1. P E R M I A N B A S I N C O M M U N I T Y C E N T E R S F O R M H M R
B R I D G E S B E H A V I O R A L H E A LT H C L I N I C
I N T E G R AT E D P R I M A R Y C A R E C L I N I C
C A S E M A N A G E M E N T :
E N C O U N T E R D O C U M E N TAT I O N
P R E S E N T E D BY
R I C A R D O O. H E N R Y, M A , T L B R I D G E S I P C - M I D L A N D
2. NATIONAL ASSOCIATION OF STATE MENTAL
HEALTH PROGRAM DIRECTORS (NASMHPD)
• “a range of services provided to assist and support individuals in
developing their skills to gain access to needed medical,
behavioral health, housing, employment, social, educational
and other services essential to meeting basic human
services; linkages and training for patient served in the use of
basic community resources; and monitoring of overall service
delivery” (NASMHPD [2014]).
3. WHAT IS CASE
MANAGEMENT?
Case management includes:
• comprehensive assessment of needs and
resources,
• development of a care plan, referral follow-
up,
• periodic evaluation of the plan
• aimed at helping the client achieve their
established treatment goals
4. NEEDS
• Medical Health
• Behavioral Health
• Social
– Housing
– Employment
– Finance
– Nutrition
– Social Skills
• Social & Community Services
• Other Services
5. ASPECTS OF CASE
MANAGEMENT
• Identification (Walk-in/ Referral)
• Assessment or Evaluation (Screening)
• Development of Care Plan*
• Symptom Management (Physician/Therapist)
• Follow-up
– Monitoring
– Reassessment
– discharge
7. ENCOUNTER INTERVIEW
• The quality of the encounter
documentation is affected by to the
quality of our interview
• The quality of the Case Management
Interview is affected by the quality (skill)
of the case manager
• The quality of the case manager is
affected by the quality of experience
(training and practice) of the case
8. BEHAVIORAL HEALTH
SCREENING
• Brief history of symptoms
• Past and current treatment
• Description of effect of symptoms
• Evaluation of cultural and linguistic
needs
• Evaluation of social support
• Evaluation of available benefits
• Signed Consents
10. POTENTIAL RESOURCES
• PBCC Programs / Units including BBH
• HHSC
• Midland / Ector County Housing (Section 8)
• Midland / Odessa Housing Authority (City)
• Goodrx.com
• Rxassist.org
• Churches & Civic Groups
• Drug Manufacturers
11. POTENTIAL EDUCATION
ITEMS
• Medication
• Nutrition
• Exercise
• Symptoms Management Self Help
• Community Services available
–Eg. WTO Transportation support for
medical appointments
12. CASE NOTES
C A S E M A N A G E M E N T E N C O U N T E R S
14. NOTES FORMAT
• DAP = Data Assessment Plan (PBCC Format)
• SOAP = Subjective, Objective, Assessment,
Plan
15. WRITING THE NOTES
Include:
Description of the context
Purpose of the conversation
Observations
Content
Outcome
Impression and assessment of the person or
situation
Plans
16. DO’S & DON’TS
• Do make them clear and concise
• Do make them accurate and complete
• DO make them legible
• DO use the THIRD PERSON
• Do not emotional reactions or value judgements
• Do not record unsupported suspicions, commentary, opinions
• Don’t write with vagueness (be specific)
• Do not create your own diagnosis
17. QUALITY TEST
Could a colleague use
my case notes to
determine the next
steps to help the
patient?
If the patient read
your case notes would
s/he feel respected
and would s/he agree
with your record of
the interaction?
18. CASE MANAGEMENT NOTES
• Identify ALL case management activities
by recording items discussed.
• Describe and smartly query mood and
demeanor during and at the end of the
session
• Record mental status observation
21. CASE MANAGEMENT HABITS
•Monthly check on ALL case files
•Check referrals weekly
•Check PAP med list weekly
•Review Resources List Annually
22. SOAP NOTE - SAMPLE
• TC met with Felix for a scheduled home visit today.
Felix said things were going well. The home was
clean. The appliances were in well working order.
Felix appeared very happy in his new apartment. TC
reviewed the 24-hour back-up plan and personal
resource list with Felix. TC discussed budgeting with
Felix. Felix shared his utility bills with TC. TC reviewed
medication list with Felix. Felix stated he was at the
doctor’s last week and the doctor changed some of
his medications around. TC updated Felix’s
medication sheet. TC told Felix she would be back
next Tuesday to visit him. Felix stated he didn’t need
anything else, but he would call her if you needed
something before their next visit together.
24. • Scenario 1- Situation: Student is talking one on one with you
I feel really tired. I have these early classes and sometimes I just
can’t get out of bed in the morning. I try to do all my readings but
they just don’t sink in, even after reading them over and over. I try
so hard at the work, but I’m not getting very good grades. I just
don’t think I get it… like I have this group project for class and
everyone in my group is so smart and I don’t think my part is
going to be any good. I just feel helpless… and I can’t talk to my
family about it because my brother’s at school right now on a full
scholarship and he’s getting great grades. I feel so guilty because
my parents had to pay for everything for me because I couldn’t
find a summer job… and my family doesn’t have a lot of money
right now. If I loose my entrance scholarship, they’re going to be
so disappointed. Most of the time I just feel alone… all my friends
went to other universities… they have new friends and their own
work and don’t want to hear about my problems.
