Transcript
Patagonia Health 0:10
Hello everyone, and welcome to Patagonia Health Healthcare Solutions webinar today, we are going to be talking about behavioral health compliance and quality of care tips.
Patagonia Health 0:28
Today, Jonathan Strange, the clinical director of Patagonia Health, is here to speak with us during the webinar. Jonathan is the acting clinical director for Patagonia Health. He's got his master's degree in counseling. He's had positions in mental health as a therapist and as an alcohol and substance abuse counselor, and he's had supervisory positions in several Behavioral Health Agencies. He's also worked directly in the EHR world since 2006 trying to assist with treatment providers and the never any trail of paperwork that's involved in the treatment process, and today, he's working with Patagonia Health, trying to make sure that we continue to make solutions to provide treatment easier and more effective for clinicians. If you're not familiar with the GoToWebinar platform today, just go ahead and familiarize yourself with a little box on the right hand of your screen. There's a communications box with a little red arrow on the left-hand side. If you click on that red arrow, it'll shrink or expand that box as necessary. Everybody is in Rewlisten-only mode right now, but we would love to hear your questions and comments throughout the webinar. We're going to be answering your questions at the end, so in that drop-down menu that says questions. That's where you can type those. Again, at the end of the webinar, we'll take each of those questions, and Jonathan can answer them directly. So please take the time to ask your questions in that box throughout the presentation. And if you've shrunk that box again, that little arrow in the left-hand corner is how you can expand that again. Today, we're going to be talking about the golden thread approach to the clinical treatment process in conjunction with documentation and how to use your EHR as a clinical tool. All right, Jonathan, I'm going to turn it over to you.
Jonathan Strange 2:10
All right, great. Thanks, Amanda. Okay, so what we're going to do today, we're going to talk a little bit about the clinical process in conjunction with documentation. Now, as Amanda mentioned, I kind of want to start with a little bit of my background. And you know, I started out my career in the behavioral health world a little over 20 years ago as an addictions counselor. And at that time, you know, there wasn't a lot of electronic charting going on, you know, a lot of paper and pencil type work in terms of documentation and so on and so forth. And back then, you know, I started out as a substance abuse counselor and moved into a forensic mental health therapist and worked in other positions, like therapists in therapeutic foster care, as well as as a supervisor and a clinical role as well in various programs. So what I saw back then, you know, as a clinician, there were very stringent documentation requirements, similar to today. However, back then, on paperwork, there weren't a lot of ticklers and reminders that could help you to learn, you know, things you had to get done. So, I just remember being very flustered and stressed out about all the documentation I needed to get done. I distinctly remember, you know, certain times of the year I would have stacks of charts sitting on my desk just waiting for treatment planner done and hoping that I can get them done before my supervisor with CI hadn't had an appeal, right? And at that time, it becomes a situation where you're actually more worried about the stringent paperwork, documentation requirements, which takes away from your quality of care to your actual client. So, you know, these things have not gone away. They've actually gotten even more stringent, and there's more requirements as insurance companies try to put more things in place for requirements for authorizations and reimbursement and so on and so forth. So we thought we'd put together a little presentation today to just go through some suggestions and ways that we can lessen the stress of documentation, compliance factors with clinicians, and, you know, maybe help a little bit to improve the quality of care so that they can, you know, focus on their client and. More and a little bit less on their documentation requirements, so on, so forth. So, you know, as a clinician, I, you know, I worked for several years doing that job, and as I mentioned, paperwork and paperwork, and eventually did move into an agency that used electronic forms of documentation, so an electronic health record. And you know, I quickly began to learn that technology can assist us as therapists, to get our work done in a more timely manner, in a more efficient manner. And in many cases, we've, you know, we've started to use these tools, and a lot of times, people aren't even aware of, you know, how to use them in an appropriate manner. So what, what I ended up doing in my career is I actually stopped my clinical career as a clinician and moved into the EHR space. So I became a clinical director for a technology company that built, you know, software specific to behavioral health. So, I quickly started developing my own framework for best practices. And how can we make this technology get clinicians to a point where you're not so much worried about the documentation requirements, but you can spend more time with your clients. So this first slide that I have opened is one of those frameworks that I created for myself in a kind of building, you know, some technology to assist in documentation, and that is the golden thread. So one of the most common things when you're working on, say, paper, paperwork, for instance, like say, before the days of electronic charting. You know, you might do an assessment, and then you might not get to your treatment plan for, you know, 30 days later or something. And many times, you forget. What are the things you identified in your assessment? And you know, what are the problems or needs that this particular client has? As we move into an electronic world, we want to make sure that we're kind of conjoining all of these documentation together. So you know, your initial assessment should be identifying the strengths and needs of your client, and then that should, in turn, be leading you into your treatment plan. So when you get into your treatment plan, you're already going to have these needs and strengths kind of maybe even pulled in or pushed into that treatment plan. So, as you're doing the treatment plan, you don't have to remember the things that you identified from the assessment. They're already going to be there. Now I'll kind of give a couple examples. So you know, let's just say, let's say, you know, all of you that have on this call have probably been through an audit before. Let's say you're getting audited and they're looking at the chart for