Are you looking back to the “good ole days” when your practice was shiny and new . . . ? Remembering when your appointment book was full and you had a two week waiting list and wondering where all the clients have gone?

Well, I’m here to tell you that they are all still right here . . . right around the corner from you and they are wondering what happened to their bright and enthusiastic therapist that you used to be!  That’s right!  You heard me!  Any client will tell you that s/he would rather return to the same therapist s/he’s seen before rather than change to a new one.  They only change when they have no choice but to go elsewhere to get the help they are seeking.

If your old clients are going elsewhere for their counseling services, then it might be time for you to give your practice a facelift and that means taking a fresh look at your office, your office practices, and yourself.

Outside the Office

• Take a look at the appearance of your building.  Has it fallen into disrepair?  Does it need trim work or to be repainted?
• Is the landscaping well-tended?
• Is the parking for your clients easily accessible and is the lot well-lit?  Does it feel safe?
• Are the windows clean?

Inside the Office

• Inside the office, take a look at the paint on the walls.  Is it dingy?
• Is the carpet dirty or stained?
• How does your office smell?
• Is the lighting warm and welcoming?
• Is your office well-insulated for privacy?
• Is the temperature in your office comfortable?

Office Practices

• Does your office staff greet your returning clients as warmly as they greet your new clients?
• Is your staff well-trained on respecting clients’ privacy?
• Are you records safely locked away out of sight so that clients do not see information about other clients?

Self Check

• Are you taking care of yourself outside of the office?  Eating and exercising?  Getting enough rest?  Attending to your personal relationships?
• Are you arriving at the office in time to get settled in and appear calm and focused when your clients arrive? Or are you rushing in harried at the last minute?
• Are you scheduling your clients far enough apart that you have time to attend to phone calls, go to the bathroom, and complete your notes in between appointments?
• Do you have a plan for continuing your professional competency and are you following it? Are you continuing to learn new and interesting things to help you in your clinical work?

These are useful things to discuss with your peer consultation group.  A fresh pair of eyes can help you identify areas that need a bit of a facelift.  And, that, in turn, may help you re-engage some of those wayward clients.

Can you think of other areas in your practice that may need a facelift?  If so, I hope you will let me know!

Tags: Location, Office, Records & Documentation, Self Care

I have made the choice not to contract
with managed care companies
for my professional services.
Here’s the  8 reasons why . . . .

Conflicts of Interest

As a Licensed Professional Counselor, I am required to avoid potential conflicts of interest.  My primary concern is for my client’s well-being.  Therapists working under the constraints of managed care companies are sometimes put in the position of having to choose between what is in their own best interest and what is in their client’s best interest.  I do not want to be put in that position.

Managed care companies were created to “manage” and contain escalating health care costs.  Their bottom line is to reduce costs and raise profits; it is not to increase the quality of care or quality of life for my client.  In many cases, therapists who contract with MCC are actually paid to NOT see clients.

Restricted Choice

Often managed care companies restrict the client’s choice of therapist by offering only short term / brief therapy that I refer to as “drive-by” therapy.  Such therapy meets the financial criteria of managed care companies but may fail to afford my client the opportunity to get the information / therapy that s/he wants / needs.  It is my belief that this often results in my client’s quality of care being compromised. And, this, of course, can result in the possibility of my client’s needs going unmet.

Managed care companies often choose to limit what  therapies are offered, can restrict what is discussed in therapy, and decide which clients can be seen and for how long. Some managed care companies have even included “gag clauses” in their contracts to prevent therapists from suggesting more effective treatments.

Professional Expertise

I believe that my client should be able to access the full range of mental health professionals according to client needs.  Often managed care companies restrict the professionals that clients are allowed to work with – preferring to refer clients to therapists who have a record of providing short term therapy rather than to other therapists who may provide better results or offer a different packaging of services.

Contractual Limitations

I believe that a client has the right to full disclosure of any arrangements, agreements, contracts, or restrictions between any third party and me that could interfere with or impact your treatment.  Managed care companies may label counselors’ choices to advocate for clients in this manner as “Managed Care Unfriendly Behaviors” and take such actions as they deem fit.  Typically “violations” such as these result in therapists being removed from provider panels or censured in other ways.

