Minimum Requirements for Treatment Plans

[Old&InTheWay]

I can't figure out if this is a institutional, insurance-based, state, or federal mandate, but we are required to have treatment plans for all patients that are updated every 3 months. I find this to be mostly unhelpful for patients and a huge waste of time (because this is basically what I do in my notes and I am constantly talking with my patients about their goals). Everyone at my program likes to talk about what a treatment plan would ideally contain, but I haven't been able to figure out what the minimum requirements are. Does anyone have a sense of what a bare-bones treatment plan might look like? I'd like to create some generic epic smart phrases for common conditions that I can insert into plans.

Thanks in advance for any advice.

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[NickNaylor]

If you work in a predominantly Medicaid-based clinic, that might be where those requirements are coming from. A lot of public mental health systems require all of this crap. If it's just a hospital policy/requirement, then I would do the absolute bare minimum.

CMS requires a "comprehensive treatment plan" for admitted patients that would probably be a good place to start. You can add/remove things since this care will be in the outpatient setting. Check out p. 32 of this manual for what's listed there: https://www.cms.gov/files/document/mln1986542-medicare-mental-health.pdf

 

[calvnandhobbs68]

Yeah this is usually a Medicaid thing and another reason not to take Medicaid unfortunately….along with all the other reasons. It’s incredibly stupid because I’m not aware that this is a requirement for any other specialty.

They usually have the requirements for this if you lookup the “provider handbook” or equivalent for your state Medicaid plan where it has all the note requirements, billing requirements, etc. there’s usually a “behavioral health” section of that.

 

[smalltownpsych]

Goal: decrease subjective report of depressed mood
Plan: medication @ x dosage and monitor for side effects and/or efficacy
Nobody reads this stuff so I wouldn’t put more than that. Eventually after a JCAHO review someone might say to add a goal or make it more measurable and then you can come up with your own personal plan.
Goal: minimize meaningless work that doesn’t relate to patient care or income
Plan: ignore them or go into private practice
I’m pretty sure no doctor has ever gotten in real trouble for crappy treatment plan documents.

 

[wolfvgang22]

I'm told most of the treatment plan demands come from JCAHO findings. So you might start with JCAHO requirments.

Periodically administration tells me I have to do these absurdly long treatment plans (they are several pages long), at which point I then point out it will take 1 hour to do a patient treatment plan for a simple patient and 2 hours for a complicated patient. I then ask them if it's ok if I start cancelling patients to do these treatment plans, or if I can get some help. They then end up being done by the social worker for a while until the process repeats again. I think lots of places have the social workers do these.

 

[ObsequiousAplomb]

I've seen plenty of people get away with the following:

- problem: yes
- goal: yes

Plan:
- biological: yes
- psychological: yes
- social: yes

Whether or not that meets the minimum requirements...well, I doubt it. But it seems to check the box of whether or not the plan was made.

At the CMHC in residency it was more of a semi-annual thing filled out by a social worker with goals and plans. Bear in mind, this was that social worker's only involvement in the resident clinic cases. They didn't read our notes or speak with the patient at any time other than to write these treatment plans. Very frequently their plans contradicted ours. For example "consumer will meet with psychiatry resident on a no less than monthly basis to optimize medication regime" [sic] was in every plan they wrote. It didn't matter if the patient wasn't taking medications, was being seen every 3 months, whatever. They also would come up with their own diagnoses, like specific phobias. Of course, the patients always denied ever saying that during our visits when we followed up on it. Anyway, our therapy notes then had to be structured to address each of these goals, whether or not they were the patient's actual goals.

 

[Sushirolls]

CMS is the source.
Medicaid, in community mental health settings is where I saw it. I believe any non-profit (even for profit?) that takes medicaid technically in outpatient also needs to have these ridiculous bureaucratic wastes of time. One job I had years ago was talking about needing to add these for the medicaid patients...

I suspect, some nurse, or SW; most definitely not a physician, came up with these time wastes.

Medicare requires I believe as others mentioned for inpatient admissions. That's what the focus was on in inpatient units I've worked "Treatment team meetings" and then some how getting a patient to also sign the meeting/plan, too. A complete waste. Like most everything government, sees a problem, has good intentions, comes up with a solution, but instead the solution creates 10 more problems.

