Treatment Planning for Person-Centered Care: The Road to Mental Health and Addiction Recovery This Page Intentionally Left Blank Treatment Planning for Person-Centered Care: The Road to Mental Health and Addiction Recovery Mapping the Journey for Individuals, Families, and Providers Neal Adams, MD, MPH Diane Grieder, MEd AMSTERDAM • BOSTON • HEIDELBERG • LONDON NEW YORK • OXFORD • PARIS • SAN DIEGO SAN FRANCISCO • SINGAPORE • SYDNEY • TOKYO Elsevier Academic Press 30 Corporate Drive, Suite 400, Burlington, MA 01803, USA 525 B Street, Suite 1900, San Diego, California 92101-4495, USA 84 Theobald’s Road, London WC1X 8RR, UK This book is printed on acid-free paper ϱ Copyright ß 2005, Elsevier Inc All rights reserved No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopy, recording, or any information storage and retrieval system, without permission in writing from the publisher Permissions may be sought directly from Elsevier’s Science & Technology Rights Department in Oxford, UK: phone: (ỵ44) 1865 843830, fax: (ỵ44) 1865 853333, e-mail: permissions@elsevier co.uk You may also complete your request on-line via the Elsevier homepage (http:// elsevier.com), by selecting ‘‘Customer Support’’ and then ‘‘Obtaining Permissions.’’ Library of Congress Cataloging-in-Publication Data Application submitted British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library ISBN: 0-12-044155-1 For information on all Elsevier Academic Press publications visit our Web site at www.books.elsevier.com Printed in the United States of America 04 05 06 07 08 09 Acknowledgments As all authors note, this book could not have been written without the assistance and support of many people Similar to the team assisting the individual to achieve his or her goals in the person-centered approach, we have also had a team accompanying us on our first book-writing journey Sincere thanks to our editor, Nikki Levy, who warned us, ‘‘writing a book will be the hardest thing you ever do,’’ and she was right! Many thanks to our colleagues who were willing to read, offer comments and support, and even edit portions of the book as it evolved: Ed Diksa, Wilma Townsend, Nirbay Singh, John Morris, Lesa Yawn, Nikki Migas, Wendy Graddison, Yana Jacobs, Penny Knapp, Sherry Kimbrough, and James W Baxter Thanks are also due to the many individuals receiving services we have met in our professional careers, who have been a source of inspiration to us They have taught us how to listen, to have hope, and to believe in them Most importantly, thanks to our respective families, who joined us on this road trip—sometimes willingly, sometimes not—and were the fountains of support, encouragement, understanding, and forgiveness that made writing this book possible To our spouses, Lucy and Marion, and to our children, Alyssa, Caleb, Parris, and Zachary, we will be forever grateful Treatment Planning for Person Centered Care Copyright ß 2004 by Academic Press All rights reserved v This Page Intentionally Left Blank Contents Acknowledgments v Prologue xi Foreword xv Preface xix SECTION I Planning the Trip Introduction: Planning the Trip Person-Centered Care 17 The Value of Individual Planning 39 Treatment Planning for Person Centered Care Copyright ß 2004 by Academic Press All rights reserved vii viii Contents S E C T I O N II Getting Started Assessment 57 Understanding Needs: The Narrative Summary 91 S E C T I O N III On the Road Setting Goals 119 Focusing on Change: Specifying the Objectives 139 Interventions 155 S E C T I O N IV Journey’s End: The Destination Evaluating the Process 179 Epilogue 211 Contents ix APPENDICES Learning by Example Aaron Howard 215 Sally Hamilton 237 Sam Hewlett 253 Carmen Suarez 265 278 Appendix D III Financial Status Current Employment/Education Status for Family ý Father’s Employer Burke Airframes & Unemployed ý Full-time & Retired & Enrolled in Training Program & Part-time & Not Seeking Employment & Enrolled in School & Receives & SSI Support ý Mother’s Employer Merry Maids & Full-time & Retired & Unemployed & Enrolled in Training Program ý Part-time & Enrolled in School & Not Seeking Employment & SSDI & Receives & SSI & SSDI Support Tell us about the employment history of the family We have been working since we came to the United States & Other & Other Family Situation Describe