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
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:
- 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
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