Orientation to MedicaidFunded Certified PeerSupport DocumentationPresenter: Janice Aspey, CPRPPR Training SolutionsDeveloped by a Pennsylvania Office of Mental Healthand Substance Abuse Services Workgroup

Course Objectives Discuss purposes of documentation and relevantregulations Examine a Strengths Based Assessment Examine an Individual Service Plan (ISP) Examine progress notes that meet documentationstandards Examine the essential elements of collaborativedocumentation

Disclaimer Completion of this training does not protect anagency from penalty due to non-compliance withregulations It is an agency’s responsibility to ensure thatdocumentation procedures are properly followed There was no commercial support received for thispresentation

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Defining Peer Support“Peer Support is a system of giving andreceiving help founded on key principles ofrespect, shared responsibility, and mutualagreement of what is helpful.” Sherry Mead, 2003 “Defining Peer Support

Role of a Certified Peer Specialist To teach and support the acquisition and utilization of skillsneeded to facilitate the individual’s recovery To promote the knowledge of available service options andchoices To promote the utilization of natural resources within thecommunity To facilitate the development of a sense of wellness andself worth To document strengths, goals, dreams, progress towardgoals and goal achievement

CPS ProgramsFind the Balance Person Centered Regulations Recovery Medical CommunityNecessity Billing CodesIntegration Core Gifts Partnering Self-Directed

What’s the Point In a small group, generate a list of WHO would beinterested in your documentation Consider the REASONS documentation isimportant to each of the persons or groups youidentify and what would happen if thedocumentation was inadequate If the person or group is a payer of your services,identify one or two things you, if you were paying,would want to see before you would pay

Process the ActivityWHO?Managed Care OrganizationWHY?Need to know what they are paying forWHAT?Adherence to their specific documentationguidelines

Purposes of Documentation To provide a roadmap for services To track progress in recovery To receive payment for services funded throughMedical Assistance To receive/remain in good standing with: Office of Mental Health & Substance Abuse Services(OMHSAS): Licensing Behavioral Health Managed Care Organizations (BHMCO) Credentialing

Licensing & Credentialing Office of Mental Health and Substance AbuseServices set the minimum licensing requirements BH-MCO credentialing requirements may be moredetailed and more stringent than licensingrequirements Refer to your BH-MCO’s Performance Standardsfor Certified Peer Support for requirements beyondthose presented here

General DocumentationRequirementsRecords must: Be legible and in ink Identify the person on each page Be signed and dated by the provider Include service plan and progress notes Include a discharge summary Include documentation of medical necessitySIGNATURE Name and Credentials

Remember No standardized way to meet all of theserequirements Requirements can change Responsibility is on the agency andsupervisors to inform Certified Peer Specialistsof all changes from BH-MCO or OMHSAS

DischargeSummaryProgress noteIndividual Service PlanStrengths BasedAssessment

Strengths BasedAssessment

Strengths Based AssessmentIdentifies an individual’sHopesDesiresSkillsSupports

Why use a Strengths BasedAssessment? Unlike traditional assessments that focus on“what’s wrong,” Strengths Based approachesidentify “what’s right,” and “what strengths, skills& resources,” the individual has. Focusing on strengths engages the individual inthe planning process in a positive way. Creates the environment of self-empowermentand establishes a partnership rather than thetraditional “I say, you do,” approach to services.

Traditional ApproachStrengths Based Approach“What’s wrong with you?”VS“What are your skills andstrengths“What symptoms do youhave?VS“What tools are you using tostay well?”“Why did you get fired?”VS“What did you love aboutyour last job?”

Review a Strengths BasedAssessment

Individual Service Plan(ISP)

Individual Service Plan Development ISP developed from Strengths Based Assessment ISP is the foundation of service delivery including: skills to be developed action steps toward skill mastery supports to be developed

Requirements for IndividualService PlansPA Bulletin: OMHSAS-09-07 “Peer Support Services-Revised”Individual Service Plans must Be developed by the individual, the Certified PeerSpecialist and the mental health professional Be developed within one month of enrollment Be reviewed every six months Be signed by the individual, the CPS & the MentalHealth Professional

Requirements for IndividualService PlansPA Bulletin: OMHSAS-09-07 “Peer Support Services-Revised”Specific Goals based on the individual needs andpersonal aspirations in the areas of: Wellness and Recovery Education/Employment Crisis Support Housing Social Networking Self-Determination Individual Advocacy

Individual Service PlansPA Bulletin: OMHSAS-09-07 “Peer Support Services-Revised”Individual Service Plans Must: Specify measurable goals & objectives Be written in individualized and outcome orientedlanguage Include the services to be provided-(Identifyinterventions directed to achieving the individualizedgoals and objectives) Include the expected frequency & duration Include the location of the services provide Include the Certified Peer Specialists role in relating tothe individual and others involved

GOALSGoal: the end toward which effort and action are directedGoal Statement: a written statement of a person’sdesire to add/change/improve something in his/her lifein the next 6 months to 2 yearsA statement of what the person wants and where he/shewants to be in their lifeA Destination!

