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Assessment Tools and Patient Placement Criteria

This episode was pre-recorded as part of
a live continuing education webinar. On demand CEUs are still available for this
presentation through ALLCEUs. Register at ALLCEUs.com/CounselorToolbox. I’d like to welcome everybody to today’s
presentation on assessment and placement. Patient placement tools the ACM FAR’s
and the locus over the course. In the next hour we’re going to differentiate
between level of care guidelines and patient placement criteria which are two
things that you use especially if you are involved with insurance billing
we’ll learn about the functional assessment rating scale which is
required in some states we’ll learn about the ACM which is required by most
insurers but not all of them some use the locus instead so we’re also going to
learn about that and we’ll discuss why these tools are used and how they can
benefit the clinician and the clients patient placement criteria suggest a
treatment intensity level that meets the needs of the client so the a sam is
actually the AC MPP c1 and to patient placement criteria the locus has also
has guidelines for what level of care the person should generally be at now
the patient patient placement criteria I’m going to try not to say that too
many more times tells you for example the person probably would benefit from
being in intensive residential or partial hospitalization but it doesn’t
specify to any great degree what services would be provided in that level
of care that’s usually governed by the insurance companies and/or the state in
which the person resides and you live the level of care guidelines are defined
by insurance providers and the state in some cases and these are the guidelines
that if you google like Blue Cross and Blue Shield level of care guidelines
residential or intensive outpatient you will come up with this list of things
that B CBS says has to be there in order to qualify for what they call IOP
services and the criteria differ a little bit between each insurance
company so if you’re working with multiple insurers you want to make sure
that you create a situation in which you’re meeting the most stringent
requirements of all places like how quickly does someone need to see a
psychiatrist how quickly does someone need to have their treatment plan
completed so why do we use these it provides a biopsychosocial approach to
care management which is really important because biopsychosocial is not
only kind of the wave of the future but it also takes into account a lot more
than just how the person’s thinking or you know what might be going on mood
wise with them we want to look at what is their environment what medical
conditions might be contributing to or exacerbating their mood conditions it
assists in defining potential strengths and obstacles to the recovery process as
the client sees them and when I talk about these things now the
ACM is typically used for addictions it’s put out by the American Society of
addiction medicine always got to remember what acronyms stand for however
ACM also recognizes that co-occurring disorders addiction and mental health
are the expectation not the exception so they’ve expanded their criteria to
include mental health but either either one can really be applied to mental
health diagnosis and/or addiction they help guide treatment planning for
biomedical issues because it brings it to the forefront and says dude does the
person have any biomedical issues that might be causing a problem I mean if
they’ve got hepatitis or if they’ve got chronic pain that might be exacerbating
their mood issues go figure so we want to make sure that we’re
paying attention to all the things that might be disrupting their sleep and
causing depression or anxiety or you know interpersonal problems obviously
they all look at cognitive emotional and behavioral issues that’s generally what
people come to us for so we would want to look at that they consider
motivational issues how ready is the person to change you may see even in
mental health situations clients who are involuntary or less than voluntary maybe
their attorney said they had to go get counseling or their spouse told them you
need to go get this taken care of because I’m tired of it those are not
the people that are coming going I got a problem and I’m ready to do whatever it
takes to get better so we want to look at where their motivation is because
then we can create a treatment plan that uses motivational techniques to help the
person move towards the goals that are important to them and also create goals
that you know by default are also what you know the referring person wanted
them to get out of it we’ll talk about that a little more later and the
recovery environment if you take a person who is trying to recover from
depression or anxiety and they are living in an environment that
is unstable that is just replete with people who are angry and stressed out
and there’s a lot of chaos how is that going to affect them versus if they are
in a stable living environment that I mean every environment has its stressors
but one that is more stable and supportive and all that happy stuff I
think we can see pretty obviously that recovery environment does play a huge
role and when I talk with my clients about recovery environment we talk about
not only where they live but also where they work because they spend 40 plus
hours a week generally at this place that they work so that is part of their
recovery environment if that place is chaotic and stressful and just miserable
to be in I mean they may not be able to leave it but we need to pay attention to
that and help them figure out how to deal with those stressors or buffer
against those stressors so it doesn’t keep them from making progress and these
tools can also assist us in providing specific measurable achievable realistic