Privacy / Confidentiality

By contracting with managed care companies, it is likely that I would be required to share my client’s deeply personal information with gatekeepers and utilization review professionals; it would mean potentially allowing literally hundreds of other to have access to my client’s personal information.

Medication

Research has consistently shown that medication for problems with mood is most effective when combined with psychotherapy.  Nevertheless, managed care companies frequently approve medication only for their members rather than permitting them to also work with a mental health counselor.  Again, the appearance is that of being more concerned about money rather than my client’s needs.

Time

Managed care companies usually require therapists to justify and convince Utilization Review professionals before treatment is approved / continued.  This is time consuming for the therapist and for the client who is required to continue his / her therapy in “fits and starts.”

Diagnosis and Stigma

Managed care companies typically cover only those services deemed medically necessary which is defined as being literally about life and death and the treatment of illness. This means that they require a diagnosis of mental illness for my clients.

My practice is solution- focused on quality of life and personal goals. My work with clients focuses on prevention, exploration, and personal growth rather than simply survival. We typically talk in terms of possibility and resourcefulness, gratitude and integrity, commitment and personal responsibility.  Working with managed care companies is not a choice that I can ethically make.

I Know Better

I have mental health professionals declare on a regular basis that you “can’t survive in private practice without participating in managed care.”  But, I know better. What I know is that you can’t thrive – both personally and professionally – while participating in managed care.

Once I realized the ethical implications of working with managed care companies, I terminated all of my contracts with managed care.  It’s not a decision that is right or necessary for all therapists but it was the best decision that I’ve made to date.

I am now celebrating 10 years of being an insurance-and- managed-care-free  private practice. I’m thriving and you can, too!  All it requires is courage.

If you, too, run a practice without managed-care, I hope you’ll drop in here to chat about your experiences.  And, if you have yet to make the choice to opt out of managed care, I would be happy to help you find your courage and to help you create a path to a fee-for-service only practice.

Tags: Choice, Contract, Courage, Ethics, Packaging

When you get ready to close your private practice, for whatever reason, you can’t just shut the door and walk away. Did you know that?  Attorney Richard S. Leslie has written a thoughtful article in the January 2010 issue of the Avoiding Liability Bulletin.  In it he details some of the following for your consideration when you decide to close up shop:

• Ask yourself who needs to be notified – clients, former clients, insurance panels, landlords, supervisees, colleagues and business associates, referral sources, and your licensing boards;
  

  "You Couldn't Have Planned This if You Tried" by Ken Douglas / Today is a Good Day

• Consider the possible circumstances that might result in you closing your door – retirement, geographical relocation, health emergencies, financial circumstances, your own death, your spouse’ or partner’s death,and other unforeseen circumstances;
• Your state may dictate certain actions that you must take when you close your practice;
• Your professional code of ethics and HIPPA will certainly have standards that you must adhere to when closing your practice;
• How to notify existing clients;
• Subsequent maintenance, storage, and access to records;
• How to provide public notice of the closing;
• When and how to notify former clients;
• Why you may not want to terminate liability insurance policies when you close your practice;
• And, in the event of your death or incapacity to handle these things, who does it for you?

Every mental health professional and every professional coach is required to responsibly close their private practice  – regardless of whether their closing is planned or unforeseen.  Whether you’ve been in business for years or you are just now getting started, now is the time to take the steps necessary to prepare for the eventual closure of your practice.

Tags: Closing Your Practice, Ethics, HIPAA, Records & Documentation, Relocation, The Unexpected

"Looking Out" by Tyler Neu / Neuski

According to the American Counseling Association’s Code of Ethics, counselors are not required to diagnose a client if they believe that to do so would cause harm to the client.  Here is an online article in Counseling Today that addresses some of the ways that diagnosing may be harmful to your client.

Tags: Diagnosis, Ethics

I’ve mentioned in the past that one of the ways that I keep my marketing  fresh is that I borrow ideas from other professions.