Johnny, and during the assessment, you identified that Johnny has a need to obtain their GED or something like that. Okay, now you get to the treatment plan, and for whatever reason, you didn't include that; you forgot about it. It just didn't come up again because there were other things that were more of a priority, but this is an overall goal that Johnny wanted to complete. Now, unless you go back to that assessment and reread the entire thing all the way through, which we all know nobody really has time to do, you're probably going to forget and you're going to leave it off, and from an auditing standpoint, they're going to say, well, you know, it looks like this person had this need and but you didn't address it in the treatment plan at all. Well, now, you know, if we have some sort of technology that will assist us in bringing forth those needs and strengths so that when we get to the treatment plan, they're just sitting there waiting to be addressed. That's part of what we're looking for in this golden thread approach. So you can think of the thread you can see in my slide here. It's kind of joining the assessment to the treatment plan, to the progress notes, to the billing and reporting and kind of threading everything together, right? So this idea of the golden thread is really just allowing us to lead all of these forms of documentation, to talk to one another and to build upon one another. So whatever documentation method you're using now, you know, if it's not doing this process, this is, this is essential. Your clinical compliance, as well as your own ability to provide the best care to your client. Okay, so that was one of my basic founding best practices, making sure that whatever we're delivering has all of these components that are linked together. So when we get to our treatment plan, or seeing the needs or establishing goals and objectives, when we get to the progress note, we're able to actually pull the goals in that are from the treatment plan and establish some progress towards those goals and interventions, which, in turn, downstream is going to lead to compliant billing, because now we've addressed all of these things that we're supposed to be working on from an authorization standpoint, so on, so forth. So what I'd like to do today is dive a little bit deeper into this model and give some specific examples of how I've used this model in technology as well as in a clinical role, so that we can come away with a better way of documenting and really a different mindset. I mentioned when I was when I started out my career, it was mostly on paper and and back then when, when I did a treatment plan, to me, it was literally a document that I needed to get signed by the client and put in their chart. You know, many, many times, that's what it was. It was, it wasn't even thought about again until 90 days later, when I needed to do a treatment plan review, which hopefully I remembered to do, right? So it became more of a paperwork pushing type of thing and less of a clinical process, which is what treatment planning should really be.
Jonathan Strange 11:57
So, I'm going to move on to actually start with the starting point of this golden thread. We'll go through each of these kinds of areas and give some suggestions as I go through this. And toward the end, I am actually going to show you how an EHR system might look as the way flows, and some pointers on how to use an EHR clinically with a client as well. So let's go on to the next phase here. So that initial point of contact, after you've gotten all that demographic information and insurance information and so on and so forth, when you're really starting that initial clinical process, is at that initial assessment. So this particular assessment is your opportunity to begin a trusting relationship with your client, right? So it's really hard to do, because you have to answer, you know, 200 plus questions on this assessment about the client's history and all the things that are going to help you meet the requirements of whatever assessment you're complete. And then on top of that, you have to have a skill set that allows for you to ask those questions in a manner that's going to build a relationship with your client. So just a couple talking points with this before we jump into some of the specific items of your assessment. But if you are somebody that is currently using an EHR system and you're providing a service of an assessment, number one, you know when I do training, this is one of the things I talk about that I stress is, you know, is, how is your office space organized? You know, is your desk facing the wall? And if so, are you able to make eye contact with your computer and your client at the same time? Right? Because, from a clinical compliance standpoint, one of the last things we want to have to do is two assessments. I don't want to have to do it on paper and then key it into some system. Ideally, you know, from an efficiency standpoint, you're able to, you know, meet with the client, talk with them, openly, and still be keying in your answers into the EHR. So what are the things that are going to help you to do that? Well, number one, like I said, your office space, so you have to have that, that clinical kind of eye contact that you can continue on with your client and still have eye contact with the computer screen in a way that maybe they are not even seeing it. So, looking at your workspace is number one. Number two, you want to have an assessment that maybe isn't 100% narrative in nature, right? So you want to be able to have some radio buttons, some pull downs, some common things that you can select and choose from and identify and get. The crux of your client's problem without having to write an entire book within this particular assessment. So how do we do that? Well, so one of the ways is just having a structured form and template that leads you to those appropriate questions so that you don't have to narratively write everything. Obviously, we can't get away from the narrative. We have to have some areas that we're free texting, but in many cases, we can get some of those notes written down during that assessment and then come back and finalize them or finish them. But for the most part, we want to have a structure that leads us in a path that's going to be conducive to working with that client in a clinical kind of relationship model. So as we go through that template, we want to make sure that it's focusing not only on the needs of the client, but as well as the strengths. So I have in here, you know, snap. And anybody that's on this call that deals with like CARF accreditation or anything like that, you know that snap is a keyword where you know you need to have that in your assessment and your treatment plan and your discharge summary, so that you're constantly building upon that, which is that whole golden thread approach again. So, what