Treatment Plan

Therapists in the Rula network are required to create an individualized treatment plan in collaboration with every client at the beginning of treatment, as well as update it throughout the episode of care as clinically indicated. Treatment plans should always be co-authored, meaning that they should be done in session with the client and reflect mutual agreement of the plan of care. This is a requirement for every commercial payer contract and is an industry-standard of ethical clinical practice. 

Treatment Plan Overview

Treatment plans serve as the “roadmap” for clinical care - guiding session focus, selection of modalities and interventions, and defining how treatment progress will be understood and measured. In the most basic terms, the treatment plan prompts these questions for our clients:

Where do you want to go?

How can I help you get there? 

It is critical that each client’s treatment plan, or “roadmap”, is individualized and tailored to their specific symptoms, functional impairments, and goals, and is updated with the evolving clinical needs of the client (just like when Google Maps reroutes when needed!).

Treatment Plan Requirements

In a commercial payer world, a treatment plan that lacks the required, client-specific clinical information can result in denial of reimbursement for services rendered or denial of future services, which can negatively affect continuity of care.

Check out some additional tips and examples for developing a quality treatment plan:

Goals

  • All clients at Rula are required to have at least one active treatment goal but can have more if clinically indicated. When defining a goal for treatment, a best practice is to identify both a client goal for treatment (which is what they hope to achieve or change as a result of therapy, in their own words) followed by a clinical goal (which is how mental health treatment will assist the client in reaching that goal) Here are some examples:

 Goal example #1:

  • The client reports their goal is to: “Not get so overwhelmed, anxious and negative about myself around other people. Isolate less” 
  • The client’s clinical goal is to: learn/improve coping for managing symptoms of anxiety 

Goal example #2:

  • The client reports their goal is to: “I want to learn how to communicate with my partner and not let the built-up resentment get the best of me ” 
  • The client’s clinical goal is to: Learn interpersonal effectiveness and distress tolerance strategies to utilize in relationship with partner

Objectives

Once you have established a clear goal for treatment, you then need to identify the smaller incremental steps that the client will take in order to make progress towards that goal, otherwise known as “objectives”. This is one of the primary ways to measure clinical progress. The three elements of an effective objective are as follows; 

  • The “what” - What are the actionable behaviors, skills, or steps that the client will engage in that tie directly into addressing the presenting problem and will promote progress toward the goal?
  • The “how” - How will progress be measured? (for example, self-report, reduction in PHQ-9/ GAD-7/AUDIT-C score, behavioral observation by the therapist, completion of homework /assignments, parent/guardian report, etc.)
  • The “when” - Timeframe that is realistic and clinically meaningful for the client to achieve this objective (for example, within the next month? within the next 12 visits?)

Here are a few examples of effective objectives, using the structure above: 

Objective example #1:

  • What will the client do to meet the goal? “Client will practice grounding and/or mindfulness activities at least 1x daily while in public settings to improve coping with social anxiety”
  • Progress will be measured by: self-report, reduction in GAD-7 
  • Timeframe: over the next month

Objective example #2:

  • What will the client do to meet the goal? “Client will be able to identify 2 or more  cognitive distortions that contribute to feelings of worthlessness and failure, and replace with a positive self-statement to decrease depressive symptoms.”
  • Progress will be measured by: self-report, behavioral observation by therapist
  • Timeframe: over the next 8 visits

The Golden Loop

“The Golden Loop” is a phrase used in behavioral health that references the need for all elements of documentation in the client's record to connect to one another, creating a logical flow of care that ultimately starts (and loops back!) to the treatment plan.

 

 

The Treatment plan essentially “kicks off” treatment by reflecting the needs indicated in the initial assessment, and includes development of the appropriate goals, objectives, and interventions that will address the client's symptoms and functional impairments.

 The treatment plan then supports shaping how you structure treatment sessions by providing a clear clinical focus for care that is aligned with what's in the treatment plan. For example, what will we be doing in session that is congruent with the established goals and objectives in the treatment plan? 

 Once the session is complete, the note you write should reflect progress towards identified goals, relevant interventions to address symptoms and functional impairments, the client's response to treatment and the ongoing plan, especially homework or behaviors the client may engage in outside of session to support continued progress towards their treatment goals.

 It is then advisable to create a practice of frequently reviewing the treatment plan to ensure it's still up to date. The treatment plan is embedded in every single progress note, which makes it easy for you to quickly look over or reference the treatment plan without having to dig elsewhere in the chart. And if you find updates are needed, then you simply make any necessary revisions to the treatment plan and it will save and carry forward helping guide future session focus and guides future note documentation.

Treatment Plan FAQ

  • How often do I have to update the treatment plan? You must update the treatment plan when clinically indicated to ensure the treatment plan reflects the presenting problem, current goals, and interventions to address the client's symptoms and treatment needs. At Rula, there is no set required timeline for updates of treatment plans, however a best practice is a minimum of every 3 months (or by the 12th visit). 
    • Aside from guiding treatment, this is particularly important when considering the need to demonstrate medical necessity for ongoing care -  A treatment plan that has not been updated in a substantial amount of time or lacks necessary clinical information can not only negatively impact care provision and client progress, but additional sessions may not be authorized by payers.

 

  • What if the client and I don’t have enough time to create a Treatment Plan during the Initial Assessment? A treatment plan is required to be completed at the time of the Initial Assessment in order to be able to sign and bill for the appointment. While the aim should always be to set some preliminary treatment goals and objectives during this first encounter, if you run out of time you may enter a preliminary goal  such as “Establish therapeutic rapport,” or “increase understanding of mental health needs,”  The first psychotherapy session should then have a primary focus of clarifying the treatment plan so the therapist and client are in agreement of client goals, objectives and treatment approaches for care before moving forward. 

 

  • "What do I do with a goal when it's no longer relevant and I need space for a new goal(s)?" When a client has successfully completed a treatment goal, or the goal no longer resonates due to a diagnosis change or other shift in treatment focus, therapists have a few options.
    • 1) You can simply delete the prior goal and/or objectives, and replace with the new goal and/or objectives. In doing so, be sure to also provide reasoning in the progress note as to why the goal is no longer relevant and a new goal was developed. Know that the deleted goal will still be visible on previous treatment plans saved with previous progress notes. 
    • 2) You can mark the goal as complete and leave it on the treatment plan as a reference for the progress that has been made, and add new goals in the additional fields. 



  •  Can I see examples of sample treatment plans? You got it! Click HERE

 

For technical support on how to update the treatment plan template in AMD, click here. 


If you have questions related to treatment planning,  reach out to our clinical quality team at quality@rula.com. Therapist to therapist - we’re here for you!

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