the family’s current living arrangements We all live together: my husband, Carmen, her brothers, and her sisters Please describe who lives with your child, number of rooms, describe your home There are rooms in our house, bedrooms Carmen has her own room since she is the oldest girl Who else has the child lived with since birth? Her grandmother when we first came to the U.S If child is adopted, please indicate and give family history here Tell us about the child’s extended family (aunts, uncles, etc.) The rest of our family still lives in Mexico Please give any other information that you feel we should know We love our daughter very much but we are very worried and frightened for her Carmen Suarez 279 Pi n e Gr o v e Me n t a l He a l t h Cl i n i c Narrative Summary for Carmen Suarez DOB 10/24/87 Carmen Suarez is a 17-year-old, Hispanic female, referred from the emergency room social worker This summary is based on information provided via self-report from Carmen’s mother and from a face-to-face interview with Carmen and her mother Both she and her family have little understanding and insight into the relationship between her recent physical ailments and her grief over the decision to abort her pregnancy last year There is no co-morbidity evident Carmen’s strengths include her ability to get along well with others, her drive to further her education, her sense of responsibility, and her love for her family She is free of medical and substance abuse problems, which is also considered a strength Both she and her parents are willing to receive services, even though they have little knowledge of what that entails They are all motivated by a desire for Carmen to ‘‘feel better’’ and complete high school so she can attend college Understanding the role of culture, identity, and tradition for her and her family—as well as the conflicts around this sensitive issue—may be critical to a successful treatment outcome It appears that Carmen is suffering from an episode of major depression, single episode, largely precipitated by feelings of unresolved grief about an abortion year ago that continues to be a source of conflict for her and tension between her and her parents— especially her father There is some suggestion of low level psychotic symptoms associated with the depression, but it is not clear that they are of clinical significance It is not known if the issues and conflicts about cultural identity are also a precipitating stressor or have been aggravated by the depression—both are possible As a result of the depressive disorder, Carmen has suffered significant distress and impairment in her normal level of occupation and educational and social function that now threatens her ability to graduate high school and pursue future plans for education and independence Carmen and her family seem united in their focus/goal at this time; Carmen feels well enough to return to school and graduate There appear to be no other priorities at this time Anticipated treatment issues to be addressed in the individual plan include the need for a psychiatric evaluation to determine if there is a need for any medications There does not appear to be any immediate risk requiring 24-hour supervision or intensive day treatment There also appears to be an immediate indication for outpatient mental health counseling to work on her unresolved feelings about the pregnancy/abortion, and a need to help her develop strategies for completing high school and going on to college Family therapy may be indicated to help repair the relationships with her parents—particularly her father Anticipated length of services is to months 280 Appendix D Me n t a l He a l t h a n d Ad d i c t i o n Re c o v e r y Pl a n for Carmen Suarez GOALS DOB 10/24/87 Goals should be stated in the individual’s or family’s own words and include statements of dreams, hopes, role functions and vision of life For each individual and family and/or setting, completion of all three sub-goals may not be necessary or appropriate Life Goals ‘‘I want to graduate high school.’’ Service/Treatment Goals Carmen will be able to resume her regular classroom attendance, after school employment and social involvement Life Enhancement Goals ‘‘I want to have my old relationship back with my father.’’ Describe the setting in terms of location, level of care, length of stay and service needs Describe ANTICIPATED DISCHARGE/TRANSITION changes in the individual’s and family’s current needs and circumstances that will need to occur in SETTING AND CRITERIA order to succeed in discharge or transition Carmen is able to attend school regularly Describe the challenges as a result of the mental illness or addictive disorder that stand in the way of the individual and family meeting their goals and/or achieving the discharge/transition criteria BARRIERS Identifying these barriers is critical to specifying the objectives as well as services and interventions in the following section of the plan Symptoms of depression Social anxiety and fearfulness Family conflict and anxiety Carmen Suarez 281 Carmen Suarez Objective Worksheet #1 This objective is related to which goal(s) or transition/discharge criteria (i.e., treatment goal) or barrier? Inability to attend school because of her problems with depression Is there more than one active objective that addresses this goal? & Yes ỵ No Using action words, describe the specific changes expected in measurable and behavioral terms Include the target date for completion Carmen will attend school every day for a full day for weeks without absences as reported by her parents OBJECTIVE #1 TARGET DATE 90 days INDIVIDUAL/ FAMILY STRENGTHS Identify the individual’s and family’s past accomplishments, current aspirations, motivations, personal attitudes, attributes, etc which can be used to help accomplish this objective Past performance, family support, motivation Describe the specific activity, service or treatment, the provider or other responsible person (including the individual and family), INTERVENTIONS and the intended purpose or impact as it relates to this objective The intensity, frequency and duration should also be specified Psychiatrist to meet with Carmen every to weeks for the next months to clarify diagnosis and prescribe medications to reduce acute symptoms of depression so that she can attend class Social worker to provide hour of psychotherapy twice a week for weeks to help Carmen resolve feelings of guilt and loss Case manager to meet with Carmen up to hours/week for weeks as required to coordinate return to school with school counselors and mental health team Family therapy for 90 minutes every weeks to resolve family conflicts that play a role in perpetuating/aggravating Carmen’s problems of depression Carmen to attend weekly peer group at Barrios Unidos community center for teens struggling with issues of identity and acculturation 282 Appendix D Pi n e Gr o v e Me n t a l He a l t h Cl i n i c Discharge/Transition for Carmen Suarez DOB 10/24/87 ý Discharge & Transfer Admission Date 02/12/04 Discharge Date 04/10/04 Reason for seeking Services Carmen had become extremely anxious, worried, fearful, and withdrawn She has significant unresolved feeling of guilt and family tensions following an abortion approximately year ago Carmen and her family had attempted traditional healing without success and following an emergency room visit for an anxiety attack, was referred to Pine Grove for mental health treatment Reason for Transfer or Discharge check below the appropriate reason for termination & Referral to AOD Treatment ý Goals met, no additional services needed & Referral to MH Treatment & Needed services not available & Referral to AOD and MH Treatment ý Referral to AOD Aftercare & Client rejects continuation & Client did not return & Referral to MH Aftercare & Client moved & Increase/Decrease (circle) level of care ý Other Peer community services Diagnosis At Admission Check Primary Axis I ý Code Description Major depression V71.09 No diagnosis Check Primary Code ý 296.20 Major depression & 296.20 & Axis II & At Transfer/Discharge: & No Change 305.00 Alcohol abuse & V71.09 No diagnosis S/P abortion Axis III Description S/P abortion Axis IV Psychosocial/environmental problem(s) Primary support, education Psychosocial/ environmental problem(s) Primary support, education Axis V GAF 43 GAF 75 Carmen Suarez 283 Indicate goal(s) addressed and progress made ý Life Goal ý Service Goal ý Life Enhancement Goal ý Met ý Met & Met & Partially met & Partially met ý Partially met & Not met & Not met & Not met & Discontinued & Discontinued & Discontinued