This morning I was reading Erika Trimble’s blog, Physical Therapy Biz Success, when I ran across a great little post on setting priorities. She recommends the A-B-C-D-E Method for setting better priorities.

A = Critical and Urgent

These are the things that if you put off, will cost you your practice.

• Professional licenses and certifications
• The rent for your office
• Your mental – physical – emotional – spiritual health
• Transportation to and from work
• A way for your clients to contact you
• Securing your client records (to protect confidentiality)

B = Important

These are the things that really need to be done but they are not critical.  If you don’t do them in the short term, there are only minor consequences.  However, if you put them off indefinitely, the cumulative effect can bump these into the A = Critical and Urgent category.

• Vacuuming the office
• Networking
• Emptying the trash can
• Cleaning the windows
• Upgrading your computer to the most current Windows settings

C = Nice to do

These include all the niceties and, often, fun-to-do’s that can so easily distract you from your business-building tasks.  They may be of added benefit to you or your clients but if they don’t get done, you don’t incur negative consequences.

• Sending birthday / holiday greetings to your clients
• Heating up the coffee / tea pot for your clients
• Lighting the candle in your office
• Writing a new blog post
• Facebook chats
• Returning friends phone calls

D = Delegate

If you don’t do it easily and well, you need to give serious thought to delegating or contracting to get the task accomplished.

• Designing artwork for your new project’s marketing campaign (unless you are artistically inclined)
• Writing the copy for your website
• Billing clients / insurance companies
• Janitorial / building maintenance services

E = Eliminate when possible

These are often acts of repetition or 100% time wasters.

• Surfing the Internet
• Creating handouts for your clients over and over again
• Explaining your policies for payment, no shows, and late arrivals
• Some correspondence including letters of introduction, marketing letters, and reminder letters

As you are gearing up for 2010, make sure you take some time to re-think your priorities.  Assign each of your to-do’s an A, B, C, D, or E using Erika’s method of prioritizing and then let me know what changes for you.

What is it that  you think is important . . . to attend to, to delegate, and to eliminate as you build your private practice?

Tags: Critical & Urgent, Delegate, Priorities

Everything you do for your client matters.  If and how you choose to diagnose your client matters a lot.  Amanda B. wrote in asking if it is OK to routinely give a diagnosis of Adjustment Disorder to her clients if they do not exhibit symptoms warranting a more serious diagnosis.  (She was trying to help them get reimbursed by their health insurance companies.)

The short answer is “No it’s not.” As tempting as it may be to slap an Adjustment Disorder diagnosis on to every client who is dealing with normal life transitions, it’s not wise and it’s not OK — clinically, ethically, or legally.

"Worried Woman" by HikingArtist.com / Frits Ahlefeldt-Laurvig

The clinical implication is this . . . by intentionally giving your client the wrong diagnosis, in this case a more serious diagnosis than is truly warranted, you pathologize your client.  This is like going to your primary care doctor for a mosquito bite and him diagnosing you with an infection.  Mosquito bites happen just like life happens.  Misdiagnosing does nothing to empower your client.  Nor does it inform her about the real nature of what’s going on or lead her toward useful strategies for managing the transition at hand.

Ethically you’ve failed . . . to provide honest, accurate and useful information to your client if you’ve told her she has something different than what is true.  You’ve also set yourself up to provide inaccurate information to others i.e. physicians, lawyers, etch.  that may gain access to your records later on.

And, legally, you’re setting yourself up for big trouble. When you choose to list an inaccurate diagnosis on health insurance claims forms and submit them, you have just committed insurance fraud.  Should you choose to put the inaccurate diagnosis into your clinical record, you have falsified documents and failed to meet the professional standard of care.

If knowing all of this you are still tempted (perhaps you believe with good intentions) to misdiagnose a client, seek clinical, ethical, and legal consultation.

[Update 10 Dec. 2009 5:54 pm - Of course, mental health professionals are not the only one fudging on diagnoses.  Check out The Last Psychiatrist blog post, "How Am I Going To Get Paid If It Isn't Autism?"]