are the strengths of admission? What are the needs at admission? What are their abilities? What are their preferences, all of these things, as you're building that out in your assessment, you're going to reassess that as you move into the treatment plan and throughout their progress in treatment, each time you do a treatment plan review, so on, so forth. Now, one of the other things that I try to focus on in the documentation process is during that assessment phase, where is this client, in terms of their, you know, willingness to change, right? So let's say I'm doing an assessment, you know, I'm going to be in kind of my, you know, my interview, my motivational interviewing mode, and I'm asking things like, you know, what do you want? You know, what, what are, what are, what do you really want in life? You know? So let's say, let's say I get a client who, let's say they're a drug court referral. They're, you know, they're in the legal system. They're, they're mandated to treatment. Okay, so I might ask this client, you know, what is it that you really want out of life, you know? And the client might say to me, I want to be a drug dealer. Say, Oh, okay. So from that, you don't want to just write that. You want to explore that a little bit. So why? Why do you want to be a drug dealer? Well, I want, I want to have money, right? So, it wasn't really that they wanted to be a drug dealer. They want to have money, right? So then we continue on with that interviewing model, and we kind of say, well, what would you do with that money, right? And they might say, Well, I would buy a house, right? And so now that initial question we asked, we've now gone a couple layers, and really what we've learned is this person just wants a stable home that they can live in and be happy in, right? So they don't need to be a drug dealer to do that. They don't need to have a ton of money to do that. So, what other ways can we accomplish this particular goal that they have? Right? So we're kind of weeding out some of the irrational thought patterns that we might be working with and we're really focusing on, you know, how can we really help this individual? So when we have structured form sets and templates that lead us down that path, it just makes everything so much easier, right? If you are a supervisor who is working with a brand new clinician out of school, you know they might not have developed their own way of motivational interviewing for assessments. They're going to benefit from an appropriate templated structure. Which leads me back to the whole way technology helps with the clinical process, right? And that's really why I got into the EHR space about 1516 years ago now.
Jonathan Strange 19:34
So in conjunction with that initial diagnostic assessment template, what else can we use to assist us as a therapist to come to the best conclusion possible of what this individual might need? Well, perhaps there's some other screening tools out there that can assist us in that so we all, we all know that you. Now, there's tools that are standardized out there that can give us a score, which can then lead us into a better way of knowing what, what should we offer this particular client? What? What's going to make them successful? Right? So screening tools like the PHQ nine, the GAD seven, maybe even depending on the client you're working with, maybe even like a Columbia suicide scale or a vocational scale, or maybe you're working with somebody with an eating disorder. You do like the Eat scale. There's all kinds of tools that are out there. But what's most important is that we've now asked the appropriate questions, and now we know, hey, might make sense to do a back Depression Inventory quick and see what their score is, right? And then, based on those scores, we can lead that into our treatment planning and start to establish goals and objectives that are appropriate. Because if you're working with a client who is in the pre contemplation stage of change. For instance, it's going to be really, really hard for you to get to a point where, you know, if I use our client, we mentioned we want to be a drug dealer, to get to a point where they're ready to obtain, you know, gainful employment, right? So that might be more at the action stage. So what do we have to do before that? What are the things that we got to do to move them from pre contemplation to contemplation to actual preparation? Maybe they have to get a GED. Maybe they have to do certain things to lead them into the job world that they really want to be in. So it's really important to know what stage of change that particular individual is in, because if we know they're in pre contemplation, we're not going to start taking action. We're going to go all the way back to where they are. And I use this all the time with my wife. I say, you know. Say, you know, I'm in, I'm still in the contemplation stage of going to the gym, right? Because I always go back between contemplation and preparation. But I, you know, maybe on a Monday, once a month, I get to the action phase of going to the gym, right? So it's that, it's that mindset that is your job to lead that client to that next level, and the only way we're going to be able to do that is to know what level they're starting right so we have screening tools that are available to us to help us to give a score of where they are at in this process. So I would encourage you, if you aren't already, to instead of start, instead of the mindset of, Oh, I gotta get a CCA done, I gotta get a DA done, and I gotta get this done, I gotta get that done. Rather, look at it from a standpoint of what else does the client right, what else is available to me that I can utilize to give this person the best care that I can possibly give them.
So during that, you know, comprehensive assessment or diagnostic assessment, I might have learned a lot of things, and now I can say, well, you know, it's going to make sense that we do this screening tool in the screening tool, and now I see a score, and now it's going to help me to improve, not only to develop goals and objectives, but to then monitor them as they go through treatment. So now we have a starting point right if we're using some standardized scoring tools, we have a score that we can use at admission. Now, I might be able to do that 30 days later and see if that score is going up or down. Are they progressing through treatment? And maybe they're in treatment for a year and a half? Well, it would be great if I had a tool that would show me the progress that they've gone through during that whole treatment process. Have they improved from admission to six months to the one year mark? Where are we at? You know, and not only that, but can we do that as an agency? Can we take all that information now, and can we look at it as an agency and see how we are doing as a whole within the community? Are we with our services?