Overall Progress In Treatment ý Much improved & Improved & No change & Worse Comments Carmen and her parents had much strength to build on, engaged actively in the process of meeting their goals, and made substantial progress in a relatively short period of time However, in the course of treatment it became clear that Carmen had a hidden problem of binge alcohol use that was aggravating her problems with mood, school attendance, and work Level of Care/Services Provided Carmen met with Dr Harris for an initial assessment and follow-up pharmacotherapy, participated in weekly individual counseling, and attended peer groups at the local community resource center The family also participated in family therapy sessions The case manager made several visits to Carmen’s school to facilitate and support her classroom reentry Medication Summary Carmen is now taking Effexor 150 mg q AM with substantial relief of her depressive and anxiety symptoms Client’s Response to Treatment and Transfer/Discharge Within one month Carmen reported feeling much better and with the support of her family and case manager was able to return to school full time after about weeks When her problems with alcohol became apparent Carmen began attending AA for teens times a week and reports that it has been especially helpful Her relationship with her father is improved, although there are some tensions that remain Continuity of Care Recommendations Carmen will continue with her antidepressants with her family doctor and will also continue with AA and the peer group at Barrios Unidos Carmen and her father may return at some point in the future to attempt to resolve issues between them This Page Intentionally Left Blank Index Addiction Severity Index (ASI), 64, 70 Addictive disorders culture of, diagnosis of mental health, 99–100, 101f EBP’s principles, 6–7 goals, 132–133 relapse possibility, 190 Adolescent Drinking Index (ADI), 70 Alcoholics Anonymous, 27, 205, 209 American Association of Addiction Medicine (ASAM), placement criteria of, 185 ASI See Addiction Severity Index Assessment See also Reassessment approaches to, 59–60, 67 competencies required for providers’ successful, 79–81, 80t, 102–103 comprehensive, 65 cultural formulation provided by, 70, 89, 264–282 culture, 24–25, 62, 67–70, 78–79 cycle of, 62–64, 63f data gathering in, 72–73 defining, 58 documentation of, 63, 183–184 domain-based approach to, 65, 73–75, 187 environments for, 69 failure of, 181–182 family beliefs, 81 goals, 83, 125 information collection, 64–65 instruments for standardized, 70–71 language, 80–81 Treatment Planning for Person Centered Care Copyright ß 2004 by Academic Press All rights reserved level of care determined, 77–78 motivation, 81–82 motivational interventions, 83 objectives/goals, 145, 145f occurrence points, 180 as ongoing, 62 of ongoing services, 190 person-centered, 57, 58–81, 63f, 77t, 80t, 85–90, 215–282 process of, 57–58 provider’s attitude, 72–73 reassessment, 63–64, 88, 180, 253–263 recovery planning worksheet, 84–85 recovery’s stages, 76–77, 77t relationship established during, 58–60 strengths-based approach, 59, 61, 75–76 tools for person-centered, 83 Attitude in assessment, 72–73 of health care providers, 35 Beck Depression Inventory-Second Edition, 70 Behavioral and Symptom Identification Scale, 70 BPRS See Brief Psychiatric Rating Scale Brief Psychiatric Rating Scale (BPRS), 70 CAFAS See Child and Adolescent Functional Assessment Scale 285 286 Index care See Person-centered care Child and Adolescent Functional Assessment Scale (CAFAS), 70 Choice in objectives’ creation, 149–151, 150f, 160–162 Communication in individual planning, 50 in person-centered care, 28–29 Competencies for individual planning development, 49–52 mental health workforce, 48–49 for provider’s successful assessment, 79–81, 80t, 102–103 in systems change of providers, 48–49 Culture assessment influenced by, 78–79 in assessment/individual planning, 24–25, 62, 67–70 defining concept, 68–69 family, 29–30 goal identifying role of, 126–127 individual planning, 31 as intervention consideration, 161 of mental health field, mental health symptoms shaped by, 78–79 in narrative summary, 100–101 objectives as appropriate to, 149 Developmental disabilities, Diagnosis co-occurring mental health/addictive, 99–100, 101f from narrative