### Blue Horizon Counseling Center
**Setting: For-Profit Private Practice**
**Back Story**
Blue Horizon Counseling Center is a boutique private practice located in the heart of the city, specializing in outpatient mental health services. Our mission is to provide personalized, evidence-based therapy to individuals, couples, and families struggling with anxiety, depression, trauma, and relationship issues. Founded by Dr. Jane Smith, a clinical psychologist with over 15 years of experience, Blue Horizon aims to be a sanctuary for those seeking mental wellness and personal growth.
### Leadership and Supervision
**Leadership and Vision**
As the founder and director of Blue Horizon Counseling Center, I, Dr. Jane Smith, am committed to fostering a supportive and collaborative environment where both clients and staff can thrive. My leadership philosophy centers around empathy, transparency, and continuous professional development. I believe in leading by example and maintaining an open-door policy to ensure all team members feel valued and heard.
**Supervision and Support**
Effective supervision is key to maintaining high standards of care and professional growth. At Blue Horizon, regular individual and group supervision sessions are conducted to discuss cases, share insights, and provide feedback. This practice not only enhances clinical skills but also promotes a sense of community and shared purpose among staff.
### Skills Needed for Supporting Staff
**Record Keeping**
Accurate and efficient record-keeping is essential for providing quality care and meeting legal and ethical standards. Staff members are trained in using our secure electronic health record (EHR) system, which ensures that all client information is documented accurately and confidentially. Regular training sessions are held to update staff on best practices and new features of the EHR system.
**Reimbursement**
Navigating the complexities of insurance reimbursement can be challenging. At Blue Horizon, we provide comprehensive training on billing procedures, including coding, claims submission, and handling denials. Our administrative team works closely with clinicians to ensure timely and accurate reimbursement, allowing therapists to focus more on client care and less on administrative tasks.
**Staff Well-being and Burnout Prevention**
One of the critical issues in practice management is preventing staff burnout. We recognize that the mental health profession can be demanding and emotionally taxing. To support our staff, we offer regular wellness programs, including mindfulness workshops, exercise classes, and access to mental health resources. Additionally, we promote a healthy work-life balance by encouraging reasonable caseloads and flexible scheduling.
Conclusion
Blue Horizon Counseling Center is a thriving private practice dedicated to delivering exceptional mental health services while fostering a nurturing environment for both clients and staff. By prioritizing leadership and supervision, we ensure that our team is well-supported in their professional roles, ultimately leading to better outcomes for our clients.
Practice and Management
There are times when we all wish things ran the way we think they should. Imagine an agency that you design. You can be a big agency or a small private practice. It’s all up to you. In this discussion board, you will need to be creative and think about what your idea would look like. Take time to be specific in your discussion board so that your peers can imagine your facility.
You will create a well-informed discussion following these steps ( You have the Kinman Strategies in your content section for additional help):
· Choose a setting (such as a Community Service Board, For-Profit (like Private practice), or non-profit agency, Grant-funded) facility
· Develop a back story, one to two sentences of the facility you choose. (Inpatient Substance abuse treatment, Abuse shelter, family services……)
· In understanding your role of Leadership and Supervision assess the skills needed to support staff in record keeping, reimbursement, and one other issue in practice and management
· Make sure to break up these topics in clear defining headings as you write.
### Blue Horizon Counseling Center
**Setting: For-Profit Private Practice**
**Back Story**
Blue Horizon Counseling Center is a boutique private practice located in the heart of the city, specializing in outpatient mental health services. Our mission is to provide personalized, evidence-based therapy to individuals, couples, and families struggling with anxiety, depression, trauma, and relationship issues. Founded by Dr. Jane Smith, a clinical psychologist with over 15 years of experience, Blue Horizon aims to be a sanctuary for those seeking mental wellness and personal growth.
—
### Leadership and Supervision
**Leadership and Vision**
As the founder and director of Blue Horizon Counseling Center, I, Dr. Jane Smith, am committed to fostering a supportive and collaborative environment where both clients and staff can thrive. My leadership philosophy centers around empathy, transparency, and continuous professional development. I believe in leading by example and maintaining an open-door policy to ensure all team members feel valued and heard.