Are we providing the best services? Are people getting help from our services? Right? So all of these things can be accomplished with your electronic health record, and if they are not being accomplished, I would encourage you to see how, how you can, you know, make that improvement in your process. Now, a lot of states are moving toward a combined assessment with treatment plan. So just last year, I saw in New York State, they got rid of the treatment plan altogether, and what they did was they made it part of the assessment. So, they did not have a separate document called a treatment plan. The elements of goal creation and objective creation still existed, but they were part of the actual assessment. And then to update it, they would do that in their progress note. So they completely eliminated, like the biggest thing that we've all thought about as clinicians, that's most important for documentation was eliminated. Now the process of that treatment plan was not eliminated. It was just worked into the assessment and then into subsequent progress notes for review. And we're starting to see this more and more often. Um, so things like, like in Illinois that have the im cans. You know, you're identifying these things now. They still have a kind of a treatment plan, but it is still combined with that assessment.
So we're starting to see this uptick in change with regards to treatment planning be in a separate process from assessment. And why is that? Well, because this is your opportunity to get the client to buy into something, right? So if, if my client has, this is the first time I'm meeting with them, or maybe the second time, and I'm still in the assessment process now, all they've seen so far is just answering a bunch of questions, right? Well, what they want is, they want some sort of solution, right? They want some sort of plan in place that they can see and follow to assist them to get to the end goal, right? So if we can include that in that initial assessment process, we're going to have a better buy-in we're probably going to have a better retention rate of our clients attending treatment, because now they have some, some plan in place, right? So if they have to wait 30 days from their assessment before they have a treatment plan or any plan in place, that's going to be a challenge to keep them, you know, engaged. So we're seeing this, you know this goal creation as part of the assessment, as a more common model. So be on the lookout for that, and make sure that you have an EHR that can assist you with making those changes, because those are pretty large changes. So being able to have something that can change quickly and with you, because those are things that are coming down the line. So that's our assessment. I'm going to move now into the treatment plan, and we've talked a little bit about this already, but the treatment plan is your opportunity to take all those things that you've now learned from that assessment process, whether it was just the diagnostic assessment alone, or maybe you use some conjoining screening tools with scores and things to help you to come up with what does this client really need and or want, right? So
Jonathan Strange 27:53
So we start to see these keywords, like smart and, and I've been in so I've done over almost 300 EHR implementations with different providers throughout the country, and I've seen this. This acronym is smart, used in many, many different ways. And some people mistake what it is. They actually think it's like this, this field structure that you need to have in your treatment plan, and so on and so forth. But in reality, it's just like the golden thread. It's, it's a way. It's like the snap, you know, strengths and needs, abilities and preferences. It's a way for you to make sure that the things that you're developing in the treatment plan are specific, measurable, attainable, relevant and time based, which helps us to determine if they can accomplish it, right? So the last thing we want to do is make a plan that can't be reached, right? It's unattainable, you know, go back to my gym, you know, example, you know, I don't want to tell myself I'm going to go to the gym, you know, seven days a week, two times a day, I know I'm never going to meet that goal, right? So I need to create more risk, a realistic goal that this particular individual has a buy in to, has a say in, and believes that they can accomplish it. Not only do they believe it, but we can see that they have the strengths that can lead them to that final, ultimate goal of accomplishing that particular objective or goal, right? So, when we look at these things, specific, measurable, attainable, relevant and time.
So that's a lot of things to have to think about while you're, you know, conducting a treatment plan or developing a goal objective intervention, right? So what they're really talking about here is making sure that your goals and objectives have this smart concept, okay, so how can we do that? How can we so that that new clinician we talked about, who. Do is just starting out. How can we teach them to do this? Like, are they just gonna remember to do this? Like, it's a hard thing to actually accomplish. So one of the ways technology can help in this is there is a way to have choices that are already created that are specific, measurable, potentially attainable for that client, if we pick the right choice, relevant in time, if we have a table based choice list that's related to the specific problem or goal that we're working on, and it gives us some suggestions of things that this client might benefit from working on that's going to assist us a great deal, okay, and having the ability to have that a little bit custom content is even more ideal. So, you know, as a provider, you might have different levels of care. You might be working with children. You might be working with adults. You might be working with people that are at the pre contemplation stage, you might be working with people at our action stage. So you have to have a vast array of choices available to you to individualize this plan, right? But we can already make sure that all those choices are specific, measurable, attainable and timed. Relevant. Relevancy is up to the clinician and the client to determine if it's relevant for their particular needs. So if we can develop enough choices for that, we can really guide the clinician into a successful outcome with creating this treatment plan.