25. • A 30-year-old female patient was referred to this
office by her primary care physician for a psychiatric
evaluation. She presents with complaints of
worriedness, nervousness, frequent cold sweats, and
tiredness, trouble concentrating especially at work,
sleeplessness, hopelessness, loss of appetite, sadness,
and occasional suicidal thoughts. A comprehensive
psychiatric evaluation and interview was conducted.
During this process, a detailed personal history of
development, life events, emotions, behaviors, and
the identified stressful events are obtained. A
stressful event identified is that her parents separated
when her mother became severely ill with stage 4
colon cancer. She became the care-giver and primary
provider at the same time. She is diabetic and history
of high blood pressure
26. A 68-year-old male established
patient diagnosed with anxiety
comes in today for a follow-up.
Patient has been struggling lately
with recall and has been gaining
weight rapidly. He currently takes
Paxil CR one a day for his anxiety.
Anxiety appears well controlled on
current medication.
Editor's Notes
Case Management as used here refers both to Medical Case Management Activities and Care Coordination
1. Case management: Case management may be defined in many ways and can encompass services ranging from basic to intensive. The National Association of State Mental Health Program Directors (NASMHPD) defines case management as
Case management is principle of managed care and is called for in the Texas Code for local authorities providing mental health services for the community
- Each time a patient presents before us we can use the list as a guide. Convert the story the patient shares into a care plan with activities/goals for future sessions. The Case Management clinic day session does not necessarily have to only be guided by the orders of day. Regularly review the plan and track the patient progress constantly revising goals.
At the moment PBCC/Bridges does not require a care plan for patients. However, it is a good practice to optimize the treatment outcomes of the patients. Therefore case managers should consider developing a care plan by which we can track the progress of our patients. This will become the subject of a future session.
An important part of
Include age, employment status, marital status, race, gender and services sought
Include medications
Include the effects on work, family, friends and other aspects (functioning domains)* ANSA; note mental status (dysphoria, euphoria, anhedonia)
Include need for translation and making arrangements before hand (where possible)**
Include notes about quality of personal , peer and family relationships. Make note of appearance (dress, hygiene, mannerism). If patient is homeless this should be clearly noted and they should also be immediately offered SOAR benefits on spot or at the earliest opportunity (after admission to services). Ask about and record transportation needs
Include whether patients currently access HHSC benefits
Use the SOAP format to document the encounter in a
phone message (information only, for future reference; activities related to a referral that cannot be documented in the referral comment block);
ISR (if patient has not yet been admitted or if there is an emergent incident;
EMR mail (aka workflow) to document any item requiring action from a provider
If its not written it was not said/done. Give yourself credit
The way the note is written reflects on you and the organization
Providers will want to know the patients demeanour then compared to how they presented at the time there were seen.
DAP is used as the layout for recording the encounter note
SOAP is used as the format for documenting the encounter.
Documentation should be
Timely
Factual
Relevant
Legible
Concise
Signed
More is not always better. provider needs the key info; make info easy to find
Manage use of abbreviations and use proper punctuations. Sentence fragments may be acceptable on the Screening note but should be legible and represent a complete thought.
Always refer to cc/cm and pt or he/she. First person is used when referring to individuals by name (initials of known persons is acceptable). Using “Patient” is also acceptable.
- Identify resources provided; information provided about medication and other processes; follow-up appointments; “supportive counselling”
Describing demeanor may be useful to other providers as well as in the event of a post encounter complaint
Mental status observation: memory, appearance, functioning, (AMSIT). These can serve a useful function to identify how the client has progressed.
Perhaps reading back or reviewing the observable measurable change with the patient.
Remind patients of the before and after. Debrief and point ahead.
HANDOUT
SOAP speaks to the format for content. It may not appear in order. The Current Care Coordination Form is laid our in the SOAP format
Subjective – Pts account of their story
Objective – e.g. pt had difficulty making eye contact; client was appropriately dressed and appeared to be in a good mood
Assessment – evaluation of patient progress; did the patient do what was done
Plan – updating goal, extend goal, adjust goal
Each month the case manager should review the list of patients and make at least one contact. Patients who have become delinquent in attendance after 3 checks or have become unreachable should be discharged after which no further checks would be required. A day might need to be set aside to do this activity (a series of hours). The check should be managed and timed e.g. 5mins and set questions are asked with a view to determine whether they may need an early appt. One the days (time) of the check all calls should be held so the case manager can keep within the time.
![NATIONAL ASSOCIATION OF STATE MENTAL
HEALTH PROGRAM DIRECTORS (NASMHPD)
• “a range of services provided to assist and support individuals in
developing their skills to gain access to needed medical,
behavioral health, housing, employment, social, educational
and other services essential to meeting basic human
services; linkages and training for patient served in the use of
basic community resources; and monitoring of overall service
delivery” (NASMHPD [2014]).](data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7)