Concurrent Documentation for Treating Patients with Mental Illness

Concurrent Documentation is strategy that can be learned and applied in a relatively short period of time. Essentially, concurrent documentation means that provider staff work with the clients during assessment, service planning and intervention sessions to complete as much related documentation as possible and appropriate.

There are a number of significant benefits to concurrent documentation including:
1. Enhancing client and family involvement in the therapeutic/ rehabilitative process (i.e. it supports the Person Centered "Golden Thread" and... clients and families like it!
2. Improves the quality of life for staff by eliminating documentation backlogs and the feeling of ‘never catching up". It can drastically reduce documentation time to direct service ratios.
3. Helps staff more easily attain performance standards and have time for other useful activities.
4. Focuses and improves the quality of documentation content

The primary steps to a transition to concurrent documentation involve:
1. Motivating staff by clearly demonstrating the clinical and personal value of concurrent documentation.
2. Moving staff from a "that's not possible" to an "I can do that" position.
3. Attainment of competencies in specific strategies for using concurrent documentation for a variety of processes (e.g. assessment, service planning, service progress notes) and in a variety of settings (e.g. office based vs. field based, individual vs. group, paper forms vs. EMR).

The ideal preparation for transition to concurrent documentation involves:
1. Staff training (preferably onsite but can be done via web-ex)
2. Recruitment of volunteers to conduct a pilot (in the present context the pilot staff would be perfect candidates)
3. Implementation of a concurrent documentation pilot that includes minimal collection of data to demonstrate the reduction in documentation to direct service ration as well as to provide support for ongoing improvement in the process.

Overcoming Specific Attendance/ Engagement Barriers Associated with Mental Illness

Additional strategies include those that target specific barriers to engagement. Here are some self assessment questions that may help identify areas to consider:

No Show/ Cancellation Protocols:
1. Is there a clear definition for no-shows vs. cancellations?
2. Does all staff know and record client absences using the definitions consistently?
3. Is there a standard protocol for intervening with clients based on no-show/ cancel thresholds (e.g. clients miss more than 1 in 6 sessions)? Some potential interventions may include:

Scheduling:
1. Are cancellations/ no shows due to inconvenient scheduling days/ times?
2. Should the schedule be reviewed with the client and appropriate accommodations made?

Transportation:
1. Does a client have difficulty arranging transportation or have unreliable transportation?
2. Can the provider assist in getting transportation commitment/ support from family, transportation providers, etc. (This may interrelate with scheduling )

Reminders:
1. Does the client report that he/she forgets about appointments?
2. Can personal reminder calls be made? Automated calls are least effective and clinician calls are more effective than support staff calls.

Other Service Preferences:
1. Are there other service preferences (e.g. provider gender) that would help with client engagement?

Medication Side Effects:
1. For clients who do not consistently adhere to prescribed medication regimens or who's attendance for medication management sessions is poor, have the obstacles to adherence been specifically identified and strategies for addressing the obstacles discussed with the client (and possibly incorporated into the service plan)

For example:
1. Does the client feel the medication does not work?
2. Does the client not know why he/she is taking certain medications?
3. Does the client experience side effects that he/she feels outweigh medication benefits?
4. Does the client forget to take or lose medications?

Possible strategies include:
1. Ongoing client education regarding prescribed medications
2. Interventions designed to address coping with and/or attenuating side effects
3. Techniques (e.g. Motivational Interviewing) to help client weigh medication adherence ‘benefits' against medication adherence ‘costs'.
4. Adjusting medications and or dosing to address distressing side effects.

Alternative Service Schedule Options for Mental Health Patients

The above approaches to improving engagement all assume that it is the provider's first responsibility to work with the client to understand and overcome challenges to engagement. It is best (and usually correct) to first assume that the problem is with the services and not the client. These types of strategies should be the first line of intervention and should be attempted for a period of time sufficient to assess effectiveness. However, clients have a choice regarding their willingness to fully participate in services. Ongoing cancellation, and particularly no-show/ patterns, despite skilled Person Centered approaches to improving engagement, can put a strain on staff's ability to maintain performance standards and thus limit access to care for other clients.

In these cases, it is sometimes prudent to apply alternative service schedule options for medication management appointments. For example, if after exhausting person centered approaches like those outlined above, clients continue to regularly ‘no show' for medication appointments, they may be transferred to ‘first come --first serve' open clinic hours as opposed to scheduled appointments. This kind of intervention should be a last resort, but sometimes clients will re-engage (or at least make an effort to attend appointments) to regain their scheduled appointments.

Customer Service Training for Treating Mental Health Patients

Another key engagement strategy is one that is core to any service delivery industry -- enhanced customer service. Numerous community behavioral healthcare organizations have recognized that there is a need to develop enhanced internal and external customer service training/approaches. Interestingly, experience indicates that there is almost always a parallel between the need to provide enhanced external customer service with the need to enhance internal customer service.

It seems that an important prerequisite to addressing internal changes is the requirement to focus on "internal" customer relations between staff members, units, programs, and locations. Where mental and behavioral health care organizations have been able to address internal customer relation needs/challenges, there seems to be a pronounced secondary benefit of being more attentive to the needs of the external consumers/customers. A positive and interesting method to assess internal customer service levels is to ask each member of the management team including line staff supervisors the following question with everyone present:

"If you had complete control of your budget, would you purchase services from your other management team members or from other units/programs within your center?"

This one question has provided a full day of important and honest feedback at management retreats. The key outcome is to identify the level of "noise" between units/programs/function areas which is produced by lack of cooperation/personality conflicts, etc. The higher the level of noise identified the more attention that management team members must divert from ensuring positive customer services is being provided daily to clients.

The consultation requests to provide consumer/customer service training has increased across the nation. The purpose of the training is to provide enhanced awareness within the mental and behavioral health care organizations of how staff can provide "delightful" service to consumers. During the course of the training, staff are challenged to identify the customer service approach they utilize when consumers visit (this exercise does not intend to address different therapeutic relationships). The focus of efforts in the training assist staff to define the four typical customer service approaches -- a job focus, a client focus, a consumer focus, and a customer focus.

As clinical and non-clinical staff members begin to define each of these terms, a significant level of similarity of service attitudes, definitions and opinions emerge between mental and behavioral health care organizations. Below is an outline summary of the four different approaches as commonly defined:

1. Job Focus - "It's just a job/ it's not my job!"

2. Patient/ Client Focus - "They need us!"

3. Consumer Focus - "They choose us!"

4. Customer Focus - "We need them!"

When a behavioral health staff defines each term and move from a job to a client to a consumer to a customer focus, the customer service changes become obvious. The difference in all four-service approaches is embodied in the summary characteristics of "It's just a job/it's not my job" Vs. "They Need Us!" Vs. "They Choose Us!" Vs. "We Need Them!" This exercise consistently produces an interesting outcome -- a concern that some staff approach consumers/customers with an "It's just a job" or "They Need Us" service delivery model.

An example of a customer service awareness change came from a customer training session several years ago where a clinical supervisor raised her hand and shared an incident that had happened the previous day. One of her clinicians told her a consumer was upset because he was required to fill out the same form for the third time. The supervisor was known as a very strong consumer advocate within the mental and behavioral health care organizations. However, she insisted the consumer follow protocol and complete the third form. At the training, she realized she had advocated for the service delivery system, not the consumer. Framed another way, mental and behavioral health care organization staff members seem to focus more efforts on customer service to benefit the service delivery system, as opposed to customer service to benefit the consumer.