Okay? And I'm going to show this a little bit more specifically in the EHR as we jump in there in a minute. Now. What did I do? So when I was a clinician, I used that as an opportunity to allow the electronic health record that I was using to become a clinical tool rather than a piece of documentation that needed to be done and forgotten about. Okay, so what do I mean by that? Well, depending on the client that I was working with, many times, I would say 90% of the time I would actually pull the client next to me and look at the computer screen together. Okay, so we're going to build a plan, right? So it's kind of like, you know, like I built the house once, and you sit next to somebody and they're showing you stuff on the computer, and you're saying, Yeah, I want that color shutters, I want this roof, this door, you know, so on. So, right? So, I'm sitting with that person to help build a plan for that house. Well, it's the same thing. I'm now sitting with my client, and I've now already pulled all the needs forward to my treatment plan, so they're sitting there already for me and that golden thread approach, and now I'm going to build goals and objectives to meet that need. Okay, so what do I do? I pull a client up in front of me. I'm popping up goals, and there's a vast array of goals there, so there's enough there that I'm not doing anything cookie cutter. Okay? So a lot of times people see choices and they say, oh, no, can't use choices, because that's going to make it cookie cutter. We can't have too many plans that are all the same, right? Well, I will say that when I use paper, I used to write the same thing over and over and over again, because my brain can only think about so many different problems and goals. Yeah, we always use the same stuff, right?
Well, now I have this tool that's going to give me 20 or 30 different goals, depending upon the problem, and then maybe even different objectives depending on the goal that I pick. Well, guess what? This interwoven spider web of choices is never going to be duplicated. It's always going to be individualistic, because the client sat there with you and picked the goals and objectives that they felt were going to be able to be things that they needed to work on and attain. Okay? So if you have the ability to take your treatment plan that's in your electronic health record, pull it up on the screen and pull your client next to you, build the plan that way, trust me, that's going to give them more ownership of those goals and objectives than just simply signing the form at the end. Okay, so it's really great, like I said, it really turns it into a clinical tool versus a document. So you want to, you want to have something valuable to you that that can do that, as we read through this, it addresses identified problems, needs from the assessment we talked about that, how those things will already push forward from the assessment, so that golden thread approach, and then getting into already talking about discharge planning at the time of treatment planning. Because what do we want to do? We want to. Be always thinking about where we want to be at the end of this process, right? So, if we talk about that at the beginning of the process, then we have that as part of our plan. So you're starting to see, you know, discharge planning as a requirement of the treatment plan in a lot of states.
And if you're not, you probably will be soon, which again, you want to have a solution that can change. As we all know, behavioral health changes every quarter, or at least every six months. There's new regs that come out, or a different payer comes out with something that's required. So you want to have some mechanism that can assist you in accomplishing these without having to remember, right? So some technology that's going to help you with whether it be from a templated standpoint or reminder standpoint, so on so forth. All right, so let's move on to the level of documentation, or the piece of documentation that pulls all of this together, and that's going to be your progress notes. So your progress notes are obviously the thing that you're going to be doing the most of you've gotten through, and you've built the foundation of the treatment process by doing the assessment and doing the treatment plan, but now you actually have to do the work to accomplish those things right, accomplish the goals and objectives that you built in that plan by providing different interventions and therapy. So, our progress note is obviously the piece of documentation that is going to allow us to do that. Now it is great if you can have some technology that allows you to have a templated format that's going to meet your needs, right? So whether it's a data assessment plan format or a subjective, objective assessment plan format or a behavior intervention response plan format, whatever your format is that's conducive to what treatment you're providing. You want to make sure that that template is available to you in whatever you know, the electronic system you're using.
Jonathan Strange 37:15
So not only do we want to have a templated format that meets our needs, but we also want this document to link back to our treatment plan, back to our assessment, and be able to pull forward goals and objectives or interventions that we identified already in our treatment plan. We don't want to have to go back to the treatment plan and copy and paste things or remember what we're supposed to be working on. That's what technology is for. It can help us to do that. So when we go into our progress note, not only should the progress note remind us of the goals and objectives or interventions this client is supposed to be working on, but maybe even more kind of more compliant things, such as, you know, specific to billing rules or payer rules or diagnostic rules. So for instance, maybe a certain diagnostic code, you know, maybe there's a certain billing code that you're completing that doesn't correspond to the diagnostic code that is associated with this client.
Well, it'd be great if you had some tickler that told you that, right? Because maybe the clinician picked the wrong procedure code, right? That's, that's a good, good you know, chance that that's what they did. Not only that, but your progress note may remind you if something is out of compliance. So, for instance, you might have to have an active treatment plan in order to bill for the service. Okay, so if I'm doing my progress new, and it warns me, Hey, your treatment plan is expired. Awesome. Now, not awesome, that's expired, but awesome. Told me that, right, because now I can actually go and fix that and then do my progress note. Because if I don't, potentially that service that now I've, I've provided, may maybe a chargeback. I might, I might not. You know, if I get audited or something and they determine that there was no active treatment plan at the time of that service, well, I might have to give back the money associated with that service. So having technology that can help you from a compliance standpoint, not just clinical compliance, but other administrative compliant items, is essential. So does your progress note remind you if a critical document is overdue? Could it even stop you from doing a note until you had to do that?