Let this be a reminder for any pre-med, students, or residents who even think that Medicare for all is some how going to be a positive solution, or any kind of improvement to the status quo mess we currently have. Medicare for all, as evidenced by our governments current track record, will make your day to day work a living nightmare.

 

[wolfvgang22]

Let this be a reminder for any pre-med, students, or residents who even think that Medicare for all is some how going to be a positive solution, or any kind of improvement to the status quo mess we currently have. Medicare for all, as evidenced by our governments current track record, will make your day to day work a living nightmare.

Respectfully, I think this is unnecessarily cynical, sorry. This is off-topic and just your opinion, none of us have a crystal ball. I feel it is necessary to say this because of the forceful certainty with which you present this as a fact. I agree with you on most things, but not this, friend.

I edited this because my initial response was too harsh.

 

[nexus73]

If you post this to a social worker or therapist forum you’ll probably get better answers because they have to do this all the time for Medicaid.

 

[Candidate2017]

As pointed out, this is a Medicaid thing. Just be aware it exists.

As a resident, don't worry about it. Let the faculty wax poetic about the ideal treatment plan. You don't get paid any more or less, and patients don't get any better if you spend more or less time on it.

When you're an attending, don't worry about it. Let the social workers and hospital deal with it.

 

[smalltownpsych]

If you post this to a social worker or therapist forum you’ll probably get better answers because they have to do this all the time for Medicaid.

Exactly why I posted because I have had to do these things in various settings. It is spreading past medicaid because JCAHO required it at last place I was at. Guess who was doing the site survey - a social worker. He was really impressed with the work we were doing with patients but found our documentation to be woefully deficient. 🙄

 

[Alemo]

Respectfully, I think this is unnecessarily cynical, sorry. This is off-topic and just your opinion, none of us have a crystal ball. I feel it is necessary to say this because of the forceful certainty with which you present this as a fact. I agree with you on most things, but not this, friend.

I edited this because my initial response was too harsh.

I think Sushi was emphasizing the ****tiness of Medicaid as an institution, rather than the property of Medicaid as available for everyone.

We can all agree that for all parties involved, Medicaid leaves a lot to be desired (to put it charitably).

Single payer healthcare for all on the other hand is a different and more controversial topic.

Sushi should correct me if necessary

 

[Sushirolls]

Sleep Doc who subleases from me, was actively taking medicaid. Considered their duty to continue doing this. I ascribe as having come fresh off the training/academic train, and then the non-profit Big Box shops. I discouraged taking medicaid. Fast forward a year or more and Sleep Doc, was spending excessive amounts of staff time resubmitting to medicaid the claims due to denials, and never consistently got answers as to why. Numerous lengthy phone calls with different levels of people in the medicaid organization to understand why the denials. Never consistent. Claims continued to be denied - randomly, but the actual payments were the exception not the rule. The patients were more complex and took extra time. The pay rate was abysmal. So essentially a double hit, paid far less than half of usual insurance rates, and did double the work clinically, and triple the work for office staff. Finally, the Sleep Doc hit their threshold and disenrolled.

My comments were a simple political punch. Government won't fix healthcare. Their track record is abysmal, and as we like to mention past behavior as correlate to future behavior, giving more market share to the government is a recipe for disaster. Naturally, single payer health care is a political topic so it could be received as a good natured PSA, or harshly like an angry 'click bait' news headline we're getting accustomed to reading.

 

[erg923]

I hope people are not objecting to the general idea of having treatment plans that have specific goals, are measurable, and are updated regularly??? Not sure what the objection to that would be?

I can understand the frustration if the paperwork is duplicative and/or overly complicated and involved, however. Treatment plans are important for guiding care and for maintaining the conceptualization of the patient for that care episode, but can usually be very briefly worded and simplistic.

 

[Sushirolls]

I whole heartedly object.

They are a waste of time.

Our progress notes already encapsulate an assessment and plan.

"Treatment plans" are redundant, add to chart bloat, add to bureaucracy, add more weight to the scales of burn out, and don't make a darn difference in outcomes.

Clearly the sentiments above they people are pushing for neglecting them, not doing them, or rubber stamping generics evidence their pointlessness.

