mental health and wellness program meeting the policy and requirement handbook (prh) requirements...
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MENTAL HEALTH AND WELLNESS PROGRAM
Meeting the Policy and Requirement Handbook (PRH) Requirements for
Documentation
Valerie Cherry, PhD
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Mental Health and Wellness Program Chapter 6.10, R3
Mental Health and Wellness
ProgramChapter 6.10, R3
General Emphasis
(a)
Assessment(b)
Promotion, Prevention,
and Education
(c)
Treatment(d)
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Mental Health and Wellness Program
(a) General EmphasisEarly identification and diagnosisBasic mental health careMental health promotion, prevention and educationEmployee assistance program approach
Short-term counseling with focus on employability Referral to center support groups Crisis intervention
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Mental Health and Wellness ProgramDocumentation
(b) Assessment Social Intake Form
Most recent was released via Information Notice 12-31- November 16, 2012
Bottom date - October 2012 Review within 1 week Signed by CMHC Completed Copy or Original in SHR
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Mental Health and Wellness ProgramDocumentation
(b) Assessment Con’t Assessments and Recommendations for
Referred Students What should the Intake include?
Reason for Referral Presenting Problem Mental Health History Chemical Health History Mental Status Exam Barriers to Employability and Strengths DSM Diagnosis, if applicable Education and Recommendations
Referral to Reasonable Accommodation Committee
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Mental Health and Wellness ProgramDocumentation
(b) Assessment Con’t Intake Assessments should be placed in MH
section of SHR Progress Note Mental Health Intake Forms (DRG) Provide student with Mental Health Chronic Care
Management Plan (MHCCMP) Student Fact Sheets and note in SHR
Job Corps Information Notice 13-51 “Updated Chronic Care Management Plans”, dated April 10, 2014 Flow Sheets for recording periodic monitoring
visits for students with Schizophrenia, Bipolar Mood Disorder, and Depression
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Mental Health and Wellness ProgramDocumentation
(b) Assessment Con’t MSWR or Medical Separations
Progress Note in MH section What should be included?
Clinical justification for the separation due to health needs beyond what can be managed on center.
Sometimes you may be asked for a recommendation on mode of transportation and if an escort is needed.
Resource: Medical Transfer, Separation, and Referral; Management of Student Injury and Death Under FECA/OWCP TAG
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Mental Health and Wellness ProgramDocumentation
(c) Mental Health Promotion and Education 1-hour CPP Presentation
Curriculum Standing day of the week for new inputs
CDP and CTP Presentations Curriculum Maintain a folder/binder, or computer file with days
and topics
Annual Center Wide Activity Maintain a folder/binder or computer file with
information
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Mental Health and Wellness ProgramDocumentation
(c) Mental Health Promotion and Education Con’t Clinical Consultation with CD (monthly),
Mgt. Staff, and HWM Minutes
Coordination with other departments Keep file on specific trainings for Counselors
and/or Residential Advisors. Include SGA, HEALs and other center
departments with center wide activities and document in your file their participation in developing the activity.
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Mental Health and Wellness ProgramDocumentation
(d) Treatment Short term with employability focus
Document on progress note in MH section of the SHR
How do we document employability focus in a note?
Sample Progress Notes in DRG MHCCMP Student Fact Sheet
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Employability Focus
Student was referred by counselor for acting out behavior in the classroom. Student has history of anxiety and expressed feeling stressed out on center and difficulty with peers. Refer for medication evaluation and return in 1 week.
Student was referred by counselor for acting out behavior in the classroom. Student has history of anxiety and expressed feeling stressed out on center and difficulty with peers. Introduced distress tolerance activity to increase awareness of feelings and how to express them in a more positive way. Student agrees to journal and will return in 1 week.
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Sample Employability Progress Note
S = Student reports having difficulty sleeping in the dorm along with feelings of sadness and disinterest in center activities over past two weeks. Student states he is becoming increasingly irritable during the day.
O = Student was generally anxious throughout the session with a flat affect. At one point became tearful and slightly agitated. Able to verbalize how current symptoms could become barriers to employment if not resolved. Denied any suicidal thoughts or past suicidal behavior.A = Student has been on center for two months and is experiencing adjustment issues which may be triggering an episode of depression. Shows moderate level of motivation to address symptoms, identify, and remain in program. P = Schedule next appointment for 5/10/2014 @ 3:30pm to begin short-term cognitive behavior therapy to address symptoms on center and provide strategies on how to handle emotions on center and in future work environment. Gave student sleep hygiene brochure and instructed to return to wellness if problems do not get better before next appointment. Refer to Counselor’s adjustment group, alert RA and Counselor to watch for behavioral changes over the week and refer back to health and wellness, if needed. Lastly, student given mindfulness exercises to practice over next week.