You know, we get a lot of requests for that, you know, can you make it so that they can't even do the progress note until they've fixed it? Sure, we can do that. So all of these things kind of make the clinicians lives easier and make it. So that you're not worried, as you know, a supervisor or something like that, that you forgot something, or that they did it wrong, you know, that type of thing. You know, does the duration match up with the service code? Is there an authorization, or is there an authorization required for that type of service for that payer? And so all of these interweavings of requirements that are, nobody can ever remember all of that stuff. So, does the technology have some way of building in the background? And, you know, in an administrative area the rules that you want it to tell you? So that's basically number one. You know, with that technology and writing progresses, and then obviously the golden thread approach. Does it pull the goals forward? Does it pull the interventions forward? Could it even incorporate the screen tools for you that day, you know, things like that. So we want this progress note to basically be that, that center hub that's talking to everything and pulls everything in, because this is what you're going to be doing each week, each month. Every time you meet with the client, you have to do a progress note. And then lastly, does the progress note allow an easy mechanism to get reviewed? Right? So some progress notes might need a supervisor signature, some staff members might need all of their stuff for you.
So, is there an easy way for me to get this note to my supervisor and for them to easily sign off on it or review it in a very time efficient manner? Right? So, we want to make sure all of those things comprise our progress note. All right, so, so what I'm going to do next here is we're going to talk a little bit more specifically about how your EHR can jump. So obviously, I've given many, many examples already with how it can help you in your templating, how it can help you in pulling forward information from one area to the next, utilizing alerts to help you to know if things are coming up due, as well as in your progress. Note, Is there things that you know you're forgetting or are expired, or even, is there a mismatch of the code with the diagnostic code and or time frame or duration. All of these things are things that can be done, hopefully in your EHR, customizing the tables, we talked about having maybe some ability to have your own goals and objective choices in your treatment plan, so on and so forth. And then lastly, having to do lists and caseload management, collaboration. So we talked about, is there a way for the supervisor to see the things they need to review, right? Is there a way for the clinician to see the progress notes they need to get done? Is there a way for the clinician to look at their caseload and see anything else that might need to get done, or any alert associated to that particular client? All of these things are things that are going to make the clinical documentation compliance factors so much easier for that clinician and allow them to give better care by spending more time with that particular client. So I'm going to actually exit this PowerPoint. I'm going to come back to it here in a second. I'm going to actually jump into an EHR and show you some of the things that I was talking about.
Patagonia Health 43:43
And Jonathan, while you do that, we have a question from Deanna. She was asking, how do you schedule the reminders for the treatment plan? So when you're talking about things like setting up those alerts, maybe you can show us an example of that?
Jonathan Strange 43:57
Sure. So ideally, your EHR would have a practice administration area that would allow for you to set up specific time frames based on the program that you're working in. So if you're an agency that does IOP and does regular outpatient and maybe even does residential. All of those programs might have different time frames for their due date compliance factors, so I might need to do a treatment plan review every 90 days for regular outpatients but I might need to do it every 30 days for IOP. So ideally you have an administrative area that allows for you to identify the program, identify the document, and then identify how many days you have to do an update from there, potentially, what would happen is you can have a caseload management tool that allows for you to see different columns. So, one of those columns could be the treatment plan review due date. So. When you're looking at your caseload and your EHR, you have all these columns going to show, when was the last service done?
How many individuals, how many groups, how many no shows, how many cancellations? When is the authorization coming up for expiration? And then you can have, when is the treatment plan review coming up for expiration? So, as you see these different dates and things. You know this, if I click it will actually take me to the authorization. If I click the client name, it'll take me into their chart. But ideally, based on that question, you have a mechanism in the administrative area that allows for you to pick the program and then the time frame for your review, and then, depending on the program the client is in, it's going to recognize that and show the appropriate upcoming due date in some mechanism in your EHR. In this case, it would be in the caseload management area or in a report. So good question. What I'm going to actually jump into is more along the lines of that golden thread process. So let's actually go into a chart here in the CHR, and let's show a little bit about some of the slides that I had shown. Let's actually give a real example here. So first of all, because we have about 14 minutes left, I'm not going to go through a full assessment, but having an EHR that has multiple assessment types, whether it be this, this one has recreational assessment, psychosocial assessment or nursing assessment, having different templates. So that's what I mentioned, templates, forms, ability to build new forms based on change.
Because, as you guys know, things are constantly changing, so having any HR that can change quickly with you is essential. However, one of those things matters, what comprehensive assessment you're doing, remember, we mentioned in conjunction to that, do you have anything available to you to do some standardized screening? Right? So if we look at our client here, Rod, we can see that Rod did a PHQ nine today. He also did one a month ago, and then almost a month before that, we can start to see if the scores are going up or down, right? So within your EHR, you want to be able to have enough things available to you. So, if I look here, this EHR has over 180 different screening tools available to this particular agency. Now they don't have to use all those. They can obviously turn off the ones they don't use and only see the ones they do. But having that library is essential to giving the best care possible. So I might be working with a client who's struggling with a gambling issue, you know. So now I can go down and I can do this, you know, the gambling questionnaire, or even this one, or a South oak screening. So you start to be able to make use of your library based on the needs or attributes of the client that you're working with, so having a library that allows for you to kind of control what things you're using is great and essential. And then having a mechanism, not only for that, but for the ability to see all your scores in a grid then. So you can now start to see if they're going up and down, and you can do multiple different screening tools and see that at a glance.
