The overarching goal in treating clients with behavioral health diagnoses is to see them achieve a healthy state where they use robust coping skills for meeting life’s challenges. However, according to Antoine de Saint-Exupery, a famous French writer and aviator, “A goal without a plan is just a wish”. That’s why effective treatment planning is vital to helping these clients by charting the pathway to reach their goals.
By regulation, a treatment plan is required for all individuals seeking treatment and it must be individualized to their unique needs and situation. The plan’s format is simple, however, it does require that specific details are included, such as:
- Substantiated Psychiatric Diagnosis: Used as a reference to create goals and interventions. It’s important to include any pertinent medical diagnosis being actively treated. While this inclusion is a regulatory requirement, it also provides vital information to help us view the whole client and the challenges they face.
- Short/Long Term Goals: These must reflect what the client wants to accomplish. They must be written in a manner that is measurable, time-oriented, and most helpful when they reflect the client’s chosen words.
- Active Problems Being Addressed: These should identify and precisely describe problem behaviors rather than generalized statements/generic terminology, such as “paranoid,” “aggressive,” or “depressed”.
- Interventions: Actions that the staff are doing/providing to support the client in reaching their established goals. Interventions need to be directly related to meeting the goals (which are based upon the active problems).
- Signatures: The final section of the treatment plan where the healthcare team and the client sign their names. This signifies that the client participated in developing the treatment plan and agrees with the content. It also demonstrates commitment of the healthcare team to the client’s success, and the client’s commitment to the plan.
The treatment plan is built around addressing the problems that the client brings with them as they enter treatment. It must consider all the physical, emotional, and behavioral problems relevant to the client’s care. It also must be based on an inventory of the client’s strengths and weaknesses. The elements of the treatment plan must work together to achieve the greatest possible gain for the client. The plan must also change as the client’s condition changes. If a client experiences a set-back, such as regression or an incident such as a fall, these must be reflected in the treatment plan.
Clients play an important role in developing their behavioral health treatment plan. It’s the client/health care team partnership that ensures successful outcomes. Although the behavioral health team will use their professional knowledge and experience to facilitate treatment planning, clients (or their representatives, as allowed by State law) must participate in the process. The client must acknowledge/accept that they need treatment to progress on the path to wellness. They must understand where the areas for improvement are and what they can do to help themselves, as well as what the staff can do to facilitate the process. They must be willing to learn skills to solve their problems in a healthy way.
If the client attends treatment planning, it’s important that the staff prepare them to participate. When the client is familiar with the staff participating in their plan, it helps the client establish trust in the process and create a comfortable environment for sharing. The treatment planning conversation needs to be presented in laymen’s terms and include open-ended questions asked of the client to solicit their input.
Keep in mind that some clients may not be willing or capable participants in developing their treatment plan when they are admitted into your care. Surveyors will question the organization if there is no documentation of the client’s lack of engagement or involvement with the care planning process. Therefore, documenting the degree to which the client is involved is imperative. That’s why it’s important to remember that the treatment plan must reflect client involvement and show the advancement, maintenance or decline in participation.
As mentioned earlier, the goal in treating every client is to see them reach a healthy state. Organizations do this by working with clients to establish the goals important to their care. Goal setting supports the client by helping them:
- Stay motivated
- Increase their confidence
- Concentrate
- Avoid feeling overwhelmed
- Achieve more
- Feel satisfied
- Avoid confusion
- Set priorities
As the healthcare team works with clients in establishing their goals, it’s important to set goals the client can reach, by setting specific metrics and specific dates to ensure that they are progressing on their journey. Consider using the SMART format as the format for these goals. The SMART acronym does vary depending on the reference source, but for our purposes SMART goals are defined as specific, measurable, attainable, relevant, and time based.
- Specific – Instead of creating goals that may be nebulous and undefined, work to develop goals that have more specific parameters or steps toward achieving a greater goal. Instead of a goal that a client is no longer depressed consider the more specific goals of identifying what makes the client feel depressed or reducing the episodes of feeling depressed.
- Measurable – Ensure the goals have parameters that can demonstrate progress. “The client and team will identify two (2) skills to help the client avoid feeling sad” is a goal you can track. A goal of “developing coping skills” does not provide a specific measure of success.
- Attainable – to promote client motivation, goals should be reachable. Losing 10 pounds a week sounds great. However, it’s an implausible goal that will likely leave the client discouraged – and is more likely for them to give up on their efforts. Choosing realistic goals that the client can meet will reinforce their efforts and keep them moving forward. Losing one pound per week or reducing the number of client outbursts by one episode per day is a more realistic and sustainable goal.
- Relevant – goals should be relevant to the identified problems that the healthcare team and the client agree upon. They should also take into consideration the client’s home situation and the available resources that can be engaged to support the client. This could include areas such as home situation, presence/absence of family support, job status, etc.
- Time-based – There should be an expectation date of when the goals should be reached. This holds the team and the client accountable to demonstrating progress with the treatment plan. These dates should be updated as needed. Once a goal is reached, a new goal should be established with new measures of success and associated time frames for achievement.
Treatment plans are living documents that require continuous updating/modification as the client’s condition changes. They form the backbone of any care regimen, guiding the interventions and ensuring that timeframes are established to ensure care is delivered efficiently. As such, they are a major focus for survey teams. Using continuous process improvement to keep your treatment plan program on point will require focused monitoring and mitigation as opportunities are identified. To be successful, organizations will need to review their treatment planning processes, policies, and practices to ensure they are meeting the needs of their clients and are aligned with regulatory requirements.