PSR Individualized

Treatment Plan
April-May 2005
PSR Services
16.03.09.453
The goal of PSR services is to aid participants in
work, school, family, community or other issues
related to their mental illness. It is also to aid
them in obtaining developmentally appropriate
skills for living independently and to prevent
movement to a more restrictive living situation.
All services provided must be clinically
appropriate in content, service location and
duration and based on measurable and
behaviorally specific and achievable goals.

PSR Services
Written Individualized
Treatment Plan
IDAPA 16.03.09.453.02
Services must support the goals of PSR which are
maximum reduction of mental disability and
achievement of the highest possible functioning
level for that participant.
For adults this means becoming independent or
maintaining the highest level of independence.
For children this means learning or maintaining
developmentally appropriate role functioning.

PSR Services
Written Individualized
Treatment Plan
The individualized treatment plan identifies the
issues, goals, areas of need, objectives and the
total number of hours and types of services
estimated to achieve all objectives based on the
ability of the participant to effectively utilize
services.
The individualized treatment plan must be
developed by the participant, family, other
support systems and the provider agency.
Must be documented by the provider agency.

PSR Services
Written Individualized
Treatment Plan
Must include the following:
An issue statement specifically describing the
participant's behavior that directly relates to
the mental illness and functional impairment
that was identified in the assessment
A statement which describes the participant's
goals relative to the goals of PSR
PSR Services
Written Individualized
Treatment Plan
Must include the following:
Overall goals and concrete, measurable
objectives to be achieved, including time
frames for completion.
At least one objective is required for the
focus areas which will most likely lead to the
greatest stabilizing impact.
This should include at least one objective in
each of the two focus areas which qualify the
participant for PSR.
PSR Services
Written Individualized
Treatment Plan
Must include the following:
Tasks that are specific, time limited activities
and interventions designed to accomplish the
objectives in the plan and are developed by the
participant and the provider.
Each task description must specify the
anticipated place of service, the frequency of
services, the types of service and the person
responsible to assist the participant in the
completion of tasks.
PSR Services
Written Individualized
Treatment Plan
Must include the following:
Documentation of who participated in the
development of the individualized treatment
plan.
The participant must take part in the
development of the plan.
The adult participant or guardian must sign the
plan or documentation must be provided why
this was not possible, including refusal to sign.
PSR Services
Written Individualized
Treatment Plan
Must include the following:
For a minor child participant, the parent
or legal guardian must sign the plan.
A copy of the plan must be given to the
adult participant and the guardian or to
the parent or legal guardian of the child.

PSR Services
Written Individualized
Treatment Plan
The individualized treatment plan
must be developed within 30 calendar
days from the initial face to face
contact between the provider agency
staff and the participant, or the
parent or legal guardian of a minor
child.
PSR Services
Written Individualized
Treatment Plan
An individualized treatment plan review by the
provider agency staff and the participant must
occur at least annually.
During the review, the staff and participant review
any objectives which may be added or deleted from
the plan.
Input from other participants in the plan including
service providers must be considered.
Other attendees of the review may be chosen by
the participant/parent/guardian and the agency
staff.
PSR Services
Written Individualized
Treatment Plan
Must be reviewed and signed by a
physician or licensed practitioner of the
healing arts at least annually indicating
services are medically necessary.
(licensed physician, physician assistant or
nurse practitioner and clinical nurse
specialist with experience prescribing
psychotropic medication)
PSR Services
Written Individualized
Treatment Plan
Once the date of a plan is established ( physician
signature date unless past due), that date continues
to be the annual date of the plan.
Any subsequent plans must be received by the MHA
on or before the expiration date of the plan.
If a subsequent plan is not received on or before
the expiration date of the current plan, services
that are provided in the interim will not be
reimbursed.

PSR Services
Written Individualized
Treatment Plan
The eligible participant will be allowed to
choose whether or not he desires to
receive PSR services and who the
providers of services will be to assist in
accomplishing the objectives stated in the
plan.
Documentation must be included in the
participant's file showing that the
participant has been informed of his rights
to refuse services and choose providers.
Individualized Treatment Plan
Authorization Requirements
Required documentation (16.03.09.451.03):
Participant demographic information
Comprehensive assessment
Written individualized treatment plan
Adult services- rehabilitation outcome data
(MH Profile Form)
Children's services- CAFAS/PECFAS
Changes in Plan Hours or
Service Type
Must be approved by the MHA.
A clear rationale for the change in
hours or service type must be
included with the request.
Changes to Plan Objectives
451.06
Include recommendation and rationale in
the next 120 day review.
Substantial changes requiring immediate
changes in the plan need to be submitted
to the MHA for approval. The request
must include the recommendation and
rationale for the change.
Minor Changes to
Individualized Treatment Plan
Tasks 451.07
Submit amended plan to the MHA detailing
the necessary and specific changes to the
plan so long as there is no change in hours
or types of services.
If no response received from the MHA
after 10 working days proceed to
incorporate those specific changes.
PSR Services
Written Individualized
Treatment Plan
PSR services that must be specifically identified
on the Individualized Treatment Plan
Pharmacological Management
Individual PSR
Group PSR
Collateral Contact
Nursing Service
Psychotherapy
Occupational Therapy


PSR Individualized Treatment
Plan
Client Name
Social Security Number
Healthy Connection Physician
Medicaid Number
Healthy Connections Number
CAFAS Score- Children only
Provider Agency Completing the Plan
PSR Individualized
Treatment Plan
Date of Amendment- when applicable
Amendment comments- Justification
and description of what is being
amended in the plan
PSR Individualized
Treatment Plan
Date of Plan- date of physician signature
120 Day Review- 120 days from plan date
240 Day Review- date due from plan date
Annual Update- date annual update needs
to be completed, submitted and authorized
by (ongoing date of the plan)
PSR Individualized
Treatment Plan
Diagnostic Summary-
Indicate Primary Diagnosis with (P)
Axis I: Clinical Disorders, Other Disorders That
May Be a Focus of Clinical Attention
Axis II: Personality Disorders, Mental Retardation
Axis III: General Medical Conditions
Axis IV: Psychosocial and Environmental Problems
Axis V: Global Assessment of Functioning (GAF)
scores for both current and highest past GAF
PSR Individualized
Treatment Plan
Duration of Principal Diagnosis
Select one
Less than one year
On to two years
More than two years
PSR Individualized
Treatment Plan
Functional Areas Identified as Deficits in
the Assessment
Must be documented and justified in the
assessment
Health/Medical - Housing
Social Interpersonal - Family
Vocational/Educational - Community/Legal
Basic Living Skills - Financial

PSR Individualized
Treatment Plan
Functional Areas
Areas identified in the assessment to be
addressed in the plan
Psychiatric
2 functional areas identified in the
comprehensive assessment
Health/Medical - Housing
Social Interpersonal - Family
Vocational/Educational - Community/Legal
Basic Living Skills - Financial

Issues
Issues- identified for each functional area
Brief summary statement that specifically
describes the participant's behavior that
directly relates to the mental illness and
functional impairment
Should also describe their strengths

Goals



If you dont know where you are going, you
will probably end up somewhere else.
Lawrence J. Peter


Goals

Broad general statements
Express the participant's desires,
what they want to change
Written in their words
Tied to discharge criteria

Goals

Goals can reflect
Life goals
Service or treatment goals
Quality of life goals

Goals

Directed towards recovery
Responsive to need
Strengths based
Written in I want to statements


Objectives

Measurable, objective steps to
accomplish the goal

Short term, time limited with time
frames for completion

Objectives
Immediate focus of treatment but not a
description of the intervention
Focus on positive changes in behavior,
improving functioning, attaining new skills
not just decreasing symptoms or stopping
a behavior
Written in The participant will
statements
Specify one change at a time
Objectives
Reasonable
Measurable
Appropriate to the treatment setting
Achievable
Understandable to the participant

Objectives
Time specific
Written in behaviorally specific
language
Responsive to the participants needs
and recovery goals
Appropriate to the participants age,
development and culture

Objectives
At least one objective for every goal
Keep the plan manageable

Tasks
The services, interventions, and
activities that will be provided by the
treatment team
Assist the participant achieve their
goals and objectives
Tasks
Describe the services to be delivered
Specify
Who
What
Where
When- frequency, intensity, duration
Why

PSR Individualized
Treatment Plan
Expected End Date
Dates may vary depending on the
objectives and tasks needed to
accomplish the goals
PSR Individualized
Treatment Plan
Type, Frequency & Hours
Summarize totals by service code
H2017 (RHIP)
1hr/1x/wk
52 hrs/ yr

PSR Individualized
Treatment Plan
Signatures- must be hand written, with
credential and date also hand written
Participant/guardian
PSR professional that wrote the plan
Physician
Others involved in the plan development
PSR Individualized
Treatment Plan
Service Plan Authorization Form
Provider/Region
Client Name
Provider Number
Agency Phone Number
Agency FAX Number


References
Treatment Planning for Person
Centered Care: The Road to Mental
Health and Addiction Recovery
Neal Adams and Diane M. Grieder
Elsevier Academic Press 2005