Thoughts from Steve Welton

The challenge of treating individuals with co-occurring mental health and substance use disorders is discussed. With approximately 7.7 million people in the United States having both diagnoses, it is crucial to address the integration of care. The Substance Use and Mental Health Services Administration (SAMHSA) emphasizes the positive impact of integrating mental health and substance use treatment, leading to better outcomes and quality of life for patients. SAMHSA encourages a "No Wrong Door" system, where clients can receive support regardless of whether they initiate treatment through substance use or mental health treatment first. If you are unfamiliar with treating co-occurring disorders or working collaboratively with colleagues from different specialties, SAMHSA offers valuable resources and a free Treatment Improvement Protocol to enhance your knowledge and practice.

The article highlights the importance of including suicide risk assessments in behavioral health treatment. Despite the alarming statistics on suicide rates, some clinicians do not prioritize assessing for suicidality when beginning treatment. Many behavioral health clinicians have received little to no formal training in completing a suicide assessment, with up to 50% lacking any training at all. However, training in suicide risk assessment has been shown to have a significant impact on clinicians' ability to effectively assess for suicidality. The author encourages clinicians to invest in training on this crucial topic and recommends utilizing tools such as the Columbia Suicide Severity Rating Scale (C-SSRS) and Ask Suicide-Screening Questions (ASQ) for comprehensive risk assessments.

 While some clients may find the process time-consuming, using well-designed questionnaire forms can enhance efficiency and the capture of historical data. By having clients complete surveys before their first appointment, therapists can review their responses during the assessment, ensuring a comprehensive understanding of their background and focusing more on present issues.

The importance of discussing spirituality, regardless of religious beliefs, in the assessment process. Understanding the role of religion in clients' lives can be helpful in determining social supports or identifying potential sources of trauma. Even if clients claim to have no spiritual aspect to their lives, exploring this topic can still be instructive and lead to healing.

Addresses the often-asked question of completion standards for progress notes. While there are time constraints and pressures on clinicians to effectively treat clients, CMS expects progress notes to be completed "at the time of service or shortly thereafter." Some insurance companies even require completion within 24 hours, with delayed entries needing additional documentation. Lengthy delays in progress note completion can be considered unreasonable during an audit and may lead to unfavorable outcomes. It is crucial to strike a balance between meeting medical necessity goals and allowing sufficient time for completing progress notes.

In this blog, the importance of gathering a detailed family medical history in biopsychosocial assessments is discussed. The author highlights how this information can be valuable in determining whether certain symptoms may stem from medical conditions rather than mental health issues. Additionally, the social dynamics and trauma resulting from significant family health issues are explored, emphasizing the potential insight gained from knowing this information from the beginning or uncovering it later in therapy sessions. Ultimately, including a question about family medical history in client intake forms is seen as an easy and essential step in the assessment process that can provide valuable insights for working with clients.

Selecting the correct CPT code for psychotherapy is dependent on documenting the time accurately. 

Having a comprehensive plan in place for emergencies and disasters is crucial for the smooth operation of clinical groups and facilities.  

If your operational manual lacks essential plans like Safety and Security, Sentinel Events, Disaster, Infectious Disease Control, or Fire Safety, it's time to collaborate with your senior staff and start building them out to ensure you're prepared for any challenges that come your way.

SMART Goals, which stands for Specific, Measurable, Attainable, Results Oriented, and Time-related, is a method used to develop treatment goals that make sense for the work ahead. Although the idea of SMART goals originated in the world of business, it has been applied to various fields, including behavioral health and treatment planning. 

Understand how SMART goals can serve as a useful option for organizing and building treatment plans, acting as a road map towards wellness for your clients.

In this blog post, the author discusses the importance of properly documenting the use of telehealth in progress notes for psychotherapy services. They highlight the fact that telehealth is not considered a unique service but rather a modality of service, meaning that regular progress note documentation rules still apply. It is crucial to include specific information in the notes, such as documenting that the service was rendered over telehealth and identifying the specific telehealth platform used. Failure to do so may result in insurance retractions during an SIU review. The author advises practitioners to begin documenting this information on their telehealth progress notes to ensure proper reimbursement and compliance.

Electronic Health Records (EHR) have greatly improved the way psychotherapy is conducted, making clinical documentation less time-consuming and more efficient. However, some features, such as the "Auto-Fill" function, can cause problems when it comes to proper documentation. A common issue observed is that auto-fill can lead to cloned progress notes, which can put a therapist's practice at risk if they appear identical for different sessions. To address this problem, it is recommended to turn off the auto-fill feature and invest a little more time in effectively documenting each session. This adjustment can have a significant defensive impact on a practice and strengthen progress notes.