**Supervision and Support**
Effective supervision is key to maintaining high standards of care and professional growth. At Blue Horizon, regular individual and group supervision sessions are conducted to discuss cases, share insights, and provide feedback. This practice not only enhances clinical skills but also promotes a sense of community and shared purpose among staff.
—
### Management and Practice: Record Keeping, Reimbursement, and Other Challenges
**Administrative Roles and Resources**
The administrative team at Blue Horizon Counseling Center utilizes the most updated resources available, such as:
– National Council for Mental Wellbeing guidelines
– Example of Codes and Rates
– Practice and Management Guides
**Changes and Challenges**
– Keeping up with evolving best practices and insurance requirements
– Ensuring compliance with legal and ethical standards
– Managing administrative workload to allow clinicians to focus on client care
—
### Record Keeping
**Progress Notes**
Progress notes are essential for documenting that a session took place and the effects of treatment. They should:
– Contain the client’s presenting problems and diagnosis
– Document the client’s functional impairments and response to treatment
– Address the treatment plan, noting any deviations or updates required
**Treatment Planning**
Progress notes must match the treatment plan. If a session addresses an issue not in the treatment plan, the plan must be updated accordingly. Notes should document that treatment is directed towards the active symptoms of the diagnosis and track progress.
**Why Write Progress Notes**
– To ensure therapy stays on track and cost-effective
– To protect the therapist from legal or ethical issues
– To provide continuity of care if a new therapist takes over
– To evaluate treatment outcomes through documented progress
**What Constitutes a Good Progress Note**
– Topics discussed in the session
– How the session addressed treatment plan objectives
– Therapeutic interventions and their effectiveness
– Clinical observations
– Progress or setbacks
– Signs and symptoms related to the diagnosis
– Medical necessity for continued services
– Actions taken outside sessions to enhance therapy
**Examples**
– **Content Discussed:** “Discussed ways in which family of origin influences current behaviors.”
– **Treatment Plan Objectives:** “Worked on Objective 1b by role-playing assertive behaviors.”
– **Therapeutic Interventions:** “Utilized empty chair technique for closure from divorce.”
– **Clinical Observations:** “Client appeared anxious as evidenced by rapid speech and hyperventilating.”
– **Medical Necessity:** “Client experiences 5 daily panic attacks, leading to frequent work absences.”
—
### Reimbursement
**Understanding Reimbursement**
– Clear documentation of the treatment plan and adherence to it is essential for reimbursement.
– Insurers require a mental health diagnosis and may exclude reimbursement for certain codes or unspecified diagnoses.
**Progress Notes vs. Psychotherapy Notes**
– **Progress Notes:** Document the session occurred and the effects of treatment, including diagnosis and response to treatment.
– **Psychotherapy Notes:** Not shared with clients or others; contain personal reflections of the therapist.
**Examples of Documenting Medical Necessity**
– “Client misses school 75% of the time due to depression.”
– “Client has reduced panic attacks from 5 daily to 3 weekly.”
—
### Treatment Plan Development
**Creating Effective Treatment Plans**
– Written after initial assessment with client cooperation
– Based on clinical information and client’s strengths, needs, abilities, preferences, and symptoms
– Goals and objectives should be specific, measurable, attainable, realistic, and time-bound
**Example Goal and Objectives**
– **Goal:** Increase self-esteem
– **Objective 1a:** Initiate at least 2 positive behaviors per week
– **Objective 1b:** Employ at least 3 assertive behaviors per week
**Validating Change**
– Ensure objectives are quantifiable and linked to functional behaviors
– Regularly update and revise treatment plans as needed
**Discharge**
– Based on achieving functional adequacy in previously impaired areas
– Document progress towards treatment plan goals
Additional Resources
– AHIMA Work Group. (2013). Integrity of the healthcare record: best practices for EHR documentation.
– American Psychological Association. (2007). Record Keeping Guidelines.
