Introduction
Patagonia Health (0:10):
Welcome, everyone, to the Patagonia Health Healthcare Solutions webinar. Today, we’ll be focusing on Behavioral Health Compliance and Quality of Care Tips.
Patagonia Health (0:28):
We’re excited to have Jonathan Strange, the Clinical Director at Patagonia Health, leading today’s webinar. Jonathan brings extensive experience in behavioral health and electronic health record (EHR) systems. With a master’s degree in counseling and roles as a therapist, alcohol and substance abuse counselor, supervisor, and clinical director, Jonathan has a wealth of knowledge. Since 2006, he has been working in the EHR space, striving to simplify clinical documentation and workflow for providers. Now, at Patagonia Health, Jonathan is focused on creating solutions that enhance clinician efficiency and improve patient care.
Before we dive in, familiarize yourself with the webinar platform’s communications box on the right-hand side of your screen. You’ll find a red arrow that lets you expand or shrink the box. Everyone is currently in listen-only mode, but we encourage you to submit your questions in the “Questions” box, which we’ll address during the Q&A session at the end of the presentation.
Overview of Today’s Webinar
Today, we’ll cover the golden thread approach to clinical documentation and how to leverage your EHR as a clinical tool to enhance compliance while maintaining high-quality care.
Jonathan Strange (2:10):
Thank you, Amanda!
Today, we’ll explore the clinical process in conjunction with documentation. Let me begin by providing a bit of background. I’ve been in the behavioral health field for over 20 years, starting as an addictions counselor. Back then, everything was documented on paper—a far cry from the electronic systems we have today. I remember how overwhelming it was to keep up with the paperwork, especially during busy times. The piles of charts waiting to be completed often left me frustrated and stressed, taking focus away from the quality of care I provided to my clients.
Documentation requirements have only grown more stringent over the years, especially with added insurance mandates for authorizations and reimbursements. Recognizing the challenges clinicians face, I transitioned into the EHR world to find ways technology can reduce this burden and allow clinicians to spend more time focusing on client care. In this webinar, we’ll share tips and strategies to ease compliance challenges while streamlining workflows for better outcomes.
The Golden Thread Approach to Documentation
One foundational concept I use is called the golden thread approach to documentation. This principle ensures that key client information flows seamlessly between clinical documents, from the initial assessment to the treatment plan, progress notes, billing, and reporting.
In traditional paper-based systems, it’s easy to lose track of details—like specific client needs identified during assessments—leading to gaps in treatment plans or progress notes. For example, say an assessment revealed a client wanted to obtain their GED, but that information didn’t make it into the treatment plan. During an audit, this oversight could cause compliance issues. With EHRs and the golden thread approach, vital details like client needs and goals can be automatically carried forward to the treatment plan and beyond, providing a consistent and integrated workflow.
Benefits of the Golden Thread Approach
The golden thread connects all documentation elements, enabling them to “talk to each other” and build upon each other:
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Assessments: Identify strengths and needs.
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Treatment Plans: Establish goals and objectives directly linked to assessment findings.
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Progress Notes: Document progress toward the treatment plan goals with interventions tied to those goals.
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Billing and Reporting: Ensure compliance by linking documentation to insurance authorization requirements.
This interconnected process promotes clinical compliance while allowing clinicians to focus more on delivering quality care rather than worrying about paperwork.
Practical Examples
When I worked as a clinician using paper-based systems, treatment plans often felt like a mere formality—documents that had to be signed and filed away, only revisited during treatment plan reviews every 90 days (if remembered!). Those plans often didn’t serve as actionable clinical tools, which reduced their value to both the client and the clinician.
With the integration of EHR systems and principles like the golden thread approach, we can reposition treatment planning as a dynamic part of the clinical process that actively drives care. For example, modern EHRs can pre-fill treatment plans with client needs identified in assessments, helping clinicians save time while ensuring accuracy and compliance. Progress notes can then pull directly from treatment plans to document interventions and track client progress. This minimizes errors, improves audit readiness, and ensures the documentation aligns with the care being provided.
The Importance of the Initial Assessment
The initial assessment is your opportunity to build trust and form the foundation of your relationship with the client. This process involves answering hundreds of questions about the client’s history while meeting the requirements of your organization or accrediting body. At the same time, you need the skills to ask these questions in a way that fosters connection and trust.
Here are key takeaways for optimizing your documentation and workflows:
1. Ideal Office Setup
Eye Contact Matters: Arrange your office space so you can maintain eye contact with both your computer screen and the client. This ensures that the client feels actively engaged in their therapeutic process without being distracted by your workspace setup.
Efficiency: Using an EHR allows you to key in responses during the assessment, avoiding the inefficiency of completing paperwork first and uploading data later.