and time limited goals SMART goals because it helps us break it down
instead of just treating depression which is kind of this big global meta
concept thing or identifying okay you want to address the biomedical condition
of your diabetes you want to address your recovery environment specifically
as it relates to getting along with your co-workers so it helps us narrow down or
specify different treatment goals that the person may need to work toward in
order to achieve their over overarching goal of recovery happiness however you
define it however they define it so we’re going to start with the far I love
the FAR’s a lot of people have never heard about the FAR’s which is why I put
it out here even if your state doesn’t require it it might be worth looking
into in terms of having it as a tool to use with your clients and to help them
use to create more specific goals and objectives is put out by the or
was initially created at the University of South Florida in Tampa and you can
get your Fajr certification online for free if you want to get certified in it
you can also download the manual which is a link to it is included in your
classroom if you like the FAR’s and you want to use it as sort of a ancillary
tool it’s not a placement guide per se it helps you identify which problems are
the worst and specifically why they’re being rated that way and if you’ll
understand more when we look at it and it helps more clearly define anchors for
behavioral observations I found that when we started using it at the clinic I
worked at in Florida the clients actually were a lot more excited because
they could see notable changes from treatment plan assessment to treatment
plan assessment which we did every thirty days and they could see their
numbers going down which is good you want to go down more towards one where
it’s not much of a problem or zero no problem at all so the FAR’s has multiple
things that it assesses and it’s ranked on a nine-point Likert scale which can
be a little overwhelming at times they do give you word anchors here so you can
use those so for depression for example if a client comes in with depression we
may just normally say alright there they’re presenting with the press of
issues they meet the DSM criteria and be done with it
this actually says what things are going on with this client that we are using to
define the depression or that might indicate that there’s depression going
on so we can mark off those and obviously the more things you Mark the
more weight it might give to that problem now for example under depression
it has anti depression meds obviously if you mark that and they are relatively
stable on their antidepressants that’s wonderful depression may be a less less
than slight problem even though it has
they marked so it gives you an idea about where you’re standing
anxiety obviously again it has anti-anxiety meds now that can be a
cause for concern for some of our clients maybe they don’t want to be on
those meds anymore it’s also important to understand whether the meds are
working if they’re presenting with symptoms of depression or anxiety that
are in your moderate range or above for example and they’re on medication for
anxiety or depression already then we want to talk to them about how much
improvement of you seen since you started taking this medication and
advocate for them as needed maybe to go back to their physician or psychiatrist
and talk about the treatment plan or what may be going on if that meds
working for them maybe it needs to be increased maybe they need to switch all
again altogether to a different type of antidepressant or anti-anxiety hyper
effect thought processes cognitive performance medical and physical now
you’re going to go through and you’re going to mark each one of these if the
client is having problems for example with cognitive performance and you have
a short attention span that can be a treatment goal in and of itself
cognitive performance is pretty broad but if we can define it as something
small and maybe it is when client presents it’s a severe problem it’s a
seven and it treatment reassessment we’ve moved it down to a five or a six
the client can see on that one particular problem they’ve made progress
most of our clients present with multiple problems multiple issues
multiple presenting symptoms and if they can see progress in one then they can
see that they’re making progress even if they’re not feeling a ton better they
can see that they’re making baby steps and that often is motivating for a lot
of our clients and it can help when you’re sending things back and trying to
get additional services or additional days authorized from the insurance
provider if you can show what your monitoring other things the FAR’s
measures and I’m not going to distribute each one of these in super detail
traumatic stress substance use interpersonal relationships you may have
somebody who has four different treatment plan problems just under
interpersonal relationships and that’s fine you can choose a place to start
addressing or ask the client what is the most important thing for you or what do
you think would be most helpful for you to get you started moving toward where
you want to be and maybe it’s their traumatic stress maybe it’s their
relationships that’s going to be kind of up to the client what they’re most
motivated to work on if they have if you’ve identified 15 different things on
the FAR’s it’s going to be overwhelming to hand them a treatment plan and say
okay we need to work on all this they’re gonna be like what that would be like
starting college and then giving you your entire curriculum and say okay
we’re going to start working on all of these classes right now you would have
looked at the advisor like they had three heads so we want to help them
narrow it down and learn how to prioritize which things they’re most
motivated to work on and they think are going to be most helpful in moving them