– Hodges, S. (2016). The Counseling Practicum and Internship Manual: A resource for graduate counseling students (2nd ed.).
– National Council. (2014). Creeping and leaping from payment for volume to payment for value.
Supervision Administration Role
Management and Practice: Record keeping Reimbursement and other challenges
Administrative roles will utilize the most updated resources available such as
National Council for Mental Wellbeing
Practice and Management Guides
Changes and Challenges
Recordkeeping
Progress Notes
Treatment planning
Reimbursement
Understanding Reimbursement
Progress Notes vs. psychotherapy Notes
Psychotherapy notes are not considered information to be released to the client or others. (Process Notes in Therapy Notes)
Progress Notes prove that a session took place, but also the effects of treatment. provide evidence
Should contain diagnosis, current issues, effects of treatment
Should contain client’s presenting problems and the diagnosis
Should document the client’s functional impairment(s) that have led to the medical necessity for services, and how they are responding to the course of treatment toward alleviation those these impairments
If the client is diagnosed with depression, then their progress notes should primarily reflect treatment for depression, and not other areas (unless they, too, have been included in the treatment plan)
Recordkeeping cont.
Progress notes and treatment plans must match.
You address the tx plan in your notes, if you address something that is not in your tx plan because it is important and needed, update your tx plan
Progress notes must clearly document that the treatment plan is being followed and that the services are being directed toward the active symptoms of the diagnosis, what progress is being made, then how goals and objectives are being addressed.
Why Write progress notes
Keeping therapy on track and steadily noting progress by following the treatment plan assures cost effectiveness in treatment
Building a rapport is much more than “socializing” or “venting” It is not sump getting the client to talk with you and is not to be the focus of several sessions.
Rapport is built up as therapy takes place. Psychotherapy is professionally focused treatment on the client’s mental health impairments, and any progress notes that do not provide evidence of such treatment are QUESTIONABLE
Well kept notes protect the therapist from litigious or ethical problems that might arise without adequate documentation.
Clear progress notes alert the new therapist to specified issues that have been addressed and the types of interventions that work best for the client.
A review of the data documented in the progress notes is perhaps one of the best means of evaluating treatment outcomes. Notations such as compliance, attendance, insight, alleviation of impairments, cyclical behaviors, and much more provide helpful information to best service the client.
What constitutes a good progress note
What content or topics were discussed in the session?
How did the session address treatment plan objectives
What therapeutic interventions and techniques were applied, and how effective were they?
What clinical observations (behavioral, affective, etc.) were made
What progress or setbacks occurred?
What signs and symptoms of the diagnosis are present, increasing, decreasing, or not longer present?
How are treatment plan goals and objectives bring met at the time?
What is the current medical necessity for services?
What is being done outside the session to increase effectiveness of therapy
What are the client’s current limitations and strengths
What content or topics were discussed in session?
Topic areas should coincide with the areas of strength and weakness addressed in the treatment plan.
If topic areas do not seem to relate to the primary purpose of the treatment, the purpose of treatment, the purpose and medial necessity of covering the topic should be documented. If these area are continued top additional sessions, they should be added to the treatment plan revisions.
Examples of content-oriented progress note statements include:
Discussed ways in which family of origin influences current behaviors
Session focused on the 4 times client has been in the hospital for suicidal gestures
Client asked for help exploring problems coping with rejection.
How did the session address treatment plan objectives
Progress notes should specify which treatment plan objectives are being treated and how they are progressing
Goal 1: Increase self-esteem
Objective 1a: Initiate at least 2 positive behaviors per week
Objective 1b: Employ at least 3 assertive behaviors per week
In this case, the progress note statements could read: “worked on Objective 1b by role playing various assertive behaviors.” Additional statements could indicate specific issues and interventions being employed to address treatment objectives
What therapeutic interventions and techniques were employed and how effective were they?
