Mental Health Treatment Plan Tracking

Business problem
Psychiatric patients must have a detailed, documented treatment plan, reviewed by a multidisciplinary team and updated every 90 days. This is mandated by CMS (CFR 482.61) and state public health departments. Ensuring that every patient has an updated, appropriately reviewed, treatment plan is a major logistical challenge. Large portions of team meetings may be spent shuffling plans for review and signature, consuming time intended for other matters. An automated process for tracking treatment plans and approvals would have a huge benefit for any group of mental health professionals.

Electronic "signatures"
The first question was whether CMS and state authorities would approve a process using electronic "signatures" by the multidisciplinary team. Our process would capture the identity of each approver, recording their network login and the time/date for each approval. Would that be acceptable? Somewhat to my surprise, both the state and CMS readily approved the concept.

Connecting Meditech
The next hurdle was connecting the treatment plan tracking process with Meditech billing. The billing process requires a current treatment plan before charges are submitted for that patient. We needed to compare charges with treatment plans and identify any charges for which there was no current treatment plan.

Bill designed an automated process to extract billing data for psych visits from Meditech on a daily basis. "New" psych patients are identified as:

• no psych visits in at least six months
• a visit in a psych location
• no active treatment plan

Every Tuesday, any treating clinician with patients who are

• in the "new patient" table and
• lack a current treatment plan

is sent an e-mail reminder to create a plan. When the plan is created, the status is updated for that patient; otherwise the clinician keeps getting reminder e-mails. Note: because new patients are associated with the treating clinician and not a team, those patients are included in reports for all teams in which the clinician participates.

Managing treatment plans
The treatment plan tracking application offers various functions based on individual permissions. Those with "user" permission may:

• approve plans
• create plans
• modify (their own) plans
• list (their own) rejected plans
• renew (their own) plans
• view (their own) plans
• print (their own) plans
• print certain reports
• read how-to documents

Those with "clerical" or "superuser" permission may also:

• transfer plans
• terminate plans
• reactivate plans

Those with "clerical" permission may also

• update system data

The application uses the same single-sign-on technique as everything else on the intranet, recognizing the current user and automatically customizing the view to display only the plans which are relevant for that clinician and functions relevant to that person's permission level.

Teams
Psychiatry is divided into teams, and each patient is assigned to a team.

• Clinicians may have roles in more than one team.
• For purposes of mental health treatment plan tracking, there are two roles for a clinician on a team:
  • signer
  • member
• For any team, a clinician may be a signer, a member, or both.
• A signer approves treatment plans for a team, but is not necessarily a member of the team for treatment of patients.
• A member does not approve treatment plans for the team, but is part of the team for treatment of patients.
• Each clinician is also assigned to a professional discipline:
  • physician
  • psychologist
  • social worker
  • nurse

Default screens
Clinicians in different roles have different default initial screens:

• Clinicians in the signer role see a list of any plans which are awaiting approval by someone who fits the profile of the current user. If there are no plans needing approval, the default initial screen is a personal list of plans needing renewal.
• Clinicians who are not in the signer role see a list of their own plans which need renewal.
• Clerical workers simply see a "select function" screen.

Approve plan
The list of plans needing approval (click the image below to see full-size image) is dynamically selected from:

• teams where current user holds "approver" role; and,
• plans which need approval by someone in the current user's professional discipline.

Approvals are handled on a "first come, first served" basis — as soon as someone who meets the above criteria approves each plan, that plan no longer appears on the list of plans needing approval for anyone else who meets the same criteria.

[Click the partial image above to see the full-size image]

Plans are sorted by team and patient name (see above), and clicking the patient name displays the plan for that patient (click the image below to see full-size image). Plans can also be sorted by date, with the oldest first.

[Click the partial image above to see the full-size image]

Enter New Plan
To create a new plan, the first step is to select a patient (any patient, not just a psych patient), by any combination of name, date of birth or unit number (shown below).

Clicking the name of the patient in the search results (shown below) displays the next screen (second image below).

The new treatment plan form displays the essential demographic information about the patient, and fields to describe the patient's current clinical status (shown below). If the selected patient has an active treatment plan, a message instructs the current user to contact the owner of the current plan.

Selecting "Continue" displays the first problems and goals form (examples of these forms are shown in Treatment Plan Update below).

Modify Plan
Selecting a treatment plan to update displays the same forms as for a new plan (above), but with all the data for the current treatment plan for that patient. The owner of the plan may update the plan and submit it for review and approval. The first form, with basic information about the treatment plan, is shown below.

The next form is Problems & Goals (shown below). This form may be repeated for up to ten problems. For each problem, goals and interventions are documented.