in the right direction because as they experience positive changes they’re
presenting symptoms or presenting issue will probably show some positive effects
which will keep them moving forward family environment and relationships are
different because you know again the environment your recovery environment is
different than your relationships necessarily socio legal issues when
we’re looking at conduct disorder when we’re looking at people who might have
substance abuse issues and you know duis things like that that becomes a
treatment plan issue potentially maybe they’re working towards going to court
for the getting off probation for their DUI or something it’s important to know
what what some of their motivators are a lot of times socio legal
can be used as a motivating factor is also as a treatment plan problem if
they’ve got pending charges doing well in treatment generally looks good to the
court for example if they’re on probation the same thing it’s a you can
use it as an advocacy sort of thing work school problems some people have some
basic issues and problems with what I consider activities of daily living so
we want to help them look at work attendance and how long they stay
employed and how they get along with others and you know presentation at the
office if they’ve been fired a bunch of times let’s take a look at that was it
an interpersonal issue or was it some sort of skill set that they didn’t have
and activities of daily living functioning you may or may not in your
particular setting handle this a lot of people consider this more case
management however banking back to Maslow’s hierarchy if they don’t have
enough money to buy food and keep a roof over their head they don’t have a safe
place to live and they can’t afford medications or medical care they’re
going to have a hard time dealing with any sort of depression self-esteem or
relationship issues so however you consider it if there are ADL issues you
may need to refer out if that’s not something you treat at your facility the
ability to care for their self most of the time this is going to be a non-issue
for a lot of our clients that we see in outpatient every once in a while it does
become an issue I’ve worked with some clients who are schizophrenic and they
are on the fact team which stands for I don’t remember what it stands for
but it’s an intensive case management program where the case managers and or
counselors go around and they touch base with people in their residence in their
home to make sure the person is taking their meds and showering and doing what
they need to do it assesses danger to self and others you know you’re going to
do that on any good assessment anyway and identifies any security management
needs so this the FAR’s is really
comprehensive at helping you identify any of those minutiae problems in
addition to the big problems that may need to be addressed or considered when
doing your case conceptualization what is it that’s contributing to this
person’s current mental health state so the FAR’s is optional in many states
it’s required for example at least when I left Florida it was required by any
state that received funding from from the state by any treatment center that
received funding from the state so if you’re not familiar with it take a look
at it if you like it great if not you know there are other tools out there
that may be more useful or you may already have an assessment tool that you
love and that’s awesome the ACM is patient placement criteria we
generally in the treatment centers that I’ve been in the insurance companies and
the organizations required the ACM to be done add assessment reassessment and
discharge so pretty much every 30 days the ACM assessed your physical dimension
it asks about acute intoxication withdrawal potential now remember this
originated as a patient placement criteria for clients with substance
abuse issues so that that one is still on there
your client even if they are not an alcoholic or a drug addict may be using
alcohol excessively right now to deal with their depression their grief
whatever’s going on so if that’s an issue and you think it is an issue of
concern you can mark that off bio medical conditions what other things are
going on that may or may not be stable that may or may not be contributing to
this current situation and that can be anything from chronic pain to hepatitis
to HIV to you know you name it so talking about the client about what
medical conditions do you have going on it becomes more important if you’re
going to try to place somebody in residential but
it’s you know less important in IOP or outpatient services because we’re going
to refer out to a to a physician we don’t have to figure out whether we can
manage it on site then it goes on to ask about emotional and cognitive issues
what emotional or behavioral issues are present and how serious are they have
treatment resistant or accepting are they so if they’ve got major depressive
disorder maybe they have some suicidal ideation and they are ready for change
they are there they are wanting to help help they’re wanting treatment that’s
far different than someone who is brought in on a Baker Act brought in
involuntarily who is not wanting to change they are still in that state
where they are wanting to harm themselves or someone else so that will
help you kind of gauge what level of care that person may be best at
obviously if they’re actively suicidal or homicidal it’s sort of a no-brainer
about the level of care you’re not going to put them in once a week outpatient
but this helps you you know really demonstrate because as they always say
if it’s not written down in the chart it didn’t happen you can demonstrate that
you went through in a systematic way not only to identify the issues that needed
to be addressed for treatment planning but you identified any issues that might