summary, 98–99 objectives, 151 as shared with family, 99 Discharge criteria for, 208 goals linked to anticipation of, 125 individual plan including plan for, 131, 188 narrative summary including planning for, 101–102 needs of family/individual assured, 190 providers’ planning for, 188–189 questions, 189–190 reassessment, 190 review process, 189–191 summary document, 191, 209 Diversity See also Culture in person-centered care, 24–25 Documentation assessment, 63, 183–184 description, 183–184 individual planning, 32–37, 33f, 182–183 standards/formats, 183–184 EBP See Evidence-based practice Environments for assessment, 69 of health care, 23, 23f of interventions, 158 objectives and treatment, 147–148, 186 of person-centered care practice, 14–15 Evaluation See also Assessment; Reassessment as continual activity, 179 of health care providers, 34–36, 191–192, 193t–199t outcomes for individual, 201, 205–206, 205t provider’s self, 182 recovery criteria, 32–34, 33f Evidence-based practice (EBP), 6–7 Experience of Care and Health Outcomes Survey, 34 Family assessment/beliefs, 81 changing/improving health care practice, 33–34 diagnosis shared with, 99 fostering independence, 188 goals of provider vs., 127 goals respected by provider of, 28, 122–123 as individual plan team member, 45 interventions, 160–162 involvement in person-centered care, 29–30 narrative summary, 92–93 objectives, 140, 146–147 provider evaluation, 192 recovery support, 29 transition needs, 190 Goals See also Objectives achievement, 179, 181 addictive disorders, 132–133 appropriateness, 133, 134t assessment, 83, 125 barriers, 138, 208–209 Index children/adolescents, 129–130 creating person-centered, 130–136, 134t culture’s role in identifying, 126–127 developing, 125–127 enhancement, 121 errors by providers with, 123–124 evaluating individual plans’, 135–136 expectations in attaining, 131 function, 122 identified in individual planning, 61 individual planning examples, 136–138, 216, 238, 248, 251, 253, 260, 269, 279 language, 133, 134t life, 120, 123, 137 manageable, 212 narrative summary, 98, 145–146 objectives, 121, 124, 145–146, 145f parsimony in setting, 134–135 planning, 119 priorities in setting, 127, 135 provider, 124, 130 reassessment, 187–188 re-connecting with past to identify, 131–132 recovery, 189 requirements associated with health care, 124 respecting, 28, 122–123 service/treatment, 120–121, 123 sobriety, 132–133, 208 statements, 119–120, 125–126 transition/discharge from services, 125 types, 120–122, 130–131 Health care See also Evidence-based practice; Person-centered care; Individual planning assessment determining level of, 77–78 billing/revenue, 43 environment, 23, 23f family level improved, 33–34 IOM, 20–22, 22t, 33, 33f language importance, 28–29 levels, 22–23, 23f, 33–34, 33f maintenance, 189 minorities, 24–25, 67–68 multidisciplinary teams for services, 27 person-centeredness, 9–10 re-designing, 20–22 values/principles, Health care providers abilities/knowledge, 35 attitudes, 35, 72–73 287 benefits from individual planning, 41 bio-psycho-social perspective of individuals’ needs, 167, 171 children/adolescents, 129–130 competencies, 48–49, 51, 79–81, 80t, 102–103 concerns made clear, 161–162 data, 95 documenting assessment, 63 education/training, 52–54 evaluating, 34–36, 191–192, 193t–199t goals, 122–124, 127, 131–132 individual’s relationship, 7–9, 11, 26–27, 45, 59, 92, 211 intervention developing by, 166–167 narrative summary, 92–93, 94–96 natural supports, 163 negotiation between individual, 97 objectives and role, 141–142 person-centered care role, 30–31 perspectives, 128–129 priorities, 96, 128–129 record review, 199–200 respect for individual/family by, 28 risk/choice, 149–151, 150f self-evaluation, 182 target dates, 185 transition/discharge planning by, 188–189 Individual planning See also Assessment; Goals; Interventions; Narrative summary; Objectives accreditation standards/regulations, 4, 41–42 addiction recovery practices, annual review of, 188 communication in, 50 competencies, 49–52 culture, 31 destinations, 13 developing/documenting/implementing, 32–37, 33f discharge/transition planning, 131, 188 documentation’s importance, 182–183 education/training for, 10–11 face validity, financial incentives, 54 framework/perspective needed to understand, 11–12 