When I was overlapped with doing inpatient work and goal of broad spectrum insurance paneling, I had briefly been connected to Tricare. Tricare from previous outpatient work, years ago, was horrendous with their repeated requests of "Treatment Plans" and sending progress notes was not sufficient for them. I put up a block with admin I wasn't taking any more Tricare. In private practice I dropped the tricare as fast I dropped the inpatient work to avoid that waste of time. This is one of the consequences of bureaucracy - diminished access to care. Shame on insurance, and government entities for thinking this is necessary.

 

[erg923]

I whole heartedly object.

They are a waste of time.

Our progress notes already encapsulate an assessment and plan.

"Treatment plans" are redundant, add to chart bloat, add to bureaucracy, add more weight to the scales of burn out, and don't make a darn difference in outcomes.

Clearly the sentiments above they people are pushing for neglecting them, not doing them, or rubber stamping generics evidence their pointlessness.

When I was overlapped with doing inpatient work and goal of broad spectrum insurance paneling, I had briefly been connected to Tricare. Tricare from previous outpatient work, years ago, was horrendous with their repeated requests of "Treatment Plans" and sending progress notes was not sufficient for them. I put up a block with admin I wasn't taking any more Tricare. In private practice I dropped the tricare as fast I dropped the inpatient work to avoid that waste of time. This is one of the consequences of bureaucracy - diminished access to care. Shame on insurance, and government entities for thinking this is necessary.

If its redundant, its redundant, I get it. Psychiatric/Psychological treatment is based in empirically-based methods and literature, is measurable, and subject to revision based on ongoing clinical data/insights and individual patient progress. Having a formal treatment plan, seems pretty legitimate to me? If that is really already encompassed by your existing documentation, I have no scruples here.

 

[nexus73]

The problem is asking for a separate document that does duplicate what's already in the clinic note. Goals being measurable is reasonable to some extent. I use PHQ9 and GAD7 which are far from perfect. But I don't have patients fill out YBOCS or PANSS scales, I just gather that information from the clinical interview. The goal is obviously reduction in symptom severity of whatever the condition is, why do you need a separate treatment plan to say: they are depressed, goal: be less depressed (or PHQ< 12 or <9 or <7 etc etc)? Does this really improve care to have something called "treatment plan"? It's also easier to add this on to a 60 minute therapy visit where you send 45 minutes with the patient and have 15 minutes to satisfy these requirements, compared to a 20-30 minute psychiatry follow-up with patients booked back to back.

medicaid doesn't require orthopedic surgeons to do this. Or neurologists, or family medicine etc. This seems like extra work just for mental health.

 

[smalltownpsych]

I have worked in organizations that require a treatment plan and in organizations where one wasn't required. I have no belief that the extra paperwork has helped or benefited me or my client in any way. I do talk therapy and the patient and I talk about what we are doing, the progress, and the goals. It seems to me that other people outside of the treatment are the ones interested in me documenting what we are doing and I get why when they are paying the bills. That is one reason I am only private pay now so it's between me and the patient again.

If I was working with a patient and it made sense for us to put something in writing, then we would do that. To this point in my practice, it hasn't ever seemed necessary for any of them. Having discussions about the process and goals of treatment has happened pretty much every single time. In fact, it's hard to think of cases, outside of small children, where it wouldn't be part of the ongoing dialogue. Periodically, if the patient doesn't bring it up, I will. I also want to make sure that we both have the same goals and are on the same page as treatment progresses. Other practitioners might like to use more documentation and structure for their treatment, and that is fine for them. Personally, I don't.

 

[comp1]

The problem is that administrators generally want a treatment plan in a different, additional note. They are entirely duplicative to progress notes and should be specifically banned/not allowed. They actively harm patients by making it more difficult to find important clinical information when needed. Just my two cents. Definitely not TJC's or CMS's.

 

[calvnandhobbs68]

If its redundant, its redundant, I get it. Psychiatric/Psychological treatment is based in empirically-based methods and literature, is measurable, and subject to revision based on ongoing clinical data/insights and individual patient progress. Having a formal treatment plan, seems pretty legitimate to me? If that is really already encompassed by your existing documentation, I have no scruples here.

It's stupid because it's not required of any other specialty.