Those things are going to assist you when you get into your treatment planning to determine the goals and objectives that might need to be accomplished. So as we move from the assessment phase and into the treatment plan phase, ideally, what's happening is these things are now going to push forward into the next documentation. So as we get into the treatment plan, we're going to be able to see various items. And I'm going to, you know, you guys all know that your template is going to have different things in it, but you know, if I say, get all problems from my assessment, it should be able to pull all of this information in automatically. So that's what we're talking about, being able to link from a golden thread perspective, it's now pulled everything forward from my problems, and now I can go down and I can establish goals and objectives to meet those needs. Now what this, what this is actually going to do is not only that, but it's going to assist me. It's going to pull my diagnostic code forward that we established from my assessment, and based on that, it's actually going to give me some suggested life areas that are associated with that code. Now that could be a life area. It doesn't have to be a diagnosis per se, but. Based on that, I've now got a list of all the types of things that are typical to be struggling with given that particular problem area. So, let's say they're working on an addiction issue.
Well, now I can establish specific problem behavior based on that, and I can get the actual behaviors that this client might be struggling with. So this is where I was saying, pull your client up in front of the screen with them, and say, so, you know, have you ever had an increased tolerance for the drug and, you know, needing more to become intoxicated? Yes. Have I? Have you ever had experiences with blackouts? Yes. Have you ever been arrested for a drug or alcohol related instance, yes. So they're answering these questions, and you're seeing you check these things off, and then you're going and you're establishing goals related to those behaviors. So now I can establish that. I can say, hey, Rod, do you feel like you're going to want to attend self-help meetings. Yes, I think that's going to help me. Okay, we want to establish and maintain sobriety, so now they're establishing goals with you. Now we can actually, based on the goals we selected with our client, establish how we are going to accomplish those goals? So we're going to do this, we're going to do that, and we're going to do this for that goal, and now we can go on and establish the specific interventions to accomplish those objectives. Now this content that you're seeing should be able to be custom content or standard content, depending on what your needs are. So remember, we want it to be a smart mechanism, so specific, measurable. So we want to make sure that these things we're picking from are measurable, and by having them pre stated, it makes it a little less likely that the clinician is going to write something that isn't measurable. Okay, so you then get into that, you know, at the end of the smart, it's time-related, right? So we can put target dates on this. So we're meeting all that smart criteria by building this treatment plan out. And this is something that this system calls the treatment planner. And when we finish this, it's going to actually save it all, and it's going to push all that information downstream, so that when we do a progress note, we're going to see all that go forward. So we can also assign this easily to a supervisor to review it. The client can sign it electronically. The staff can sign it, and we can kind of move on to the next level, which would be our progress note.
Jonathan Strange 52:44
So, lastly, let's talk about that last slide I showed you, which was the progress note. So remember, the progress note is that mechanism that should be able to talk to everything and pull it all together. Right? Now, I forgot that I had turned on my note stop feature. So I'm going to show something I didn't intend to show, but we're going to see here that this progress note is telling us, Hey, you're missing a clinical assessment or it's expired. So this is that stop feature that I was telling you about, that you could potentially have. So what I'm going to do is go and turn it back into a warning so I can show you the proper scope, but this gives me an opportunity to actually show you some of the mechanisms that an EHR could do, so we can see that this administrative area is telling us to block the note when these things are missing, right? So this is a setting that the user can set up, so you're creating your own rules, and from a compliance standpoint, being able to restrict people from doing things they shouldn't be doing. Well, I'm going to take that off, because I want to show you progress. And I'm going to say, just give us a warning instead of a block, okay?
And then I'm going to go back into rod's chart here, and we're going to go back into that progress move. So that does, though, lead into that clinical compliance, right? So having that level of control of what your staff are required to do or not required to do is essential. So being able to have all that stuff at your fingertips without having to go to the development team and ask them to do it is a great feature. So let's go back into that note, and now we're just going to get a warning here. So it's going to warn us that these things are overdue. But now I can go down and I can show you how the progress note would follow that kind of golden thread approach. So service code. So if I pick a service code that might require an authorization, he doesn't have one, it's going to tell me, Hey, you didn't get an authorization for this. I'm going to say that's okay. I'm going to move forward anyway. But we can go back to authorizations over here and add it if we need to. We talk about the golden thread as incorporating goals and objectives and. Interventions to our note. So now I can pick include goals, and it would populate, populate any goals associated with raw I can do include interventions, and I can populate any interventions associated with rod as well. Now these interventions, when I select them, came from that treatment plan. I can save that, and it's going to show me today's interventions, right? Not only did it do that, but it pulled forward our PHP nine score too. So having a mechanism, or an EHR that allows you to pull goals, pull interventions, forward, screening tool scores, and then you're going to have whatever note format meets your needs. So whatever you need, having your narrative note area is going to be essential to being compliant in your documentation needs. And then, like I said, the ability to easily assign it to a supervisor who then actually sees that show up on their dashboard as a note that they need to review and sign off on and it will go to billing. So those are essential components to EHR, making sure it meets all the golden thread formatting and process which is going to, in the end, lead to a more compliant way of documentation and a lot less stressful way of documentation for your therapist, which is going to allow them to give better care to your clients. Go back here.