make the treatment placement more important where someone needs a higher
level of care to maintain their safety behavioral looking at relapse or
continued use potential continued use obviously we’re talking about substances
but behaviorally we also want to look at your mental health issues if someone was
self harming if they were cutting if they were engaging in binging and
purging behavior if they were doing some using some sort of compensatory
behavioral thing in order to deal with depression or anxiety or grief or anger
that’s going to be important for us to identify how safe is it basically
is what the ACM is getting at to have somebody in once a week do they meet
once a week care or do they really need to touch base more often in order to
maintain any gains that they’ve gotten from higher levels of care and the
social and environmental aspect what is their recovery environment like do they
have social support is it a safe stable environment where the same people live
there and they relatively they get along with them relatively well or is it a
chaotic violent destructive environment may or may not be able to change that
but we can identify whether you know if it’s not a supportive environment we may
recommend a higher level of care and they score out for a higher level of
care by the same token if they choose not to maybe they score out for
residential on the a Sam you know you go through and do all your checkmarks and
it says yep the best placement would be residential for you but this person says
now can’t do residential or I won’t do residential and they have an option
which generally they do then we want to understand that recovery environment
might be a primary priority in treatment planning so how can we help this person
make mental health and/or substance abuse related gains you know start
getting better in an environment that’s not 100% conducive so you’re a cm levels
are really pretty simple early intervention which is basically
getting to people before there’s a big problem you know before it becomes an
addiction before they become clinically depressed and relaxed prevention so it’s
at the beginning at the end when they trying to prevent them from ever having
to use services giving them the tools that they need and at the end helping
them maintain their gains probably once a week group this is really high level
if you will or services or you’re not going in depth with the person it’s
mainly psycho ed and community building outpatient is
less than nine hours a week and that’s what most of you probably are involved
in you’re probably in private practice or working on an outpatient basis where
you’re seeing clients once a week maybe three times a week for group it’s less
than nine hours per week so that’s a pretty broad range of what you can
qualify for outpatient generally insurance is not going to pay for nine
hours of individual a week so you know there’s some question about how to build
for services but it does not meet the standard of intensive outpatient until
it becomes nine or more hours a week partial hospitalization this is
basically people who don’t want to be in residential but they need somewhere safe
to be the majority of the time but they’re not at work so oftentimes it’s
like after work from 6:00 until 10:00 five days a week at 20:00 hours and
maybe optional Saturday and Sunday services not services but Saturday and
Sunday groups to help them when there’s downtime people in PHP need a whole lot
of structure in order not to start decompensating residential pretty
self-explanatory they’re going to be staying there 24 hours a day seven days
a week level four is medically managed
inpatient services and these are the people who need to be in a psychiatric
hospital they need to be somewhere where physicians are on duty all of the time
because of medical conditions psychiatric conditions that may require
that level of intensity so the ACM is what’s used at a lot for a lot of
facilities especially ones that provide substance abuse services and I think
partly and I’m guessing here purely speculation from using all of these
instruments the ACM is really quick to do once you get used to it you can do it
in under five minutes figure out where somebody scores and be done with it the
locus on the other hand measures a lot of the same things but it
is a much longer instrument to use so some agencies may may not want to use it
certain insurance companies require the locusts to be used so okay so what does
the locusts measure very similar to the ACM the risk of harm how what is the
risk that they are going to harm themselves if they are in a outpatient
situation minimal so that would probably be outpatient low again outpatient once
you get higher you’re probably going to move towards if they have a high risk of
harming themselves you want them to be in residential their functional status
and on the locusts you can go through it you can download it in your class they
give you definitions for what each one of these represents so they are anchored
so you know what minimal impairment is defined as but I didn’t figure you’d be
interested in going through the minutiae today somebody with minimal mild
moderate serious or severe impairment you can see that the lower the score the
lower the intensity of services they’re probably going to be put in so we’ve
looked at risk of harm and functional status then it goes to medical addictive
and psychiatric comorbidity which is a little bit different than the a Sam
which separates biomedical from cognitive and behavioral but you know
we’re still looking at kind of the same thing when they talk about comorbidity
they’re saying you have your presenting issue whatever that is
depression anxiety addiction what other things are going on so do you also have
medical conditions that are comorbid to the primary presenting issue a lot of
people will have some level of comorbidity however it may not be severe