For this patient, there are two problems (second problem shown below, with three interventions).

Once all the problems and goals are documented, the entire plan is presented for review (shown below).

Rejected Plans
When a signer rejects a plan, an e-mail is sent to the plan owner with the reason the plan was rejected, and a link to the plan. Any plans which have not been approved are listed as being in "revision status" (shown below). These plans must be modified and resubmitted for approval. The screens are exactly the same as for updating treatment plans (above).

Renew Plan
The list of plans needing renewal is grouped by relative urgency (click partial image below to see full image).

• First (most urgent) are expired plans, with an effective date >= (today - 97 days). The team leader also receives a daily e-mailed alert for any expired plans.
• Next are expiring plans, with an effective date >= (today - 90 days).
• Next are plans expiring next week, with an effective date >= (today - 83 days).
• Finally come plans expiring in two weeks, with an effective date >= (today - 76 days).
• For any expired plans, the treating provider receives a daily e-mail reminder containing a direct link to the Renew Plan page.

[Click the partial image above to see the full-size image]

View Plan
If a clinician needs to see (but not edit) a plan, the View Plan function is available. This offers the opportunity to view not only the current plan but also all archived plans. The standard patient lookup displays a list of all treatment plans for the selected patient (shown below).

Viewing a plan displays a read-only version of the plan (click the image below to see a full-size image).

[Click the partial image above to see the full-size image]

The read-only version of a plan is also available in a printer-friendly format (click the image below to see a full-size image).

[Click the partial image above to see the full-size image]

Transfer Patient
Transferring a patient to a new provider requires two steps. First the new team is selected (shown below).

Having selected a team, the specific clinician is selected and a transfer date identified (shown below). If the new clinician is not known, "TBD" may be selected until the treating clinician is identified.

Terminate Patient
To terminate care of a patient, the Terminate Patient function first asks whether the patient is terminating all mental health services (shown below).

• If yes, a termination date is input (shown below).
• If no, a warning is displayed: "If this patient is continuing treatment with another clinician, use the transfer function by clicking on the 'Transfer Treatment Plan' menu item at left." For example, sometimes a patient will discontinue therapy but continue treatment for psychpharm; in that case the patient should be transferred, not terminated.

Reactivate a patient
Reactivating a patient begins with selecting the correct patient from among all patients with old treatment plans in the database (shown below).

The second step to reactivate a patient is selecting the team which will treat the patient (shown below).

The final step to reactivate a patient is selecting the clinician who will treat the patient and set a transfer date (shown below).

Clerical
Many tools are available to help individual clinicians, team leaders and administrators keep the treatment plans current (click the partial image below to see the full image).

[Click the partial image above to see the full-size image]

One particularly useful tool is the "dashboard" for a clinician or a team (click the partial image below to see the full-size image).

[Click the partial image above to see the full-size image]

Print Plans
Because this application was first developed before implementation of the Epic outpatient EMR, all treatment plans were printed and placed in the paper chart.

• Each plan has a specified "chart location," which was where the paper chart is stored for that patient.
• One of the roles ("printer") in the application is for medical records staff who print records.
• Each "printer" is associated with a specific location. Users with "printer" permissions are sent a daily e-mail alert whenever plans are ready to print for their location.
• When someone with "printer" permissions selects the Print Plans tab, all the unprinted treatment plans are displayed in printer-friendly format, in one long, continuous screen. Selecting "Print" sends all the plans to the local printer, with page breaks between plans.
• When the plans are successfully printed, the medical records person indicates that the plans were printed, which sets a flag so those plans are no longer listed as ready to print.
• With the implementation of the Epic ambulatory EMR, there is no longer any need to print plans for the paper chart, except at a handful of sites where Epic is not yet used.

Help
A number of help documents are available (listed below).

Outcomes

• Although it took over a year to achieve real momentum, the psychiatry department has thoroughly adopted this process and it gets heavy use.
• Although we did not collect data, psychiatry department managers are certain that the treatment plan process is significantly improved.
• Training for new clinicians is an ongoing issue; new clinicians make mistakes simply because they do not understand the rules. One could argue that a well-designed process would be self-evident, but an automated process that is flexible enough to handle any necessary process variation will require user training.

Lessons learned

• Strong operational leadership is necessary for good adoption rates. The psychiatry department did not assign adequate resources to this project for the first year, resulting in minimal adoption. Only after a dedicated department resource was assigned did the application achieve any momentum.
• We had expected this application to be retired when we implemented the Epic outpatient EMR, but were disappointed to realize that the Epic system could not support treatment plan tracking. It would clearly be optimal to have all things clinical in one place (Epic).

Posted 10 June 2008