For instance, for another common chronic medical condition "asthma-> well controlled, <1x week frequency of albuterol use with Flovent-> Continue current management of Flovent 100mcg BID and Albuterol 90mcg 2 puffs q6hrs PRN"

So my treatment plan should be able to be (what should be in my assessment/plan anyway) "GAD-> GAD-7 as above. Significant reduction in daily anxiety, irritability, disruption of concentration, sleep on Prozac 40mg daily, engaged in psychotherapy regularly-> Continue Prozac 40mg daily, psychotherapy as scheduled"

The end. I don't need to fill out a bunch of stupid checkboxes about every functional goal I want the patient to achieve. If "treatment plan" is another name for "assessment and plan" than that should be at the end of every progress note.

 

[erg923]

The problem is asking for a separate document that does duplicate what's already in the clinic note. Goals being measurable is reasonable to some extent. I use PHQ9 and GAD7 which are far from perfect. But I don't have patients fill out YBOCS or PANSS scales, I just gather that information from the clinical interview. The goal is obviously reduction in symptom severity of whatever the condition is, why do you need a separate treatment plan to say The are depressed, goal: be less depressed (or PHQ< 12 or <9 or <7 etc etc)? Does this really improve care to have something called "treatment plan"?

It's stupid because it's not required of any other specialty.

For instance, for another common chronic medical condition "asthma-> well controlled, <1x week frequency of albuterol use with Flovent-> Continue current management of Flovent 100mcg BID and Albuterol 90mcg 2 puffs q6hrs PRN"

So my treatment plan should be able to be (what should be in my assessment/plan anyway) "GAD-> GAD-7 as above. Significant reduction in daily anxiety, irritability, disruption of concentration, sleep on Prozac 40mg daily, engaged in psychotherapy regularly-> Continue Prozac 40mg daily, psychotherapy as scheduled"

The end. I don't need to fill out a bunch of stupid checkboxes about every functional goal I want the patient to achieve. If "treatment plan" is another name for "assessment and plan" than that should be at the end of every progress note.

Do not disagree. I do not like symptom checklists for measuring treatment/treatment goals at all, however. At least not solely. Having one goal based on this is fine, but "ecological validity" can be a bitch. Additionally, if there is any any kind psychotherapy going on, goals that speak to functional impairments of daily living/aspiration really need to be a part of it. That MAY not be part of your job/responsibility to monitor, however. So, I get that.

 

[MedMan80]

OMH/medicaid requirements suck up probably 2-4h of my time a week (including useless crap needed to do on intake)

 

[Mad Jack]

I've seen plenty of people get away with the following:

- problem: yes
- goal: yes

Plan:
- biological: yes
- psychological: yes
- social: yes

Whether or not that meets the minimum requirements...well, I doubt it. But it seems to check the box of whether or not the plan was made.

At the CMHC in residency it was more of a semi-annual thing filled out by a social worker with goals and plans. Bear in mind, this was that social worker's only involvement in the resident clinic cases. They didn't read our notes or speak with the patient at any time other than to write these treatment plans. Very frequently their plans contradicted ours. For example "consumer will meet with psychiatry resident on a no less than monthly basis to optimize medication regime" [sic] was in every plan they wrote. It didn't matter if the patient wasn't taking medications, was being seen every 3 months, whatever. They also would come up with their own diagnoses, like specific phobias. Of course, the patients always denied ever saying that during our visits when we followed up on it. Anyway, our therapy notes then had to be structured to address each of these goals, whether or not they were the patient's actual goals.

Reading "consumer" made me cringe

 

[Mad Jack]

I think Sushi was emphasizing the ****tiness of Medicaid as an institution, rather than the property of Medicaid as available for everyone.

We can all agree that for all parties involved, Medicaid leaves a lot to be desired (to put it charitably).

Single payer healthcare for all on the other hand is a different and more controversial topic.

Sushi should correct me if necessary

If Medicaid was the single payer, the headaches alone would push me out of accepting insurance entirely, or leaving the field if that were not an option. Treatment plans are but one head of the loathsome bureaucratic hydra that is Medicaid.

 

[MedMan80]

If Medicaid was the single payer, the headaches alone would push me out of accepting insurance entirely, or leaving the field if that were not an option. Treatment plans are but one head of the loathsome bureaucratic hydra that is Medicaid.

Not to mention not being able to decline care for any reason. I was told we can't even tell people we have a waitlist..

