Partnering for recovery in mental health : a practical guide to person-centered planning

__Partnering for Recovery in Mental Health__ is a practical guide for conducting person and family-centered recovery planning with individuals with serious mental illnesses and their families. It is derived from the authors’ extensive experience in articulating and implementing recovery-oriented practice and has been tested with roughly 3,000 providers who work in the field as well as with numerous post-graduate trainees in psychology, social work, nursing, and psychiatric rehabilitation. It has consistently received highly favorable evaluations from health care professionals as well as people in recovery from mental illness. This guide represents a new clinical approach to the planning and delivery of mental health care. It emerges from the mental health recovery movement, and has been developed in the process of the efforts to transform systems of care at the local, regional, and national levels to a recovery orientation. It will be an extremely useful tool for planning care within the context of current health care reform efforts and increasingly useful in the future, as systems of care become more person-centered. Consistent with other patient-centered care planning approaches, this book adapts this process specifically to meet the needs of persons with serious mental illnesses and their families. __Partnering for Recovery in Mental Health__ is an invaluable guide for any person involved directly or indirectly in the provision, monitoring, evaluation, or use of community-based mental health care. Cover 1 Title Page 5 Copyright 6 Contents 9 Acknowledgments 11 Module 1: What is mental health recovery and how does it relate to person-centered care planning? 13 Goal 13 Learning Objectives 13 Learning Assessment 13 Where Did the Idea of Mental Health Recovery Come From? 15 Is Mental Health Recovery the Same as Recovery from Addiction? 15 Getting Beyond Us versus Them 16 Recovery as an Emerging Global Paradigm 17 A Common Misconception: Is Recovery = Cure? 19 How Does the Concept of Recovery Transform Care? 20 “Both/And” rather than “Either/Or” 21 Hope as the Foundation 21 How Does Person-Centered Care Planning Relate to Recovery? 22 What Does Person-Centered Care Planning Mean and Why Is It Important? 23 Is This Really any Different from Traditional Approaches to Care Planning? 24 Status of PCCP Implementation 25 What Does PCCP Actually Look Like in Practice? 26 Exercises 30 Learning Assessment 32 References 32 Module 2: Key principles and practices of person-centered care planning 35 Goal 35 Learning Objectives 35 Learning Assessment 35 A Caveat 35 Key Principles and Practices of PCCP 36 Active participation and empowerment is vital 38 Developing trusting, reciprocal, and collaborative relationships is key 40 Plans capitalize on the strengths and the value of lived experience 45 High expectations for recovery are the norm 45 Natural community activities and relationships are emphasized 46 Responsible risk taking and growth are valued as part of recovery 49 Focus of care and planning is on personally valued life goals 50 Cultural preferences and values individualize care 51 What does this look like in practice? 52 Stages of Change are considered in Recovery Planning 52 Exercises 57 Learning Assessment 62 References 62 Module 3: Preparing for the journey: Understanding various types of recovery plans and orienting participants to the PCCP process 65 Goal 65 Learning Objectives 65 Learning Assessment 66 What Are the Different Types of Plans? 66 WRAP and other recovery plans 66 Service or treatment plans 67 What is the Role of the Person in Recovery in PCCP and What Type of Orientation/Preparation is Helpful? 69 Supporting the person to understand his or her rights 70 What is the role of the peer in the PCCP process? 74 What is the role of the natural supporter in PCCP and what type of orientation/preparation is helpful? 77 Exercises 77 Learning Assessment 80 References 80 Module 4: Strength-based assessment, integrated understanding, and setting priorities 83 Goal 83 Learning Objectives 83 Learning Assessment 83 Building a Person-Centered Plan 84 Guiding Principles of Strength-Based Assessment 85 Collaborate 85 Ask asset-based questions 85 Reframe “negatives” as potentially transferable skills 85 Draw on social capital outside of the mental health system 85 Explore diverse strengths 86 Assess needs and resources in multiple life spheres 86 Include personally identified strategies in the plan 86 Implement solution-focused approaches 87 Avoid simplistic cause and effect explanations 87 Expand the assessment over time as needed 87 The Role of Culture in Assessment and Formulation 87 Importance of Understanding 89 Identifying and Prioritizing Goals 91 Exercises 96 History, demographics, and presenting issue 97 Family background/early childhood 98 Education/employment 98 Health status 98 Mental health symptoms and treatment 98 Alcohol/drug use 99 Strengths, interests, and goals 99 Sample Formulation 99 Learning Assessment 101 References 101 Module 5: Creating the plan through a team meeting 103 Goal 103 Learning Objectives 103 Learning Assessment 103 Determining Who Should Attend 104 Setting the Logistics of the Meeting 105 Respectful Team Meetings: Starting with the Basics 106 Defining Roles and Responsibilities of Team Members 106 The Role and Responsibilities of the PCCP Facilitator 107 The Role and Responsibilities of the Person Receiving Services 111 The Role and Responsibilities of Family and Other Natural Supporters 111 The Role and Responsibilities of Administrators 112 Exercises 113 Learning Assessment 123 References 124 Module 6: Documentation of PCCP: Writing the plan to honor the person AND satisfy the chart 125 Goal 125 Learning Objectives 125 Learning Assessment 125 Introduction to the Documentation of Person-Centered Care Plans 126 Medical Necessity and Documentation of the PCCP 127 Goals 128 Goals: Important to the Person 129 Goals: A Manageable Number 130 Goals: Time Framed? 