspended twice because of these altercations.
Goal Objectives Intervention/Services
Kathy will identify and connect Joey to service providers to meet his behavioral health needs within the next two months.
FPA will meet with Kathy once a week for one hour from 10/1/2019 – 12/30/2019 to: • Identify behavioral health
resources within Joey’s community.
• Support Kathy to arrange behavioral health appointments for Joey.
• Link Kathy to transportation resources for Joey’s appointments to identified behavioral health providers.
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3. Kathy will ensure that Joey’s behavioral health needs are met.
Progress Note Example‣ FPA met with Kathy to plan for next week’s school meeting. Kathy
expressed a concern that the school staff won’t listen to her because they ‘think she is demanding’. The FPA reassured Kathy that her concerns were reasonable and reflected her concern for Joey. FPA and Kathy reviewed her list of questions and concerns and role-played how she could talk about these with school staff in a way that focused on their shared interest in Joey’s success. Kathy reported that this was helpful, and she asked the FPA to help her stay on track during the meeting.
‣ FPA also helped Kathy think of some ways to help Joey feel less anxious about attending the meeting. FPA checked to be sure Kathy had a ride to the meeting next week. FPA and Kathy will debrief immediately following the meeting.
Supervisors...‣ Improving documentation is an ongoing
process! ‣Make documentation review a regular
part of supervision to assure completeness, appropriateness, quality and compliance.‣ If you have questions, ask!
Please Note: ‣ It is important to note that this presentation provides
general guidance on documentation best practices. Please consult state guidance documents.‣The organization you work for will provide you with
agency-specific training on their documentation requirements and process.‣Documentation requirements may vary based on the
specific service, modality, and payor.
Reso
urce
s
In Case You Missed It...
The recording for the FPSS Documentation Best Practices: Part 1 held on October 16, 2019 can be
found here:
https://calendar.ctacny.org/event/?id=873
CTAC Online Learning ModulesQuality Documentation Series
Billing ResourcesCFTSS Billing Guidance Page on the DOH website: https://www.health.ny.gov/health_care/medicaid/redesign/behavioral_health/children/billing.htm
Understanding Paper Claims Submission Webinarhttps://ctacny.org/training/understanding-paper-claims-submission
MCTAC Billing Tool – Interactive UB-04 Formhttps://billing.ctacny.org/
PEP Online Training Modules
Documenting YourWork
Creating a Plan to Support Families
Measuring the Impact of Your Work with Families
Children’s Behavioral Health Transition to Managed Care
https://www.health.ny.gov/health_care/medicaid/redesign/behavioral_health/children/index.htm
Family Assessment of Needs and Strengths (FANS)
https://www.ftnys.org/training-credentialing/family-needs-strengths-fans/
Support for Family Peer AdvocatesIf you are a Family Peer Advocate and you would like to connect to others doing similar work, please reach out to Families Together in New York State. FTNYS has statewide and local events and a team of Regional Parent Advisors. For more information, email Nancy Craig at: [email protected]
If you have questions about Family Peer Advocate Training and Credentialing, email Susan Burger at: [email protected]
www.ftnys.org
State MailboxesDivision of integrated Children and Family Services:[email protected]
NYS OMH Managed Care Mailbox:[email protected]
NYS OASAS Mailbox:[email protected]
NYSDOH Health Homes for Children:[email protected]
NYS OCFS Mailbox: [email protected]
OMH Children’s Designation [email protected]
OMH CFTSS ListservTo subscribe to the OMHCFTSS Listserv, please follow the below instructions:
‣ STEP #1: send an email to: [email protected] cc or bcc or subject. no salutation
‣ STEP #2: in the message field type:"sub listname first name last name" (ex: sub omhcftss jane doe)
‣ STEP #3: Send e-mail.
NOTE: “sub” stands for subscribe
Other Listservs‣ Children’s Managed Care Listserv
http://www.omh.ny.gov/omhweb/childservice/
‣ DOH Health Home Listservhttp://www.health.ny.gov/health_care/medicaid/program/medicaid_health_homes/listserv.htm
‣ Health Home Bureau Mail Log (BML) https://apps.health.ny.gov/pubdoh/health_care/medicaid/program/medicaid_health_homes/emailHealthHome.action
Contact CTAC Please send questions to:
Logistical questions usually receive a response in 1 business day or less.
Longer & more complicated questions
can take longer.
We appreciate your interest and patience! Visit www.ctacny.org to view past
trainings, sign-up for updates and event announcements, and access resources
Thank You!Yvette Kelly Director of Children's Services and Healthcare Innovation CTAC/MCTAC
Anne KuppingerSenior Research Coordinator CTAC/MCTAC