 

[allantois]

We often forget that medicaid is state run. When I worked in NC; medicaid was fine (not sure how they paid compared to commercial), but they really didn't require anything extra on the psychiatry side of things (I believe they did require extra things from therapists). Here, in FL they also require we fill out a form for kids to be prescribed psychotropic meds saying we discussed other options such as psychotherapy which seems to unnecessarily scare parents about treatment. Funny enough, I haven't worked for any office that has taken Medicare as it was too complicated for management to figure out how to enroll

 

[smalltownpsych]

We often forget that medicaid is state run. When I worked in NC; medicaid was fine (not sure how they paid compared to commercial), but they really didn't require anything extra on the psychiatry side of things (I believe they did require extra things from therapists). Here, in FL they also require we fill out a form for kids to be prescribed psychotropic meds saying we discussed other options such as psychotherapy which seems to unnecessarily scare parents about treatment. Funny enough, I haven't worked for any office that has taken Medicare as it was too complicated for management to figure out how to enroll

Great point. In Wyoming medicaid was straightforward and paid relatively well. In this state and others it has been handed over to Optum (aka United Healthcare) and I already have had my fill of them from other states where they were just providing employer provided type insurance and everything I hear about them here is a nightmare. We just had the main hospital in our town close it’s outpatient psychiatry clinic and inpatient substance abuse unit and inadequate compensation from medicaid was cited as the main factor. Interestingly, they didn’t name Optum in the articles about it. Also, these are actually the only options in our rapidly growing county with population of about 300k and they were busy as can be with long waiting lists.

 

[Mad Jack]

Not to mention not being able to decline care for any reason. I was told we can't even tell people we have a waitlist..

"I'll schedule you for May 7th, 2037, does that work?" Care that isn't timely does no one any favors, which is the situation this creates. Politicians really shouldn't be involved in healthcare, they have no clue what they're doing

 

[calvnandhobbs68]

Not to mention not being able to decline care for any reason. I was told we can't even tell people we have a waitlist..

Yes, medicaid plans have stupid requirements as well typically about how quickly you should be able to schedule people in while paying you 30 bucks for a 99214. Medicaid is state to state but in the 3 states I've been in, it's not been great. It's honestly basically charity care for individual practices and should be viewed as such, not a real insurance plan unfortunately for the people who have to have it. CMHC or FQHCs are a totally different story as they get extra block grants from medicaid/state funding to bolster their funding stream that individual offices aren't eligible for, also hospital associated clinics get to bill the facility fee. So I have no problem not taking medicaid and letting them all go to the places that can afford to take them...FQHCs and hospitals.

Medicare at least tends to pay you reasonably (at least it's a livable wage) for the crap you have to go through and are a reliable payor as long as you have the documentation in order.

I mean private insurance companies technically have these too but nobody ever enforces them (like I'm pretty sure all my private insurance panels say I should be able to schedule someone in within 1 week but right now my news are out to mid July lol).

 

[Sushirolls]

Yes, medicaid plans have stupid requirements as well typically about how quickly you should be able to schedule people in while paying you 30 bucks for a 99214. Medicaid is state to state but in the 3 states I've been in, it's not been great. It's honestly basically charity care for individual practices and should be viewed as such, not a real insurance plan unfortunately for the people who have to have it. CMHC or FQHCs are a totally different story as they get extra block grants from medicaid/state funding to bolster their funding stream that individual offices aren't eligible for, also hospital associated clinics get to bill the facility fee. So I have no problem not taking medicaid and letting them all go to the places that can afford to take them...FQHCs and hospitals.

Medicare at least tends to pay you reasonably (at least it's a livable wage) for the crap you have to go through and are a reliable payor as long as you have the documentation in order.

I mean private insurance companies technically have these too but nobody ever enforces them (like I'm pretty sure all my private insurance panels say I should be able to schedule someone in within 1 week but right now my news are out to mid July lol).

I will consider accepting medicaid when/if these things happen:
1) the paperwork and bureacracy and forms become the easiest of all insurance to deal with and has best customer services when one does have issues and needs to call them.
2) The government allows me, a private practice entity, to write off bad debt, AND contractual reductions for what they pay me. I.e. I bill $300, medicaid reduces to $80, I want that other $220 to reduce my taxes. If they don't pay me squat, I want another benefit. As long as I get no perks that all these Big Box shops that are supposedly "non-profits" get, I can't compete by taking inefficient financial loses.