2. Structuring Assessments in Your EHR
Your EHR should include:
Structured Forms: Incorporate dropdown menus and radio buttons to simplify data entry for common questions. This minimizes extensive narrative writing, saving time without compromising the depth of documentation.
Narrative-Free Text Areas: While structured forms are efficient, designated spaces for narrative answers are essential for more detailed and nuanced observations.
3. Integrating Strengths-Based Approaches
Incorporate strengths, needs, abilities, and preferences (SNAP) into your assessment. These guide the clinical journey from the initial assessment through the treatment plan and discharge summary:
- Highlight strengths at admission.
- Identify the needs and priorities for treatment.
- Build on their abilities and preferences to create personalized goals.
- Motivational Interviewing and Client Engagement
During the initial assessment, understanding a client’s stage of change is vital. Motivational interviewing helps you explore their goals and motivations with empathy and curiosity. For example:
If a client says their goal is to “become a drug dealer,” a deeper exploration might reveal their desire for financial security and stability. Questions such as “Why do you want this?” or “What would you do with that money?” can lead to uncovering their broader aspirations, like owning a home or achieving independence.
This approach shifts the focus to achievable and constructive alternatives while challenging irrational thought processes along the way. Templates within your EHR that guide motivational interviewing can assist clinicians, especially those new to the field, in navigating these conversations effectively.
Utilizing Screening Tools for Better Outcomes
Screening tools are invaluable for gathering deeper insights and tailoring treatment plans effectively. Standardized assessments provide measurable, actionable data to inform clinical decisions. Here are examples of commonly-used tools:
- PHQ-9: For depression screening.
- GAD-7: For anxiety levels.
- Columbia Suicide Risk Assessment: For assessing suicidality.
- Vocational Scales: To explore career opportunities.
- EAT Scale: For screening eating disorders.
These tools allow clinicians to measure progress over time. For instance, using a scoring tool like the PHQ-9 at admission and re-evaluating scores periodically gives valuable insight into whether treatment is effective.
Stages of Change Model in Treatment Planning
Understanding a client’s current stage of change—such as pre-contemplation, contemplation, or action—helps to align treatment strategies effectively. If the client is not ready to make major changes, clinicians should focus on small, achievable goals to move them forward.
For example:
A client in pre-contemplation may need foundational steps, such as obtaining a GED, before pursuing employment-related goals.
This staged approach ensures that treatment aligns with their readiness and sets them up for long-term success.
Optimizing EHRs for Better Care and Agency Insights
EHR systems should enable clinicians to easily track progress and outcomes. Features that support consistent measurement, such as standardized tools mentioned earlier, allow:
- Individual Client Progress Monitoring: Measure improvement with scores over time (e.g., from admission to six months to one year).
- Agency Performance Metrics: Aggregate data across clients to evaluate your agency's effectiveness within the community.
- These insights not only improve client care but also demonstrate the value of your services to stakeholders.
- Emerging Trends: Combining Assessments and Treatment Plans
Several states are shifting toward combining the diagnostic assessment and treatment planning processes. For example:
New York State has eliminated separate treatment plan documentation, instead integrating goals into the assessment and updating them regularly through progress notes.
Illinois’ IM+CANS System similarly blends treatment planning elements into assessments.
This change emphasizes streamlining documentation while still maintaining a focus on goal creation, progress monitoring, and compliance.
Why is goal-setting important during the assessment process?
This is your opportunity to engage the client and build buy-in. For example, if it's my first or second meeting with a client, we’re still in the assessment phase. So far, they've mostly been answering questions, but what they're really looking for is a solution—a plan to help them reach their end goals. If we can incorporate a preliminary plan into the initial assessment process, it improves engagement and retention. Clients are less likely to drop out when they can see a tangible path forward. On the other hand, if they have to wait 30 days after their assessment to get a treatment plan, that delay can make it harder to keep them involved.
Increasingly, we're seeing goal creation integrated into the assessment phase. This is becoming a more common model, so it’s important to ensure your Electronic Health Record (EHR) system can accommodate this shift. You need a system that's adaptable and can evolve with these emerging processes.
From Assessment to Treatment Plan
The treatment plan is your opportunity to synthesize the information gathered during the assessment—whether from diagnostic tools alone or a combination of screenings and data—and translate it into actionable steps for the client.
One commonly referenced framework is SMART. It stands for goals that are Specific, Measurable, Attainable, Relevant, and Time-Based. SMART enables you to create objectives the client can realistically achieve. A common mistake some providers make is setting overly ambitious goals, which can discourage both the client and clinician. For instance, telling myself I’ll go to the gym seven days a week, twice a day, is an unattainable goal. Instead, the treatment plan should focus on realistic objectives that the client feels confident about and invested in.
It’s crucial that each goal considers not only the client’s strengths and preferences but whether they genuinely believe they can accomplish it. Success hinges on balancing ambition with feasibility, while ensuring objectives align with the client’s ultimate goals.