Jonathan Strange 56:34
So Amanda, I don't know if any other questions came over.
Patagonia Health 56:37
We did have a couple. And I just want to let everybody that is watching know that the EHR system that Jonathan was doing this to kind of give you guys an example of how an EHR can support the golden tribe was the Patagonia Health system. So if you have particular questions about how some of that functionality works in our system, I absolutely invite you all to reach out to us or to Jonathan for a more in depth demo on our system and how our system supports those things. But in general, you know, we are talking about just how EHRs can support this functionality and the golden thread. But a couple of the questions that we did get may be a little bit more appropriate to answer in a demo situation. But one of those questions was, how do we create a caseload? And in relation to that, where can we find the caseload tab, or how does that widget show on the dashboard?
Jonathan Strange 57:31
Sure. So if you are a current user of the Patagonia Health EHR system, I would encourage you to submit a ticket for that. There is a thing that needs to be enabled to turn on your caseload widget. There is no cost associated with it, so we can turn that on for you. Just need to get that request from you. It is linked to the service enrollment tab. So when you are putting in your provider in the service enrollment it'll automatically show up in the caseload widget. So you're probably already doing that. You just might not have the caseload feature so you can put in a request for that, and in most EHRs they should have that. Any other questions? Yeah,
Patagonia Health 58:13
I just had a question about, we're talking about using this golden thread process. What about with other providers that you might be working with with the same client? We talk a lot about whole person care and behavioral health integration. Well, how can other providers link with this type of documentation? Should they be or should it be kept separate?
Jonathan Strange 58:34
Sure. So we see this a lot when you talk about medication management and mat services, things like that. So a lot of that is, you know, are they meeting with a psychiatrist? Are they being prescribed medications? And can we, in turn, be able to have access to that, you know, from a continuing care type of method? So, there are things like encounter notes that will pull all the medications into your service. Note, whatever template you need. It's going to be able to pull the medications. It's going to be able to pull any allergy information, things like that, that other providers might have identified. So yes, that is an essential component to a fully integrated EHR, because, you know, if they're on a certain medication and they're constantly struggling with sleeping, that might be, it might not be related depression might be related to the medication they're taking. So we want to know what, what other things are happening with this client with coordination of care. So if we're able to combine and conjoin these documents together, that's going to allow us to do so in a more elegant manner, and we can do that through counter notes and various other ways.
Patagonia Health 59:55
Great. And what about when we're talking about different payer sources? And there each of those payers requirements in the documentation, such as in the progress notes. How do those payer sources affect the requirements of this type of documentation?
Jonathan Strange 1:00:13
Sure. So a lot of times we'll get Hey, so and so has, you know, Alliance and they require XYZ, right? And that might be certain demographic information that needs to be gathered. It might be that a certain level of credential counselor needs to be providing a particular service that might be related to an authorization, so on, so forth. So the way we can do that is through we generally handle that on the billing, the billing rules side, but that's in conjunction with the documentation. So if, if a particular provider did this service type and the payer equals, you know, Alliance or whatever, then do this, right? So we're actually in the process of finalizing, in this EHR a billing rules engine, so based on diagnosis, based on payer, based on provider, adding a certain modifier, being able to do bundle billing based on programs, all of these things are being completed in our billing rules management so it's going to allow a lot of flexibility for the user To set up their own rules based on their own payers and their own procedures that they offer, which I think is essential to you know, just being in compliance and and having an EHR that's going to help you save time.
Patagonia Health 1:01:33
Great. I know that we have a written blog content on the golden thread, and how, really, if you carry that through the whole process, it does go all the way through with billing as well, but we didn't have any more questions at this time. But thank you so much, Jonathan for sharing all this information with our audience today, and you know, kind of giving us an example, showing us in the Patagonia Health system how one EHR can approach, utilizing the golden thread and keeping track of those types of notes in the system. Great. Alright, here's going to the final slide. Everybody, like I said, if you would like to ask more questions directly to Jonathan about this topic, or if you'd like to get a demo of our system, please do reach out to Jonathan at Jonathan at Patagonia health.com you can also go onto our website for more types of content, like this at Patagoniahealth.com thank you everybody for joining us, and I hope you have a great, great rest of your afternoon.
Patagonia Health 1:02:31
Thank you everybody.