CMHC, Ph.D. # 1010
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Assess/Info Gather Psycho-education Motivational Interviewing Crisis Intervention Stress Management CBT/ACT Empathic Exploration Social Skill Training DBT/Mindfulness Decision Making Psychodynamic/Relational Other
INTERVENTIONS FOR EMPLOYABILITYIndicate primary types of interventions utilized (Check all that apply). Describe in summary of session.
Sample Progress Note
SUMMARY (Include how the session ties into employability or the work environment for the student) Session Phone contact Case Management/Consultation Other
____________________________________________________________________________________________________________________________________________________________________________________________________________________________
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Mental Health and Wellness ProgramDocumentation
(d) Treatment Con’t Collaboration with TEAP
Minutes of meetings Collaboration with CP - Psych Meds
Note on chronological record or note in MH section of SHR Standing meeting with CP and/or Wellness staff
Collaboration with Counseling staff in developing and/or leading psycho-educational groups Schedule of groups on center provided by counseling If you referred student to group, should be indicated in the
SHR- MH section If you are conducting a group, should be indicated in the
SHR
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Documentation of Case Conferences and CMHC Led Groups
Pre-printed adhesive labels that allow enough space for brief sentence update. Signed and dated
Emotional Regulation GroupStudent was active in group and participated in deep breathing exercise.
5-1-2014 CMHC, PhD.
Case Management MeetingStudent continues to attend anger mgt. group and is doing well. No further MH services needed at this time. 5-1-2014 CMHC, PhD
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Mental Health and Wellness ProgramDocumentation
(d) Treatment Con’t Regular case conferences between CMHC, Counselors, and other
appropriate staff- Case Management Documentation of Case Management and Feedback Form (DRG) in SHR
in MH section Progress Note in MH section
Referral to Off Center- Case Management Release of Information to exchange updates Work with Wellness staff to come up with system to document off
center updates in the SHR
Written referral and feedback system- Case Management Use of Referral and Feedback Form (DRG)
Provide feedback to the referral source at the bottom of form. Copy in SHR Follow-up on feedback at next case conference and document in SHR
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Care Management vs. Case Management
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Care Management
PRH requirement [PRH-6.10: R1, 4] states “students identified as having chronic health problems during the cursory or entrance physical shall be monitored as directed by the CP or other appropriate center health provider.”
What CMHC tasks are considered care management?
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Case Management
PRH requirement [PRH 6.10 R3, d5] states “Information exchange through regular case conferences between the Center Mental Health Consultant, counselors, and other appropriate staff based on individual student needs.”
Case management requires communication among staff, monitoring, and follow up
We do not recommend the use of CIS by CMHCS
21 Chapter 5 and Training
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Chapter 5 - Exhibit 5-4
Centers shall include, at a minimum, the following: a. Five hours of annual training in adolescent
growth and development for all staff. Topics could include effective communications, anger management, sexuality, suicide prevention, behavior management system, zero tolerance policy, appropriate staff/student boundaries, sexual assault prevention and response, sexual harassment and related social skills training, crisis intervention techniques, bullying prevention, violence prevention, and safety issues.
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Best Practices that Make Assessors Happy!
Document, Document, Document Smartly!
Have documentation organized and available.
Include discussions on how emotions and behaviors impact employability with students and document in progress notes.
Include documentation in the file on students discussed and updated during meetings with counselors.
Consistently provide information back to the referral source with a copy easily found in the SHR.
Notation on Chronological Record in SHR “May 1, 2014 - See Note in
MH Section”
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In A Nutshell
SHR - MH Section Social Intake Form Referral and Feedback
Form Specifics for Referral
Source Intake Assessment
MHCCMP RAC
Employability Progress Notes
Case Management Notes On and Off site
Med-Check in Notes Group Notes
Mental Health Promotion and Education Binder CPP, CDP, and CTP
Presentation Info Documentation of center
wide activity Documentation of any
staff trainings
Chronological Record Document dates students
receive services with corresponding note in MH section.
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Regional Mental Health Specialists
Region 1 David Kraft, MD, MPH
dkraft@external.umass.edu Maria Acevedo, PhD (PR
Centers mmacevedo@onelinkpr.net
Region 2 Valerie Cherry, PhD
vcherryphd@gmail.com Region 3
Suzanne Martin, PsyD, MPH suzannempsyd@gmail.com
Region 4 Lydia Santiago, PhD
lydia.v.santiago@att.net Region 5
Helena Mackenzie, PhD helena.mackenzie530@
gmail.com Region 6
Vicki Boyd, PhD vdelboyd@aol.com
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