Simplifying SMART Goal Creation for New Clinicians
For clinicians who are less experienced, creating consistently SMART goals can be challenging. Technology can play a significant role here. By utilizing EHR systems with pre-populated, customizable options for goals and objectives, clinicians can choose relevant suggestions tailored to the client’s specific needs. These options can help ensure the goals remain SMART while allowing flexibility for individualization.
This is especially useful when working with different populations—children, adults, or individuals at varying stages of change, such as pre-contemplation or action. Having an array of choices pre-loaded into the system ensures that treatment plans are personalized, yet efficient.
Often, clinicians worry that using such tools may create cookie-cutter treatment plans. However, when compared to manual documentation, which typically results in repetitive language and identical templates, a robust EHR system offers more diversity. By involving the client in the selection of goals and objectives, the plan becomes unique to their circumstances and needs.
Collaborative Planning: Using the EHR as a Clinical Tool
When I was a clinician, I used my EHR system as a clinical tool rather than just a documentation system. Here’s how: I would sit side by side with my client, looking at the computer screen together. We would build the plan collaboratively, much like when designing a house—choosing the features, colors, and layout together. Clients involved in this process tend to feel a greater sense of ownership over their goals and objectives, which increases engagement.
The EHR system allowed me to pull forward all identified needs from the assessment automatically, using a "golden thread" approach. It also provided a diverse array of goals and objectives related to their needs, ensuring the treatment plan was tailored without being cookie-cutter.
Integrating Discharge Planning Early
One emerging trend is to include discharge planning at the time of treatment planning. This ensures we’re always thinking about the end goal of treatment and helps set the framework for achieving it from day one. Many states now require discharge planning as part of the treatment plan, so it’s vital to have an EHR system that can adapt to these legal and regulatory requirements.
Behavioral health changes frequently, often quarterly or bi-annually, with new payer mandates or state-level regulations. Technology that can seamlessly adjust to these changes makes compliance far easier.
Progress Notes: Connecting the Dots
Progress notes are the documentation you’ll use most often to track treatment. After building the foundation through the assessment and treatment plan, progress notes document the actual interventions used to accomplish identified goals and objectives.
Optimally, your progress notes should reflect a templated format appropriate to the type of treatment being provided. This might include structures such as SOAP (Subjective, Objective, Assessment, Plan), DARP (Data, Assessment, Response, Plan), or BIRP (Behavior, Intervention, Response, Plan). It’s essential to use an EHR system that supports your preferred format while allowing integration with the treatment plan and assessment.
For example, your progress notes should automatically pull forward the relevant goals, objectives, and interventions identified in the treatment plan. This minimizes the need to copy, paste, or manually search for information, saving time and reducing errors. Ideally, your system should also address compliance needs specific to payer requirements, diagnostic codes, and billing rules.
Streamlining Clinical Documentation with EHR Systems
In some cases, diagnostic codes may not align with the billing codes selected for a client. This mismatch can happen if the clinician selects the wrong procedure code. Technology can play a crucial role here by alerting you to such discrepancies. For example, if your progress note flags that a treatment plan has expired, you can address it immediately to avoid compliance issues. Failure to fix this could result in a chargeback if an audit reveals there was no active treatment plan during the service provided.
Having an EHR system that ensures compliance—both clinically and administratively—is essential. Does your progress note system alert you to overdue documents? Can it even block you from completing a note until the issue is resolved? We often receive requests for such features, and yes, this functionality can be built into your system. These safeguards reduce errors and ease the burden on clinicians, supervisors, and administrative staff.
For example, does the duration of service match the service code? Is prior authorization required for a specific type of care based on the payer? No one can remember all of this manually, so having an EHR with built-in rules to handle these requirements is key.
Additionally, a progress note should integrate seamlessly with the "golden thread" approach. It should pull goals and interventions forward from treatment plans and incorporate screening tools as needed. The progress note acts as a central hub, pulling data from different areas because it’s a task clinicians perform weekly, monthly, or after every client session. To streamline the workflow further, progress notes should enable easy supervisor review and approval, especially for notes requiring a signature.
Demonstration of EHR Capabilities
Next, we’ll transition to discussing specific EHR features. For example, EHR systems can automate alerts for tasks like treatment plan reviews or document renewals. Let’s say your agency operates multiple programs: outpatient, intensive outpatient (IOP), and residential. Each might have different compliance requirements—perhaps a treatment plan review is required every 90 days for outpatient services but every 30 days for IOP. Ideally, your EHR should allow you to configure these time frames within an administrative area, tailored by program type.
Some systems also feature caseload management tools with columns tracking details like the last service date, pending treatment plan reviews, or authorization expiration dates. Clicking on these entries can navigate you to relevant parts of the client’s record. These features ensure that reminders and compliance tasks are handled efficiently without manual oversight.
Example: Screening and Assessment Tools
Within the EHR, you should have access to a library of standardized screening tools. For example, our client “Rod” completed a PHQ-9 today, last month, and the month before. With scores presented in a grid format, we can easily track progress over time. A robust EHR library might include tools for specific issues like gambling or substance use. Clinicians can select and apply only the tools relevant to their client population.
The results from these assessments should then integrate into the treatment planning process. For instance, an EHR might automatically pull problem areas identified during an assessment into the treatment plan template. From there, clinicians can set goals, objectives, and interventions directly related to those problem areas.
Example: Goal Setting and Intervention Planning
For a client struggling with addiction, the system might suggest life areas or behaviors typically associated with the diagnostic code for substance use. During the session, the clinician could review these behaviors with the client—e.g., "Have you experienced blackouts?" or "Have you been arrested for a substance-related offense?"—and collaboratively work on setting goals. For example, the client might agree to attend self-help meetings or work on maintaining sobriety.
From these collaboratively set goals, you can define specific objectives and interventions. For instance, one intervention might involve attending weekly group therapy sessions, while another might involve participating in a relapse prevention program. By linking each step—from assessment to treatment planning and interventions—EHR systems ensure that the “golden thread” remains intact.
Demonstrating EHR Functionality in Real Time
I’ll exit the PowerPoint now and walk you through an EHR demonstration to show these processes in action. Please feel free to ask questions, as Deanna did earlier about setting reminders for treatment plan updates. A well-designed EHR enables customized settings to match compliance requirements for various programs, making workflows more efficient and reducing errors.
EHR and the Golden Thread in Documentation
Jonathan Strange:
Let’s talk about customizing content. The system allows you to choose between standard and custom content based on your needs. Our goal is to ensure documentation meets SMART criteria—specific, measurable, achievable, relevant, and time-bound. By defining measurable elements beforehand, clinicians are less likely to create ineffective or vague treatment plans. For example, SMART includes assigning target dates, ensuring time-bound objectives are achieved.
The system uses a Treatment Planner to build out these plans, saving all the data and forwarding it downstream to progress notes. Progress notes link directly to the treatment plan, enabling supervisors to review, approve, and sign electronically, simplifying workflows. Once signed, the documentation flows seamlessly to billing. This process meets compliance requirements efficiently while reducing administrative burdens for therapists—ultimately enabling better care for clients.
Jonathan Strange:
Let’s move to the progress note. This feature consolidates essential clinical data, ensuring completeness. For example, it flags missing or expired clinical assessments by default using a "stop feature." This mechanism can be customized to warn users instead of blocking progress, allowing flexibility while maintaining compliance. Staff can also set rules for restricting actions or flag overdue items, enhancing accountability without requiring technical team intervention.
The progress note incorporates the Golden Thread concept by tying treatment goals and interventions directly to notes. Clinicians can pull forward goals, interventions, and screening tools (e.g., PHQ-9 scores) from treatment plans. This ensures documentation is thorough while adhering to clinical workflows.
Additionally, clinicians can assign notes to supervisors, who receive notifications on their dashboard. Once reviewed and approved, notes are sent for billing. The system’s integration simplifies complex processes while meeting compliance standards for documentation and ensuring consistency with the Golden Thread approach.
Audience Q&A:
Patagonia Health:
Jonathan, can you explain how Patagonia Health supports caseload management?
Jonathan Strange:
For existing Patagonia Health users, caseload management can be activated by submitting a request ticket to enable the caseload widget. The widget integrates with the provider's service enrollment tab, pulling data automatically. If it isn’t visible in your system, contact support for activation—there’s no additional cost.
Patagonia Health:
How does documentation accommodate collaboration with external providers for integrated care?
Jonathan Strange:
Integrated care requires coordination between providers, such as psychiatrists for medication management. Patagonia Health enables this through encounter notes that include medications, allergy information, and other provider inputs. These features ensure continuity of care by consolidating data into shared documentation templates.
Patagonia Health:
How does the system address specific documentation requirements for different payers?
Jonathan Strange:
Payer-specific requirements, such as demographic data or authorization criteria, are handled via billing rules. For example, specific diagnoses, providers, or payers can trigger modifiers or bundle billing based on program configurations. Our team is finalizing a Billing Rules Engine to provide users with more flexibility in managing payer documentation requirements, ensuring compliance while saving time.
Closing Remarks:
Patagonia Health:
Thank you, Jonathan, for showcasing how EHRs like Patagonia Health can support the Golden Thread approach and streamline clinical documentation. If you’d like to learn more or request a demo, please contact Jonathan at jonathan@patagoniahealth.com. Visit www.patagoniahealth.com for additional resources.
Thank you all for joining today, and have a great rest of your afternoon!
Jonathan Strange & Patagonia Health