GOALSShould Be Person Centered Stated in positive terms“ I will” NOT “I will not” or “I will have no ” What the person wants Expressed in the person’s words Appropriate to culture & values

SMARTDetailed, results and action-oriented Measurable: Describes the end result. Achievable: Can the goal be achieved? Determined by theperson. We inspire HOPE Realistic: Does the person feel the goal is realistic for them?We inspire HOPE Timeframe: Determine a timeframe for the completion of thegoal

Objectives Skills the individual identified as wanted/neededto develop in order to achieve their goal Supports the individual identifies aswanted/needed to develop in order to achieve thegoal

Action Steps Services (interventions) to be provided by theCPS, individual, family, natural supports, etc. toassist in the achievement of objectives/goal Specific to each objective As steps are completed, new steps can beadded until the objective (skill) is mastered

Intervention Language Role modeled Demonstrated Facilitated Provided Shared

Individual Service Plan Tips Be sure the goal is SMART Be sure it is signed by all Be sure the goal relates to the areas identified inthe strengths based assessment Be sure the objectives relate to goal achievement Be sure the action steps describe the role of theCPS (intervention)

GOALOBJ’sActionStepsDesired outcomeSkills to be acquiredInterventions to be provided

Review Jane’s ISP

Exercise: ISP Evaluation1. Evaluate the sample ISP2. What can be improved?

Progress Note

Progress Notes: RegulationsProgress Notes must: Record the date, location of visit, start and stop time &circumstance of contact, regardless of whether or not abillable service was provided Describe how the service or encounter related to theindividual’s goals, objectives or interventions identified inthe ISP Summarize the purpose and content of the peer supportsession Specify the intervention utilized as related to the goal in theISP If contact cannot be made with the individual, the progressnote will reflect attempts to contact the individual

Progress Notes Tips Always use recovery language and focus on strengths Include how the individual responded to the intervention Describe progress towards the goal Must be signed and dated by CPS Best practice: the person in service signs as well Document how your service relates to the person’s needsas identified in the strength’s based assessment.


Definition of CD Collaborative Documentation is a person-driventherapeutic approach and an interactive process thatsupports recovery-oriented services in whichdocumentation of the assessment, goal setting, andprogress notes is integrated into the delivery ofservice. The individual is face to face with the providerand engaged in the documentation process byproviding input and perspective on their services andprogress.

Definition of CD Person-driven therapeutic approach Interactive process Documentation of assessment, goal setting, andprogress notes is integrated into the delivery of service Provider and individual are face to face Individual is engaged in the documentation process byproviding input and perspective on their services andprogress.

Essential Elements of CD1.Utilized in person-driven assessments, service planningand progress notes2.Incorporates the ideas of the individual and theprovider in real time during the face to face session3.Used as an intentional technique to engage theindividual to develop their objectives and support theirgoals4.Highly engaged conversation through shared narrativebetween the provider/individual to assure that both areof the same understanding regarding accomplishmentsof the session and next steps

Essential Elements for CD5. Provider clearly defines CD and the individual isfully informed of the process and may choose toparticipate in the process.6. Used to benefit the individual as part of theirrecovery7. CD must clearly indicate that the documentationwas collaboratively written with the individual

Essential Elements for CD8. CD must occur within the scheduled time limit forthe session9. Providers must have specific policy/procedures forusing CD which include training for staff prior to theuse of CD and ongoing supervision focused onfidelity

CD Is NOT Provider completes documentation during or at theend of the session while the individual is NOTinvolved or waiting to leave. To be billed beyond the scheduled appointmenttime To be mandated by the provider Used for convenience of provider to simply completedocumentation “concurrently” WITHOUT engagingthe individual.

CD Is NOT To be used during telephonic sessions NOT meant to replace any required documentationelements delineated in the PA Medical Assistancehandbook or various PA regulations. All requiredelements must be included in each encounter

Review Jane’s Progress Note

Activity: You be the Reviewer1. Utilize the checklist to identify problems in thesample progress notes2. What can be improved?

Write a Progress Note1. Utilize the Individual Service Plan2. Write a progress note for Jane

Discharge Summary

Discharge SummaryShould Include: Summary of the person’s participation The services provided and progress made The reason for discharge Note how the person was informed about futureenrollment Signatures of the person, the CPS and the MentalHealth Professional Discharge due to disengagement, explain thecircumstances and rationale for discharge

Reminder OMHSAS establishes minimum requirements Providers must follow guidelines policies in place(including those from MCOs) Slides on Collaborative Documentation wereproduced from the OMHSAS CD Workgroup “NextSteps” CD training focusing on: Essential ElementsBest practicesCompetency criteria and standards

ssNoteIndividualService Plan

Relevant Regulations & StandardsTitle 55 Pa. Code §§ 1101.51(d) & (e)Medical Assistance payment regulationsPeer Support Bulletin – “OMH-09-07”Establishes the MINIMUM standards for licensurePeer Support Provider HandbookPg. VII-8, Section D covers documentationrequirements

Please complete Post Testand Evaluation

Source DocumentsPSS Bulletin MA Bulletin Revised 010110.pdfPSS Provider Handbook Handbook Pages Revised.pdfPSS Frequently Asked Questions FAQ Complete 073009.pdfMA Provider Payment hapter1101/s1101.51.html

Thank You!Janice Aspey, CPRPPR Training [email protected]