functions of, 39–40, 40f goals, 61, 119–122, 134–136 health care providers’ benefits, 41 288 Index Individual planning (continued ) history, 4–6 importance, 181–182 language used, 31 managing complexity, 46–47, 47f as map, 12–13, 13f medical necessity of services, 42–45 natural supports, 172–173 outcomes, 40–42, 103 person-centered care, 20, 27–31, 30t provider’s education/training for, 52–54 reassessment points, 180 recovery goals of individual reflected, 189 review, 208 solutions for utilizing, 52 steps, 60–62, 60f strengths-based approach, 143 teaching practical skills, 53 team role, 45–46, 50 time frames, 185 treatment access, 40–41 what v why in, 66–67 workforce competency, 48–52 Instruments, for standardized assessment, 70–71 Intentional Care Performance Standards, 150–151, 150f Interventions assessment, 83 biological, 171 care level, 165–166 change, 167, 168t–171t, 171 culture as consideration in selecting, 161 defining, 155–156 developing, 165 environment, 158 evidence-based, 163–165 examples of, 173–176, 207–208 family, 160–162 narrative summary as, 92 natural supports as, 175–176 needs/objectives, 164 objectives, 155, 159 as person-specific, 163 psychological, 171–172 purpose specified, 158–159 record review, 206–207 recovery phase, 163 services’ amount specified, 159–160 social, 172 specificity, 156–158 strategies for developing, 166–167 team’s role, 175 time elements, 158 Involvement of family in person-centered care, 29–30 Language assessment, 80–81 goals, 133, 134t health care, 28–29 individual planning use of, 31 objectives’ use of, 147–149 person-first, 29, 102 service/access barriers due to, 79 Level of Care and Utilization Scale (LOCUS), 114, 165 domains of assessment for adult, 77–78 reassessment, 185 LOCUS See Level of Care and Utilization Scale Maintenance, in health care, 189 MAST See Michigan Alcoholism Screening Test Medicaid, 42 Medical necessity components, 43–45 planning services, 42–45 Medications, individuals not taking, 66–67 Mental health See also Individual planning addictive diagnosis co-occurring, 99–100, 101f culture of field, culture/social contexts shaping symptoms, 78–79 EBP’s principles as applied to services, 6–7 history of recovery, 18 individual/provider relationship, 7–9 needs, 100 partnership, 27 psychoanalytic/psychodynamic tradition of practices for, 8–9 self-determination, workforce competencies, 48–49 Mental health consumer/survivor movement, 18 Mental Health Statistics Improvement Program (MHSIP), 34 consumer survey, 192, 193t–199t MHSIP See Mental Health Statistics Improvement Program Michigan Alcoholism Screening Test (MAST), 70 Minnesota Multiphasic Personality Inventory (MMPI), 70 Index Motivation assessment, 81–83 strengths-based approach to individual planning, 143 Narrative summary barriers, 108–109, 109f creation, 103–108 cultural formulation, 100–101 data included, 94 diagnosis, 98–99 elements included, 109–112, 111f examples, 112–115, 215–282 family, 92–93 fishbone diagram, 108–109 function, 92 goals, 98, 125, 145–146 health care provider’s role, 92–93 individual planning process, 91 intervention, 92 narrative outline approach to creating, 106–107, 113–114, 238–252 objectives identified in, 115 prioritization, 96–97 problems encountered, 94–96 requirements/standards, 93–94 six P’s approach to creating, 104–106, 112–113 team coordination, 103–104 time/human resources needed to complete, 95–96 transition/discharge planning, 101–102 Natural supports community resources, 172–173 example, 207 intervention, 175–176 strength for individual, 162 transition from provider dependence, 163 use, 162–163 Needs bio-psycho-social perspective of individual’s, 167–171 family’s transition, 190 hierarchy, 127–128 interventions, 164 mental health, 100 Objectives achievable, 148 activities, 144 289 assessment/goals, 145, 145f attainment, 140, 146 barriers to goals, 145–146 choice, 160–162 culture/age/development appropriate, 149 deliverables, 184–185 determination of status, 181 development, 146, 149 diagnosis, 151 environment of treatment, 147–148, 186 examples of person-centered approach to creating, 151–154, 232–237, 249, 252, 261–263, 280 family’s role in attaining, 140 features, 140–141, 147 formulating, 143–144 goals, 121, 124, 139–140 interventions v., 155 language use, 147–149 manageable, 142 measurable, 147 