Assessment: Staff will gather information from you, your family, other agencies and other supports, if appropriate, in order to complete a thorough assessment that accurately determines your diagnosis and the problems that need to be treated based on this diagnosis.
Treatment Planning: After the assessment has been completed, staff will work with you to develop a treatment plan that guides your treatment.
Treatment: Treatment direction is based on the treatment plan that you and the treating staff develop together.
Referrals: It might be helpful for you to use other services, either within the Center or outside the Center, to help you improve. We will discuss these with you and make the appropriate referral.
Transition: As you begin treatment, staff plans ahead with you to the time when you no longer will be needing services of one program and/or may transfer to less intensive services with staff’s assistance.
Discharge Planning: As you begin treatment we will discuss with you the goals you need to meet in order to be discharged from our program.Core Services which comprise the Clinical Program are comprehensive in scope in order to facilitate and improve the client’s overall functioning.
A more In-depth view of our Treatment Process (Out of the nutshell)
The Clinical program’s Core Services:
• Completion of a Mental Health Assessment
• Treatment Planning
• Treatment Intervention
• Progress Notes
• Psychiatric Services
• Ongoing Assessment and Treatment Plan Review
• Case Management
• Referral Services
• Crisis Services
• Discharge Planning
1. Assessment: Assessment begins upon the first contact with the individual or group and continues throughout the client’s treatment and discharge contacts. The Mental Health Assessment form covers a variety of areas including the client’s symptoms, strengths, needs, and abilities. Any client who is a danger to self or others will be assessed for voluntary or involuntary admission to a psychiatric unit. A comprehensive history will then be gathered to note presenting problems; mental status; social history; and the person’s goals. All five Axis are completed to determine eligibility and treatment direction. A short interpretive summary will include a discussion of central themes noted during the interview; the client’s self perceptions regarding his/her own strengths, needs and abilities; factors which will effect treatment prognosis; recommendations; and the anticipated length and intensity of treatment. All Mental Health Assessments shall be completed within three sessions from the initial intake. Assessment continues at an informal level upon every contact with client and collateral and changes are made if the client’s status or life circumstances change. Formal ongoing assessment is documented upon treatment plan reviews and discharge summaries. Each client will complete a new Mental Health Assessment on an annual basis from their initial intake date. The communication to the client/legal guardian or other referring sources takes place once the assessment is formally completed. At this time all appropriate signatures are required.
2. Treatment Planning: The client served participates in the development of their individualized treatment plan and is assisted by a qualified mental health professional. All treatment plans are reviewed by a Licensed Practioner of the Healing Arts and follow various regulatory requirements. The individualized Treatment Plan always relates to the problems and issues identified by the client and counselor from the Mental Health Assessment. The Treatment Plan is written in measurable/achievable terms which reflect age appropriateness, language the client can easily understand, and is culturally/community based. The plan shall be receptive to each client’s specific disorder, disability, and concerns. The plan reflects the frequency, mode and projected length of treatment. All legal requirements, referral sources, and fees shall clearly be identified in the plan if applicable. The Treatment Plan shall be completed at the time of the mental health assessment and no later than forty five days. A Treatment Plan Review will occur no less than once every six months. DCFS Clients’ complete a Treatment Plan Review every three months. A formal summary is also sent to the DCFS caseworker at that time. If gaps in service are identified or changes/modifications are needed a formal Treatment Plan Modification takes place.
3. Treatment Intervention: The Clinical Program provides individual, group, family, and couple counseling and education to the client, their families, and significant others.
4. Progress Notes: The Counselor shall write a progress note for each and every contact with a client. All progress notes need to be completed within one week from the time of service. The progress note shall contain the date, time of service, duration of service, the type of service provided, and identified goals and objectives. The progress note will contain various events and changes identified by the client. The services delivered shall reflect directly back to the treatment plan. The Counselor assuming responsibility will ensure the implementation of the treatment plan. It is the Counselor’s responsibility to maintain the participation of the client with the development and ongoing discussion of the treatment plan to ensure that the client is oriented/engaged to the treatment and to avoid possible gaps in service. The note shall reflect communication with family/guardians, referral sources, advocacy on behalf of the client, and collaboration on how the client can access other community resources. The coordination and facilitation of follow-up or transitions to other provider’s services shall be clearly recorded in the progress note.