Related Posts

A Speedy Little Tool for DSM-IV and ICD-9-CM Coding

Tags: Diagnosis, Documentation, Ethics, Fraud, Standard of Care

If your post-graduate supervision is not all that you had hoped for, there may be a really good reason.  Do you know that clinical supervision is different from administrative supervision?

An administrative supervisor typically operates from a business model rather than a clinical model.  His priority is to make sure that the organization (or her department) runs smoothly. There are local, state, and federal regulations  (like the EEOC guidelines and the Disability Act) that impact his decisions concerning her supervision of you.

Administrative supervisors are often

"In Which Zac Never Realized . . . " by Zac Peckler

what you encounter as a new graduate entering the workforce through an agency, hospital, or school setting. You will recognize an administrative supervisor because he will emphasize paperwork and productivity, managing your caseloads, scheduling, and accountability.

An administrative supervisor must train employees to systematically complete basic paperwork, manage crises, work within systems, and deal with large numbers of clients needing many different things at the same time.  There is much to be learned from an administrative supervisor that will serve you well throughout your career but this is NOT clinical supervision.

If you are frustrated with the quality of the supervision you are receiving, perhaps you assumed that the supervision you would be receiving from your supervisor would be clinical supervision rather than administrative supervision.  Here are some things that you can do to insure that your experience under supervision is all that you want it to be.

Related Posts

9 Steps You Can Take to Insure a Great Supervisory Experience

4 Things to Consider if Your Supervision is Less Than Ideal

Supervision or Consultation?

Tags: Client Load, Crisis, Documentation, Schedule

This is the fifth post in a series that highlights standardized formats for your clinical notes.  The series began here.

"Intense Color Coded Notes" by mandiberg

I have only recently stumbled across the Gillman HIPAA Progress Note here.  Of the four methods that I have mentioned, this is the only one that has been developed after the introduction of HIPAA. It was developed by Peter D. Gillman, Ph.D. in response to the implementation of HIPAA.   As such, he has taken the extra precaution to intentionally exclude information that is not protected by HIPAA.  I consider that to be a significant improvement over previous iterations of standardized note taking.

I have not yet used this method but plan to try it out.  At first glance, it seems thorough, efficient and equally important, it is fully HIPAA compliant.

If you are not satisfied with the current format of your progress notes, I would encourage you to try this one.  Here’s what you need to include:

• Time of your session,
• Treatment and frequency of modalities you provided,
• A summary that includes, client’s symptoms and functional status, progress, diagnosis, treatment plan and prognosis.

To obtain this information, Gillman recommends asking yourself these six questions . . . .

1. “What symptoms did my client present today?”
2. “How is this impacting their ability to function?”
3. “What progress did my client make since his last session?”
4. “How does this change my thinking around diagnosis, treatment, planning, and prognosis?”
5. “What is my immediate treatment plan and recommendation?”
6. “What is my immediate prognosis?”

Let me know if you try the Gillman HIPAA Progress Note and how it works for you.  I’m eager to compare notes!

Tags: Diagnosis, HIPAA, Prognosis, Record & Documentation, Treatment Plan

This is the fourth post in a series that highlights standardized formats for your clinical notes.  The series began here.

"Id, Ego, and the Misplaced Monkey" by paintMondkey / Daren Higham

A third format for clinical note taking is commonly known as BASIC SID.  This is yet another mnemonic.  The letters stand for Behavior, Affect, Sensation, Imagery, Cognition, Spiritual (and Religious), Interpersonal, and Drug (and Biology).

Behavior refers to what you see your client doing and not doing. 

Affect refers to both your client’s mood and congruence with expressing those moods. 

Sensation refers to your client’s awareness of his five senses and includes hallucinations, perceptual illusions, muscular tension or pain, excessive sensitivity to environmental stimuli, and what the client saw and heard. 

Imagery related to your client’s past, present or future in any way includes dreams, fantasies, obsessions, flashbacks and responses to guided imagery. 

Cognitive focuses on your client’s constructed meaning i.e. self talk, mental abilities, personal narrative, beliefs and mental schema.