narrative summary, 115 parsimony in creation of, 145 pitfalls, 143–145 provider’s role, 141–142 risk/choice, 149–151, 150f services, 160 success, 141 target dates specified in, 184–186 team’s role, 141–142 time frames for attaining, 142, 148 as understandable, 148 unmet, 186 Outcomes individual planning as identifying, 40–42, 103 individual’s evaluation/recovery, 201, 205–206, 205t Person-centered care See also Individual planning assessment, 57–81, 63f, 77t, 80t, 85–90, 102–103, 215–282 barriers, 26, 36 communication in, 28–29 components of, 166 concepts translated into practice of, 14–16 culturally competent, 68 development of plan, 10 diagnosis, 98 diversity, 24–25 endorsement, 36–37 290 Index Person-centered care (continued ) evidence, examples, 10, 212–214 family involvement, 29–30 feedback, 192, 193t–199t, 199–201 financial incentives, 54 future, 8–9 history, 4–6 importance, 1, individual planning, 20, 27–31, 30t individual/provider relationship in, 11, 26–27 language use, 29, 30t literature, 10–11 mandates on planning, 48 narrative summary, 92–93 on-going help, 190–191 practice environment, 14–15 principles, 15 provider’s role, 30–31 recovery, 17–20, 32 respect, 28 roots, 25–26 self-determination, 25–26 structural barriers, 36 summary document, 191 SWOT analysis, 15–16 systems change, 36–37 tension in commitment, 164 value, 211 Pharmacotherapy, 190 President’s New Freedom Commission on Mental Health report (2003), 7–8, 12 Priorities goal-setting, 127, 135 hierarchy of needs, 127–128 narrative summary, 96–97 providers, 96, 127–129 Providers See Health care providers Reassessment assessment and, 63–64, 88, 253–263 discharge/transition, 190 formal annual, 187–188 goals emerging in, 187–188 LOCUS and, 185 points, 180 record systems, 187–188 unmet objectives, 186 Record review accreditation standards, 199 examples, 206–209 expectations/values implicit in, 200–201 interventions in, 206–207 organization of quality, 200–201, 202t–204t provider’s role in, 200 Recovery change stages of, 81–82 criteria for evaluating, 32–34, 33f defining, 18–19 education, 126 examples, 212–213 family support, 29 history of mental health, 18 individual plan’s importance in practices for addiction, individual plan’s role, 20, 31–32 interventions matched to phase, 163 mental heath consumer/survivor movement, 18 milestones, 205–206 misconceptions, 189 person-centered care and, 17–20 person-centered outcomes in, 201, 205–206, 205t planning worksheet, 84–85 as process, 17–18 provider’s role in process, 30–31, 214 reconsidering stage, 185 stages, 76–77, 77t Relationships assessment established, 58–60 children/adolescent and providers, 129–130 individual/provider, 7–9, 11, 26–27, 45, 59, 92, 211 SASSI See Substance Abuse Subtle Screening Inventory Screening, 58 SED See Severe emotional disturbances Self-determination, in person-centered care, 25–26 Severe emotional disturbances (SED), services provided to children with, Sobriety, as goal, 132–133, 208 SOCRATES See Stages of Change Readiness and Treatment Eagerness Scale Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES), 71, 208 Substance Abuse Subtle Screening Inventory (SASSI), 71 Index Summary document discharge, 191 information included, 191, 209 Symptoms, culture as shaping mental health, 78–79 Texas Recommended Authorization Guidelines (TRAG), 185 Time interventions’ element, 158 narrative summary, 95–96 291 objectives attained in frames, 142, 148 The Tipping Point (Gladwell), 14 TRAG See Texas Recommended Authorization Guidelines Transition See Discharge Triage, 58 University of Rhode Island Change Assessment (URICA), 71 URICA See University of Rhode Island Change Assessment This Page Intentionally Left Blank .. .Treatment Planning for Person-Centered Care: The Road to Mental Health and Addiction Recovery This Page Intentionally Left Blank Treatment Planning for Person-Centered Care: The Road to Mental. .. expectations for coherent and visible planning Yet some of the implicit values and expectations of the field and the traditions of practice were antithetical to the idea of planning Moreover, the skill and. .. transference and power differentials in the relationship between the individual and the provider The new emerging model for the mental health and addictions field clearly calls for reexamination and re-alignment