Progress notes include descriptions of the specific therapeutic interventions taking place during the session
Documenting specific treatment interventions also helps the therapist keep the session on track and therapeutic. Without such documentation, sessions could deteriorate to “chitchat” or discussions irrelevant to treatment. Examples:
Utilized empty chair technique to help client with closure from divorce. Client wept through the entire procedure, later stating that he felt better because he ad been holding in too many feelings
Client states that she does not want to practice relaxation techniques in the sessions anymore because the make her more upset
What clinical observations (behavioral, affective, etc.) were made?
The therapist’s clinical observations are crucial in evaluating the course of therapy and in assessing the client’s current condition.
Notations should include clinically significant observations of verbal and non verbal behaviors
Observations should be integrated with the client’s presenting problem and diagnostic concerns.
Example, if a client is diagnosed with depression, progress notes should regularly assess the client’s level of depression. It is expected that the client would appear less depressed as therapy progresses. Unless progress notes document these observations, their is no way to assess the efficacy of treatment.
Examples of clinical observations include:
The client appeared depressed as evidenced by slumped posture, crying often, and a blunted affect.
The client appeared anxious as evidenced by speaking more rapidly that usual, hyperventilating, sweating, and getting out of the chair four times
The child continues to demonstrate defiant behaviors as evidenced by yelling at their mother three times during session, telling this therapist “this is stupid, your stupid” and refusing to answer questions over 50 % of the time
Progress note statements documents observations that validate the diagnosis and treatment plan. Without statements of this nature, a third-party auditor or insurance case management may not find sufficient evidence to warrant payment for additional services. In some legal and ethics cases, treatment has been rendered to a client but the progress notes did not clearly document that a disorder existed or was properly treated. Results have led to licensure issues, malpractice, or other disciplinary measures. Concise documentation helps solve all of these issues.
What is the current medical necessity for services
Most insurers require evidence of medical necessity in order to reimburse mental health services. Thus, progress notes should document the medical necessity of services needed by recording the client’s functional impairments caused by the mental illness.
Some therapy, however, is not considered medical necessary by third-party payers, including counseling solely for personal growth psychoeducational treatment, treatment for non-diagnosable disorders, relationship therapy, and other types of therapy in which the client is not significantly impaired by a mental disorder.
Although clinicians need not necessarily steer clear fro those types of therapy, they ay have to tell patients that the a have to pay the bill themselves. Unfortunately, some third-party payers forbid their contracted therapists form charging for mental health services that are not medical necessary. Examples of documenting continued medical necessity:
The client has experienced an average of 5 panic attacks daily, lasting 20-30 minutes, leading to going home from work early most days or missing work most days (this shows impairment of daily functioning)
Since the onset of medication and insight-oriented therapy, the client has been able to get out of bed at least 3 days per week but remains unable to go to classes
Discussed termination of series due to significant progress in meeting therapeutic goals, which has resulted in no issues reported in daily functioning
What is being done outside the session to increase effectiveness of therapy
Although most psychotherapy occurs at the clinician’s office, progress is not measured solely in the context of isolated in-office sessions
Measures of progress are best indicated outside the session, it is important to document statements made by client or collaterals (guardians, cadre, teachers, etc.)
Such documentation may include compliance and progress of homework assignment, behaviors generalized form the sessions, and interventions utilizing collaterals. For example:
Client reports initiating 3 conversations at school party, as rehearsed in the previous session. He describes decrease anxiety resulting from rehearsal
Compliance in homework assignments remains at over 80%
Most common Progress notes
Sample DAP
SAMPLE SOAP
S: “I wanted to talk to my kids about how guilty I feel about my drinking.”
O: Tearful at times; gazed down and fidgeted with shirt buttons
A: Consumer has gained awareness in how drinking behavior has embarrassed and hurt his teenage children. He expresses intense feelings related to his drinking and appears to assume responsibility for his past behaviors.
: Completed Tx Plan Goal #1, Obj 1. Continue with Goal #1, Obj 2, in next session 10/12/17 at 2pm. HW: Self Reflection.
Reimbursement and Tx planning
Therapists must clearly document that the treatment plan is being followed and that the services are being directed toward the active symptoms of the diagnosis, what progress is being made, then how goals and objectives are being addressed.