5. Psychiatric Services: The Clinical Program has the opportunity to refer adult clients to IMHC’s two Psychiatrists to address symptom management and medication monitoring issues. A formal written referral is needed at the time an appointment is scheduled with the Psychiatrists. This procedure will complete the referral to the Psychiatrist. Ongoing consultation with the Psychiatrist as it relates to the client is expected from the Counselor.
6. Ongoing Assessment: The counselor/therapist will continue to re-assess the strengths, needs and progress each session. This re-assessment process culminates in a formal treatment plan review and the review for the appropriateness of continuation of services at the current level based on the program criteria. Documentation of the treatment plan review will be entered into the client’s record after it is formally signed by the client and appropriate staff.
7. Case Management: Case management primarily consists of linkage, advocacy, and consultation with other providers or resources on behalf of the client, both within and outside of IMHC. Members of IMHC treatment team involved in the client’s care include: all Clinical staff involved in the client’s care; the medical director, Clinical Director, LPHA, Substance Abuse Director, and PSRS Director, who work directly with the client and/or their significant other(s). Case management services facilitate continuity of care and coordinate between the Clinical Program, other services within IMHC and external to IMHC, and other providers. Case management services are provided to individuals, groups, families, and significant others. They are provided to clients who are presently admitted into the Clinical Program, and to those who have been discharged from treatment.
8. Referral Services: The focus of referral services is to identify those resources and providers outside the Clinical Program in order to meet the identified needs of the client and to complete referrals directly on the client’s behalf. The following may indicate that the client has special needs which may require referral services. Client’s with specific needs which cannot be met at IMHC nor through the usual referral network will continue receiving services at IMHC on a temporary basis until appropriate resources are discovered and until the client is referred and admitted into that program. Client’s with identified needs for substance abuse counseling services will be referred to the Substance Abuse Program of IMHC, with the client’s consent. Client’s needing psychiatric services will be provided with a referral and an appointment to see the IMHC psychiatrists, provided with client’s consent. Other areas which may require a referral service include the following concerns: case management beyond those provided by IMHC; community housing programs; domestic violence services; crisis intervention services; inpatient or PSRS services for mental health disorders; medication management; protective services; vocational services; and /or services involving income maintenance. Services also include establishing and maintaining formal linkage agreements with appropriate agencies and completing all necessary activities in order to transfer treatment records in accordance with respective laws and regulations.
9. Crisis Services The Crisis Program staff provides crisis intervention for those experiencing an acute episode of distress real life issues. Services include screening, assessment, referral and linkage, brief counseling, and consultation. Crisis services are provided seven days a week, twenty four hours per day throughout the year. If a client is in need of Crisis Services they will be assessed by the Crisis Director if available, or a member of the Crisis Program Staff, or any available Counselor, or a referral to the Crisis Counselor on call. The client will be assessed within an hour of the request. Please refer to the Crisis Service Policy for further information.
10. Transition/Discharge Services: Discharge planning begins upon the client’s admission to the program and seeks to identify those resources that should optimally be in place upon discharge in order to support gains made while in treatment. In the Clinical Program a Discharge Summary also serves as a Transition Plan. The Counselor is responsible for all transitions and discharges from the program. This includes unplanned transfers and for clients who have dropped out of treatment. The Discharge Summary tries to maintain the continuity of service with as little disruption of service as possible. Resources should be considered in the following areas: specific services relating to mental health issues; case management; substance abuse issues; domestic violence issues; medical services; psychiatric, pharmacological, health maintenance, and medication management. Upon identification of consumer needs in the aforementioned list, the counselor will proceed with the referral process. Discharge services are made with input from the consumer to include specific and measurable goals expected of the discharged person. A Discharge Summary is completed upon treatment termination or transition to another provider that includes strengths, needs, abilities, preferences, the reason for discharge; progress made by the client in relationship to established treatment goals and objectives; prognosis at discharge; and all identified referrals and activities recommended for the person served. The client/guardian, family, and significant others will all participate in the process of the Discharge Summary and/or Transition Plan. At the time of discharge the client is provided a copy of the Discharge Summary which includes all appropriate signatures. A Discharge Summary is sent to the client and another offer for further services is provided to the client. If the client does not respond after a two week period the file is formally closed.Treatment Process: