Continued Care: Treatment Planning

The facility creates an initial treatment plan within 24 hours of the patient’s admission. This plan introduces the patient to the facility and the care team, the providers initiate the medication regimen and begin treatments such as group sessions or detoxification (if applicable). Within 24-48 hours, the facility must also develop an ongoing treatment plan that defines goals, objectives, and interventions based on the Biopsychosocial (BPS) Assessment or American Society of Addiction Medicine (ASAM) evaluation form to address the patient’s identified problems.

Required Permissions: Therapist, Case Manager, Doctor, Super Admin, and Records Admin

Video Steps

Best Practice Workflow Steps

Let's review Kipu EMR's best practice workflows for treatment planning.

1. Add the initial treatment plan form through centralized documentation.
• The initial treatment plan can be linked to the Scheduler appointment card.
2. Send the document for signature via the Patient Portal or obtain an in-person signature.
   
• Best Practice: Always send documents requiring patient, guardian, or guarantor signatures through the Patient Portal.
3. Complete a BPS or ASAM evaluation using centralized documentation unless the form is linked to the Scheduler appointment card.
• Note: This assessment captures biographic, social, psychological, treatment history, and diagnostic information. A therapist, case manager, or clinical director typically completes it within 48 hours of admission. In some cases, a psychiatrist may contribute with a History and Physical or Initial Psych exam form. Identify and document compliance-regulated information, diagnosis codes, and patient problem areas to guide treatment planning.
4. Add the problem list identified in the BPS or ASAM.
5. Add the treatment plan evaluation to the patient chart via centralized documentation.
• Note: A separate form is required for each identified problem in the treatment plan. Kipu separates treatment plan sections into separate forms based on roles, such as Case Manager, Therapist, Nurse, Doctor, Nutritionist, and Psychiatrist.
6. Add treatment modality for each problem.
• Important: The system defaults treatment plan modalities to Clinical and Nursing. Super admins can customize Golden Thread modalities such as Case Management, Medical, Alternative, Dietary, and others. However, modalities should not represent a level of care, as treatment plans remain active throughout treatment.
7. Define goals in the patient’s own words, set measurable objectives and interventions with frequency, and target dates. Ensure documentation reflects individualized care rather than generic content.
8. Use the Wiley Treatment Planner for guidance and content support.
   
• Best Practice: The Golden Thread feature includes pre-loaded Wiley Treatment Plan components, such as common addiction-related problems, diagnoses, behavioral definitions, goals, objectives, and interventions. However, most states and regulatory bodies require treatment plans to be customized for each patient. Use this content as a guide and incorporate patient statements to ensure individualized treatment.
9. Obtain necessary signatures from the patient and providers for each section.
   • Collect patient, guardian and/or guarantor signatures via the Patient Portal.
10. If a licensed provider review is required, the document appears as Ready for Review in the Current Census tab of the Dashboard.
• Best Practice: Apply signatures across multiple sections efficiently from the Golden Thread List View tab.
11. Continuously review and update the treatment plan based on patient progress and compliance requirements.
    
• Best Practice: Providers review the treatment plan during 1:1 session and adjust objectives/ interventions using statuses to demonstrate active participation.
12. Utilize the Golden Thread button to link supporting documents (e.g., individual progress notes, group sessions, etc.) to the treatment plan.
13. Update treatment plan target date as needed.
• Best Practice: Collect patient, guardian and/or guarantor signatures via the Patient Portal to update pending statuses and treatment plan. Enable notifications to alert users when a patient signs a treatment plan via the Patient Portal.
14. Initiate a comprehensive discharge plan using centralized documentation to ensure a smooth transition and update the Discharge Summary throughout the patient’s care based on the patient’s progress, readiness, insurance coverage, and treatment type.