131 Goals: Attainable and Realistic? 131 Goals: Something We Get Paid For? 134 Goals: A Note on the Stage of Change 134 Strengths and Barriers 134 Strengths 135 Barriers 135 Objectives 136 Objectives: How Ambitious or Modest? 137 Objectives: How Can I Meet All the Technical Criteria? 138 Objectives: A Common Quality Error 140 Interventions 141 Types of Interventions 142 Addressing Regulatory and Fiscal Pressures in Writing Interventions 142 Putting the Pieces Together: A Sample PCCP Excerpt for Juliet 144 Introducing Juliet 144 Exercises 145 Learning Assessment 152 References 152 Module 7: So you have a person-centered care plan, now what? Plan implementation and quality monitoring 159 Goal 159 Learning Objectives 159 Learning Assessment 159 Charting to the Plan 160 Essential Elements of a Progress Note 162 Types of Progress Notes 162 Maintaining the Person-Centered Dimension of Progress Notes 164 Concurrent Documentation 165 When to Review the Plan 166 The Role of Continuous Quality Improvement 167 What Is the Role of the Supervisor in Promoting Quality and Accountability? 168 What Is the Role of the Person in Recovery in Promoting Quality? 169 Types of Continuous Quality Improvement 170 Outcomes evaluation: Monitoring the impact of PCCP 171 Practitioner Self-Evaluation 172 Workforce Development as an Essential Part of Continuous Quality Improvement 174 Defining recovery competencies 175 Exercises 187 Learning Assessment 189 References 189 Module 8: PCCP implementation: Common concerns and person-centered responses 193 Goal 193 Learning Objectives 193 Common Practitioner Concerns 194 Concern 10. Emphasizing service user choice inevitably devalues clinical knowledge and professional expertise 195 Concern 9. While person-centered care planning may be useful, it is really the responsibility of nonclinical practitioners. It has little to do with treatment 196 Concern 8. We do “recovery” already; our care is already person-centered 198 Concern 7. The care plan is not really that important and is not actually used to drive care. It is just for accreditation and reimbursement purposes 199 Concern 6. Person-centered care planning is supposed to be based on people’s own goals, but many people with serious mental illnesses give up on any goals. They are doing their best just to get through each day and may not want to make any changes. Who is to say that they have to be working toward "goals?" 199 Concern 5. Don’t the principles of person-centered care contradict the current emphasis on using evidence-based practices? 201 Concern 4. Person-centered care makes sense only when the person has accepted treatment and it has been effective. But many people with severe mental illnesses are too disabled to pursue recovery goals. The first step is getting their clinical issues under control. Later, they can make their own choices 201 Concern 3. Person-centered care planning takes time and is labor intensive. With high caseloads, practitioners simply do not have the time it takes to do it 203 Concern 2. Person-centered care planning is not consistent with the concept of "medical necessity" and therefore will not be reimbursed. It is also not consistent with the stipulations of regulatory and accrediting or commissioning bodies 203 Concern 1. Allowing people with serious mental illnesses to set their own goals and make their own decisions increases risk and exposes practitioners, and their agencies, to increased liability 205 Conclusion 208 Exercises 209 Learning Assessment 211 Index 213

Partnering for Recovery in Mental Health is a practical guide for conducting person and family-centered recovery planning with individuals with serious mental illnesses and their families. It is derived from the authors’ extensive experience in articulating and implementing recovery-oriented practice and has been tested with roughly 3,000 providers who work in the field as well as with numerous post-graduate trainees in psychology, social work, nursing, and psychiatric rehabilitation. It has consistently received highly favorable evaluations from health care professionals as well as people in recovery from mental illness.

This guide represents a new clinical approach to the planning and delivery of mental health care. It emerges from the mental health recovery movement, and has been developed in the process of the efforts to transform systems of care at the local, regional, and national levels to a recovery orientation. It will be an extremely useful tool for planning care within the context of current health care reform efforts and increasingly useful in the future, as systems of care become more person-centered. Consistent with other patient-centered care planning approaches, this book adapts this process specifically to meet the needs of persons with serious mental illnesses and their families.

Partnering for Recovery in Mental Health is an invaluable guide for any person involved directly or indirectly in the provision, monitoring, evaluation, or use of community-based mental health care.