you may not have severe medical issues and severe psychiatric issues it could
be some minor chronic pain that’s being managed pretty well and your presenting
issue which is maybe major depressive disorder
so you’re getting an idea about whether there’s anything else that we need to be
attending to recovery environment assess on both a Sam and Locust your level of
stress and your level of support I do like how the locust breaks this out how
stressful is the environment remember I said I talked to my clients about home
versus work because both of those are their recovery environment it just
happens to be which time of day so what is the level of stress and what is the
level of support in each environment maybe they have an extremely chaotic
stressful work environment with our home environment is super supportive so with
their level of support at home even though they’ve got a fair amount of
stress in part of their recovery environment they may be able to manage
and our treatment and recovery history when they’ve gone to treatment before
assuming they have what happened did they respond well well great then we
know that we probably can tune up some skills that they had before they already
know what works for them that’s awesome if they’ve had moderate or an equivocal
response so you’re looking at it going not sure if it helped very much that’s
going to be more of a problematic because we don’t know what’s going to
work for this person we have an idea that what they did before didn’t work
super well or there was something that prevented it from working well sometimes
motivation levels or the way it’s presented can prevent prevent them from
benefiting from treatment as much or maybe something just completely
different that was going on maybe they had somebody in her family died and they
weren’t focused on treatment at that point but we want to look at what their
history has been if they’ve had a negligible or poor response then we may
need to look at a higher level of care now one of the rationales for this is
that if you move them into higher levels of care then your extra cating them if
you will from some of the stress SURS that may have distracted them and
kept them from being as engaged or treatment from being as effective as it
could have been this may or may not fit with your clients history so you want to
look at really consider this what went on that may have prevented the person
from getting maximum benefit from that treatment program it may have just been
a poor fit and so that’s something that we want to consider and not say well you
need a higher level of care if the prior level of care maybe act adequate and
accurate but the last program was not a good fit for that client engagement
number one is optional optional optimal the client is there they’re ready to go
in substance abuse recovery and even some mental health recovery we’re
starting to look at the stages of change more this would be the action stage the
client is there they’re like I’m done with this I’m sick and tired of being
sick and tired help me figure out what to do
level 2 the person is preparing and determined to do something about it in
the very near future they may just be dipping their toe in the water not quite
ready to commit yet level 3 4 & 5 the person’s really not engaged in the
treatment process now if somebody is not engaged in the treatment process it may
or may not benefit them to be in a higher level of care but you’ll see in a
few minutes the locus dimensions will push them more towards a higher level of
care for their own safety or two hopefully maximize treatment gains so
how do we use all this information you rank them on all these sub scales you’d
give them between a 1 and a 5 what do you do so level 1 is basically your
prevention your early intervention up to 3 hours a week now remember there was a
much different definition with with the ACM but for locusts is up to
three hours a week the risk of harm is a two or less so they’re pretty much
pretty much no risk of harm they’re a good level on their functional status
again a – or or less comorbidity is it – or or less so they don’t have a lot of
compounding issues in their recovery environment their treatment and recovery
history they’ve always done pretty well when they’ve tried and some clients
don’t have any history so you might not have anything to put here
their engagement they’re highly engaged they’re ready to do something so these
clients are probably going to benefit from your lower intensity services if
you will their level to which which is your low intensity IOP is more than
three hours a week the risk of harm is still a two or or less because they’re
living in the community their functional status they need to maintain a 3 or less
they need to be relatively independently functional on their own but there can be
a little bit more impairment we still are looking for low comorbidity and a
supportive low stress recovery environment positive recovery history
and an engagement we want them to be optimally engaged we want them to be
ready to go for Li o P again these are people who are not going to be seeing
you more than a few hours a week so they need me to be able to maintain gains and
not be compensate without seeing you every single day or multiple days
multiple hours multiple days a week level three on the locus usually equates
more to IOP and PHP anywhere from nine hours to 20 hours a week these people
have a higher risk of harm but it’s still not one where you’d be concerned
as a clinician that the person needs to be in in an inpatient setting their
functional status is still really good they’re able to for the most part do
what they need to do to function their quality of life
may not be optimal if it was they probably wouldn’t be seeing us however
they’re able to feed themselves bathe you know do the basic things comorbidity