Spiritual includes your client’s beliefs related to a Supreme Being, affiliation and practices with religious groups, religious resources, conscience and moral development, themes of guilt and forgiveness, creativity, and personal comfort related to ideas of spirituality. 

Interpersonal references your client’s relationships with others, level of social skills, degree of acculturation, and any incidents of social injustices. 

Drug and biological includes your client’s use of chemicals (both illegal and legal), medical compliance and concerns, and any incidents of delirium or dementia.

What I really like about a BASIC SID clinical note is that the acronym provides prompts to help me remember to focus on all areas relevant to my client’s progress.

Tomorrow I will talk to you about taking clinical notes using the Gillman HIPAA Progress Note.

Tags: Records & Documentation

This is the third post in a series that highlights standardized formats for your clinical notes.  The series began here.

"Writing Scathing Notes" by JasonRogersFooDogGiraffeBee

A second format for documenting your clinical work is called DA(R)P notes, sometimes referred to as DAP notes.  These are similar to clinical SOAP notes. 

DA(R)P is a mnemonic that stands for Data, Assessment (and Response), and Plan.

Data, in this format, includes both subective and objective data about the client as well as the therapist’s observations and all content and process notes from the session.

The Assessment and Response includes your clinical impressions, hunches, hypotheses, and rationale for your professional judgment. Progress is also noted here.

Plan refers to your original treatment plan and any response / revisions needed based on your most recent interactions with your client.

This method of clinical note taking is also an acceptable format for your documentation.

Tomorrow I’ll talk to you about BASIC SID notes.

Tags: Assessment, Records & Documentation, Treatment Plan

This is the second post in a series that highlights standardized formats for your clinical notes.  The series began here.

"Soap Carving" by Narisa Spaulding

Probably the most common form for standardizing your clinical notes is SOAP notes.  It’s likely that you learned how to document in this standardized form early on in your training as a mental health provider and you may have continued to use this format up until now.  SOAP is a mnemonic that stands for Subjective, Objective, Assessment, and Plan.

In this format, Subjective includes only the client’s subjective information.  Often this looks like a summary statement or direct quote from the client.

The Objective portion of your clinical note is observable data or information that coincides with the subjective statement.  Typically this includes the client’s body language and affect.

The Assessment is your professional and clinical judgment based on the aforementioned Subjective and Objective statements.

The Plan includes your intentions for future clinical work, any homework that was given, any referrals / interventions made, and any follow up needed or completed.

Many agencies and organizations use SOAP notes as their standard format for note taking.   Although it can be awkward and does not always easily permit the inclusion of data that you might feel is pertinent, SOAP continues to be a commonly accepted format for documentation of clinical notes.

Tomorrow I’ll talk to you about DA(R)P notes.

Tags: Assessment, Follow Up, Homework, Record & Documentation, Treatment Plan

On Monday, Brenda Bomgardner, a student intern at Regis University, wrote in asking for efficient ways to record her clinical notes.  This is the first of five posts to help you sort through your choices for clinical note taking.

"Leave Me Alone - I Know What I'm Doing" provided by foundphotoslj

You can be reasonably confident that  if you are working in an agency, the content and format for your clinical notes are already stipulated.  However, for those of you entering private practice, you have more leeway in deciding what your client notes, often called “progress notes“,  will look like.

All mental health disciplines require documentation of your clinical work.  Although the required content for that documentation varies from discipline to discipline and from jurisdiction to jurisdiction, there are general categories of information that are required for you to keep in your records. These categories typically include contact information, your client’s presenting problem, your assessment, treatment and plan.

In addition to free form notes, there are at least four common ways to standardize and record this information.  They are:

• SOAP Notes,
• DA(R)P Notes,
• BASIC SID Notes,
• and Gillman HIPAA Progress Notes.

Next week, I’ll share with you how each of these differs.  Then you can decide how best to keep your own clinical notes.

Do you know of other formats that you like to use?  If so, please share them with us here so that we may all learn from you!

Tags: Assessment, Record & Documentation, Treatment Plan