IC&RC Domain II: Treatment Planning, Collaboration and Referral

IC&RC Domain II: Treatment Planning, Collaboration and Referral 42 CFR, Part 2 - ✅42 CFR = Code of Federal Regulations (commonly referred to as "Part 2") The federal confidentiality laws that specifically pertain to alcohol & drug health information concerning services and clients.

Access to documentation is governed by... - ✅confidentiality laws: CFR, Part 2 and HIPPAA Action - ✅BEGINS the change process by implementing the solution or plan Motivational task: help client take steps toward change, support initial steps towards change, provide corrective feedback An important predictor of client's treatment outcomes is - ✅self- efficacy Assessments - ✅Used to diagnose and identify problems (biopsychosocial) to be addressed during treatment Authorizations must include: - ✅+client's signature +to whom the information is to be released +the specific information to be released +the time frame for the release (includes both written & verbal information) Before a client in need of continued care is discharged... - ✅a counselor MUST provide the client with a list of resources available to assist tin procuring further treatment Case Management - ✅The traffic control of treatment, it includes: medical, legal, psychiatric, housing, employment, family, etc.

Collaboration= Service Coordination= Case Management - ✅Coordination of all activities that bring the client, treatment services, and other resources together to focus on issues and needs identified in the treatment plan Contemplation - ✅Aware of a problem; but ambivalent about change

Motivational task: tip the balance, evoke questions about making a change and the risks of not changing, strengthen the client's self-efficacy to change, but NO action Discharge Summaries - ✅Provide what will happen to the client after they complete the current treatment Discharge Summaries include... - ✅summary of treatment (goals, methods, outcomes and progress), status at discharge, follow up recommendations (aftercare) and referrals.

Documentation - ✅The recording of the screening and intake process, assessment, treatment plan, client related data, clinical reports, clinical progress notes and discharge summaries.

Documents for a referred client... - ✅the counselor should document the client's attitude in the subjective description Exceptions to authorizations - ✅+release to state and federal agencies +accreditation bodies +third party payers +court orders +medical emergencies (a subpoena is not sufficient to release, it must be a "good cause" court order) HIPAA - ✅HIPAA (Health Insurance Portability & Accountability Act) In general, requires the protection and confidential handling of all protected health information. Provides minimum restriction.

Maintenance - ✅DEVELOPS new behaviors to maintain changes and solution. Risk of relapse high in first six months to one year.

Motivational task: help client identify and use strategies to prevent relapse, support success and reinforce motivation and self-efficacy Pre-contemplation - ✅No awareness of problem; no intention to make a change Motivational task: raise doubt, provide information and education to increase client's perception of problems with their current behavior Preparation - ✅Ready to change; client considers change and plans a commitment to action Motivational task:

help client determine best course of action, focus on small meaningful steps Progress Notes - ✅Chart the day to day progress of the client.

Progress Notes format - ✅SOAP Subjective- what client saids Objective- what counselor observes Assessment- counselor makes judgment based on what was said and observed Plan- counselor's plan for the future Referral - ✅Identifying the needs of a client that cannot be met by the counselor or agency and assist the client to utilize the available support systems and community resources.

Release of records is now known as... - ✅Authorization to release Screening documents - ✅Used to document the person's appropriateness and eligibility for treatment services Stages of Change - ✅Pre-contemplation Contemplation Preparation Action Maintenance Treatment goals should be expressed as... - ✅specific, measurable, expressed in behavioral terms (i.e. the client will...) and include target dates for completion Treatment Plan - ✅Used to identify target problems from the assessment, set short and long term goals, determine behavioral objectives and set dates for completion Treatment Plan includes: - ✅problem statement objectives goals completion date Treatment Planning - ✅Process by which the counselor and the client identify and rank problems needing resolution; establish agreed upon immediate and long-term goal: and decide upon a treatment process and the resources to be utilized When developing a treatment plan with a client, the first step following the identification of a problem is... - ✅defining the long term goals