is still pretty low for IOP and PHP we want to make sure that they are not
going to suddenly decompensate medically if they’ve got a medical issue or an
addiction issue going on that’s not their primary presenting issue the
comorbid issues are relatively under control and not causing a significant
impact on the primary presenting issue their recovery environment can be a
little bit more chaotic but we still want it to be relatively supportive and
not overly stressful if it’s overly stressful they’re probably not going to
be able to focus on treatment and do the things they need to do which will lead
to low compliance and potentially low benefit potentially some clients will
not go to a higher level of care even if their recovery environment is not super
supportive so we just need to have that out there and know how we can work with
it and their engagement can be a little bit less for IOP and PHP if they’re just
not like all over it and super enthused about doing what needs to be done and
doing their homework assignments and all that kind of stuff you know that’s okay
because you’re going to see them more often so you can provide more prompts my
son is in high school right now and I kind of think of it this way as you know
I see him every day so I can prompt him to do his homework do his assignments
make it get his stuff done if I need to and you know follow up and do that sort
of thing because he’s got all that engaged in some of the stuff he’s
studying right now you know I’m just it is what it is I’m a realist hopefully
when he gets to college and he only sees his teachers you know once maybe three
times a week he’s going to have more enthusiasm and will be more self
motivated so he won’t need somebody kind of looming over him
levels four through six on your locus correspond to residential I didn’t see a
need to go through those in high level minutiae but you can get an idea how
those the ACM and the locust are really looking at similar things they break
them down a little bit differently and they identify a need for a higher
intensity level of care more connection with the clinician based on how bad how
severe the problems are how unstable the environment is and how low the
motivation is which you know like I said there are some reasons for that may not
always play out the way you had hoped I worked my first job out of college was
working with felony probation and parole and those clients were really not
motivated to be there there’s just there really I can’t think of a single one of
them who was excited to go to group would they have been better off you know
we had them in outpatient care because they were not willing and even if we
would have put him in residential they probably wouldn’t have done the work
they would have done what they had to do to get by and probably not internalized
it because they weren’t motivated to learn they weren’t motivated to work on
that issue at that point one of the other nice things about these guidelines
no matter which one you use the locus or the ACM when you look at motivation
levels if they have low motivation then it probably points you in the direction
of brushing up on those motivational interviewing skills and the motivational
enhancement approaches to figure out how to create win-win situations a lot of
times that puts the client more in control where you’re saying what is it
that you want to work on when I work with substance abuse clients if they’re
not ready to give up the substance they don’t think they need to get up the
substance but they’re on probation for example I’m like okay you know you’re
not ready to do that you’re stuck with me for the next 12 weeks
or however long it is you should usually it was a 12-week session and you don’t
want to go back to jail I don’t want you to go back to jail but
in order to stay out of jail you can’t use so how can I help you not use and
comply with the requirements of your probation or whatever your employees
that employer says or whatever it is how can I help you meet your goals which are
to get off probation and not have to see me again and generally the way to do
that was to comply with my goals and it was staying clean for that period of
time so I wasn’t telling them from the get-go you can’t ever use again I was
telling them I hear what you’re saying let’s see what we can do
during this 12 weeks one of the other things I would often tell them is I am
state-sponsored therapy you know the court is paying for you to see me you
might as well get benefit out of it so what can we work on together that you
might benefit from sometimes that would alter the conversation a little bit
where they didn’t feel like I was trying to judge them because they used cocaine
or put them into a group with everyone else you know I was really talking to
them about how is it that I can be of service to you so the 5ms these are what
we need to do at every level regardless of is early intervention services
intensive outpatient residential we need to motivate clients look at their
readiness for change and the recovery environment engage them and build
alliances by creating win wins we want to model this because as we model it
they will learn from it if we ask them instead of saying okay your treatment
plan goals are X Y & Z if we ask them what do you think would help you meet
the requirements that you’ve got or you want to be happier you’ve lived in your
skin for 40 years I’ve known you for 40 minutes so you’re the expert on you why
don’t you tell me what the first thing is you think would be helpful to work on
to start moving you forward stepping down we are always
probably going to be seen by most clients as an expert there’s always
going to be a power dynamic but we can minimize that some by being somewhat
realistic and saying you know you better than I know you
help them feel comfortable speaking up and saying that’s not going to work for
me and then figure out how to make it a