Today, nearly all payers still require an Mental health diagnosis; moreover, there is a trend to exclude reimbursement for V-Codes, and limitations on otherwise-specified diagnosis.
Reimbursement can also be refused for not providing required specifiers for certain diagnosis.
Symptoms are described in distinct terms by which a mental or physical disorders defined where as impairments are problem areas or functional limitations in life that are adversely affected by the symptoms.
Treatment Plan development
Typically written in second session or after initial assessment is complete
Client’s cooperation and collaboration is essential
Therapist goes over the diagnostic information collected in the initial session collaborates with the client concerning what impairment will be addressed.
Based on detailed and accurate clinical information that corresponds with clients
Strengths
Needs
Abilities
Preferences
And symptoms and respective functional impairments
GOALS AND OBJECTIVES
Objectives are incremental steps used to accomplish treatment plan goals.
Without specific goals and objectives to provide direction, treatment maybe vague and lack direction.
Measurable and observable objectives allow the therapist and the client to evaluate the effectiveness of interventions, client progress, level of treatment, and the appropriate time of termination.
Regular evaluation of the client’s progress toward goals can serve as a motivator for the client to stay on target with treatment issues.
Some treatment goals are implemented in the session (teaching techniques, mindfulness, etc.) and other implemented outside the session (homework, referrals)
In most cases, goals should reflect the alleviation of unwanted symptoms by attaining positive functional behaviors.
Treatment goals should be linked to living, learning, and workable activities.
In addition, objectives should be written in observable, measurable terms,
Specific
Measurable
Attainable
Realistic
Time bound
Example: Goal: “increase positive social interactions” Objective: “attend one social function per week” or “attend weekly social skills group meeting”
Therapist interventions such as “positive reinforcement of target behaviors” or “role playing means of meeting new people”
Objectives are steps toward the goal, and the last objective should best reflect the goal.
Tips Third Party Payers.
Avoid vague objectives: “increase communication skills”
Objectives incorporating words such as “increase” , “decrease” “add” or “change” with no further clarification are vague because they do not QUANTIFY or give helpful direction to the degree of change.
It is difficult to measure and observe symptoms, but the resulting impairments are easily documented in a measurable manner.
For example, documenting that a client is 75% depressed is a poor way to provide measurable evidence of impairment because the construct of depression is too vague to quantify, but the behavioral effects of depression can be quantified by stating, “the client misses school 75% of time (symptom) due to depression(impairment).
Validating Change
Vague, “increase social interactions, revise to “initiate and average of 2 new social interactions per week by August 10” When client accomplishes this objective, it could then be revised to “initiate 3 social interactions by October 15”
Not all behaviors are measurable in clearly quantifiable terms; however, it is advisable to do so whenever possible. For example it is difficult to quantify behaviors such as level of insight, respect for authority, level of self-esteem, and ability to concentrate
Discharge CASES
Discharge:
If treatment goes a full course, it lasts until the client is able to function adequately in those areas that were previously impaired. Documentation is provided by regularly evaluating progress toward the goals of the treatment plan.
Additional Resources
AHIMA Work Group. (2013). Integrity of the healthcare record: best practices for EHR documentation. Journal of AHIMA, 84(8): 58-62. http://library.ahima.org/doc?oid=300257#.WToeauvyvIW
American Psychological Association. (2007). Record Keeping Guidelines. American Psychological Association. Vol. 62, No. 9, 993–1004. DOI: 10.1037/0003-066X.62.9.993 http://www.apa.org/pubs/journals/features/record-keeping.pdf
Hodges, S. (2016). The Counseling Practicum and Internship Manual: A resource for graduate counseling students (2nd ed.). EBSCO: EBook Collection. Chapter 5: Clinical Writing and Documentation in Counseling Records.
Third Party Reimbursement
National Council. (2014). Creeping and leaping from payment for volume to payment for value. Mental Health First Aid National Council. Retrieved from https://www.thenationalcouncil.org/capitol-connector/2014/09/creeping-leaping-payment-volumepayment-value/
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