Developing a treatment plan is one of the first steps to overcoming addiction. A treatment plan is essentially a custom solution for each of your patients. It summarizes all of your work, and it is essentially a representation of your organization’s expertise. It has to work for both your organization and the patient.
All substance abuse treatment plans follow a standard format. However, each plan’s efficiency depends on the clinic’s success in diagnosing the problem and formulating a solution.
Here are some tips and guidelines on writing effective substance abuse treatment plans.
It Begins with a Thorough Bio-Psychosocial Assessment
Writing an effective substance abuse treatment plan begins with a thorough and accurate bio-psychosocial assessment. This assessment is holistic as it considers the patient’s problem from different angles. This is important because problems don’t exist in a vacuum — to this end, substance abuse is often triggered by problems and complications in the patient’s life.
A bio-psychosocial assessment evaluates three aspects of the patient’s life: biological, psychological, and social factors. Consequently, some of the factors considered include the patient’s medical history, financial status, family history, life-changing past events, and other factors that fit these three aspects.
The bio-psychosocial assessment will help your clinic better understand each patient’s situation and needs. This will be instrumental in formulating a solution, making for an effective treatment plan.
Follow the Four-Step Standard Format
Every substance abuse report should be customized to meet the individual patient’s unique needs. However, virtually all treatment plans follow a four-step standard format. This format includes:
A problem statement is a report of an individual’s condition requiring treatment. In this case, the condition is the patient’s addiction to his/her substance of choice (or a range of substances).
The problem statement should be based on the results of the bio-psychosocial assessment discussed earlier. Consequently, it is important to keep detailed and accurate patient records during assessment when formulating the problem statement and writing a treatment plan. Consequently, an electronic health record solution is recommendable.
The treatment plan doesn’t have to be limited to one problem statement. Many statements contain a list of problems. Additionally, they may contain other problems besides substance abuse, such as anxiety and other underlying psychological and biological factors. It is also worth noting that the problem statement is dynamic — it will change over time as the patient tries to recover.
The main goal of substance abuse treatment is to help the patient overcome his/her addiction. However, an efficient substance abuse treatment plan should contain multiple goals — as many as necessary for the patient’s successful recovery.
The goals should be based on the bio-psychosocial assessment and problem statement(s). They should also be reasonably achievable during the patient’s active treatment phase.
However, the goals should also have a long-term outlook to prevent the patient from relapsing after the active treatment phase ends. Consequently, it is advisable to set goals to replace the patient’s dysfunctional behaviors that influence their substance abuse with healthy, positive, and productive ones.
Objectives are tactics designed to enable the patients to achieve their goals. They should be based on the patient’s bio-psychosocial assessment, problem statement(s), and goals. They essentially represent the patient’s roadmap to recovery. As such, they should be effective to ensure that the treatment plan is a success.
The objectives should be clearly defined. Consequently, it is advisable to adopt a SMART (Specific, Measurable, Attainable, Relevant, and Time-based) approach. This approach should entail the following:
- Specificity — Spell out exactly what the client should do to achieve each goal (avoid making vague generalizations).
- Measurability — Each objective should be measurable to track the patient’s success. Consequently, it is advisable to quantify the objectives.
- Attainability — Each objective should be realistic and attainable within the active treatment period (and afterward for long-term goals).
- Relevance — Each objective should be relevant to the problem, bio-psychosocial assessment, and the goals stated in the substance abuse treatment plans.
- Time-limited — The objectives should be achievable within the set duration.
One of the most important things about objectives is that they should be observable. This is important when following up with the patient to ensure that they adhere to the treatment plan.
Interventions are the tactics that your organization will take to help the patient complete their objectives, attain their goals, and ultimately recover from addiction. They form a part of the patient’s roadmap to recovery (together with the objectives), and the treatment plan’s success depends on their efficiency.
The interventions should be clearly defined and measurable to help gauge the patient’s progress. Additionally, different objectives should be assigned to different employees based on their skills and specialties. For example, an intervention that involves helping the client form social relationships should be assigned to a group counselor.
A thorough diagnosis of the patient is necessary for writing effective substance abuse treatment plans. This relies heavily on one-on-one interaction with the patient. However, technology can also help refine your results.
For example, behavioral health data analytics solutions can help make sense of every bit of data collected during the bio-psychosocial assessment. Additionally, substance abuse e-prescribing solutions can help ensure that patients get the correct medication type and dose on time. What’s more, a medical administration record solution will maintain a comprehensive history of each patient’s prescriptions.
Treatment Plans are Dynamic
Recovery from addiction is a long-term and dynamic process. Aspects such as goals and objectives change over time as the patient’s needs change. Consequently, it is important to closely track each patient’s progress and adjust their treatment plans to reflect their immediate needs.
Consequently, it is important to keep detailed patient records, as mentioned. A data analytics solution can also help you identify changes quickly.
Your Ideal EHR Solution
The ideal EHR solution can help you write effective substance abuse treatment plans. However, TenEleven’s Electronic Clinical Record (eCR) is more than just an EHR. Our software offers a wide range of features that support every guideline covered in this article. Try our demo to see how our eCR solution can help improve your organization’s treatment plans.