win-win if they score on the ACM of the locus for residential and they say I’m
not doing that for cultural reasons because I am a
single parent and I’ve got two kids at home because I can’t lose my job there’s
a whole host of reasons they might not be able to or be willing to do
residential even though it would probably be the best placement I want
them to feel comfortable telling me that instead of just walking out and never
coming back so we can talk about okay well what can you do and then how can we
fill in the gaps to minimize or mitigate those things that might cause harm to
your recovery we need to manage and it’s just to make it an M family significant
others work school legal and financial we need to help them figure out how to
balance all these things figure out how to bring in a healthy support network
which may or may not be blood relatives that’s going to be partly culturally
defined and partly defined by the client themselves help them figure out how to
make work you know that’s part of their recovery environment we need to help
them figure out how to make that not harmful to them preferably helpful and
inspiring and all that kind of stuff but at least not harmful how can I deal with
their legal issues I don’t want them go into prison after they’ve gone through
you know eight weeks of treatment with me and financial issues obviously we’re
not financial counsellors we’re not CPAs we’re going to refer out for some of
this stuff but it’s important to make sure that we’re making the referrals so
the clients can get that lower level of Maslow’s hierarchy all in order
medication is needed for detox for HIV AIDS for medication-assisted addiction
treatment and I separate that from psychotropic medication because most
people don’t lump them together medication addiction treatment is more
like your methadone and your suboxone psychotropic medication also assists
treatment if they’re on an SSRI or an SSRI
there’s one of those other mental health medications that’s working for them but
we need to advocate for them advocate help them advocate for themselves their
meds aren’t working or if there are side effects that they’re finding troublesome
we also need to help them make sure that they can pay for their medication and if
they can’t again you may refer to a case manager but do know you can go to a
pharmaceutical company’s website find the patient Assistance Program page and
most insurance companies have patient assisted programs for most medications
that are out there it so in most cases it’s like a half a page or one page
sheet the doc sells out faxes in and the client can get low-cost medication that
may not be on other formularies they need to go to meetings some sort of
integration with other people mental health or otherwise if they’re in
if they’re seeing you for Greece there are grief support groups there’s
depression not depression just divorce support groups there is our support
groups for survivors of suicide so when I talk about meetings I’m not just
talking about addiction I am talking about helping people connect with other
people that are going through similar things and you know succeeding at moving
towards the moving towards recovery and we need to monitor the continuity of
care we want to make sure that relapse prevention activities are in there if
they’re seeing you for depression and you see that they’re starting to
decompensate or they’re starting to do things that you know is trigger their
depression in the past or you’re coming up on an anniversary of a significant
loss which may trigger their depression you know this is what we want to monitor
for and point it out to them so they can learn to self monitor and we’re also
encouraging them by us monitoring what they tell us about the recovery
environment and social supports we’re encouraging them to be more aware and
you could put mindfulness here but that would just be another M we want them to
learn how to do all of these things for themselves so they can advocate
they can self-motivate they know where they can go to find other people who are
supportive so the FAR’s is a very helpful tool to conceptualize problems
and rank severity and kind of create sub goals for treatment plans it provides
small focus areas that we can use and that clients can hone in on so if
they’re working on instead of just relationship skills they can work on
specific aspects of that and see that aspect improve which is obviously going
to improve the meta concept to the ACM and locusts are used relatively or
changeably to identify the appropriate level or intensity of treatment for
clients some places require it some places is optional I find it very
helpful if for nothing else than to document in a very consistent way across
charts that this is what I look at and yes I looked at all these aspects when I
did the case formulation treatment intensity does not necessarily equal
treatment program placement so if somebody scores out for residential that
may not be where they are going to be best served from an individual
culturally respective respectful standpoint so recognize that all these
tools are just guidelines and like I said earlier a lot both of those tools
point you towards higher intensity levels of care for people who are less
motivated and you may run into a client who’s just very involuntary and is not
going to benefit from residential care so you want to take all those factors
into consideration and yeah you’ll have to justify why you deviated from the
recommendations but that’s usually one or two sentences insurance companies
often define the services to be provided each level of care for reimbursement
purposes but states may Florida is a perfect example in 65 – 30 where it’s
the state of Florida actually define certain services that have to be
provided at certain levels of care so you can listen to this again if you
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