Progress Reports! The good, the bad and the ugly.Progress Reports are the one area most reviewed by everyone. They include every piece of progress, or lack of it, for the last service period.
- The initial paragraph gives the reviewer a glimpse of what is going on with the client and their family. Hospitalizations, CPS reports or involvement updates, financial changes/stressors, changes in guardianship-the list goes on and on. When reviewing this section ask yourself-does this show what is going on? It should change each month-even if it is not a month it needs to be submitted for new services.
- Progress in accessing services-UGH! I so do not like how this section is labeled. It implies “how were the requested Plus services used”, but it really means so much more. This section actually needs to include every service, resource, referral status, etc….and how were the requested Plus services used.The form itself is designed to indicate it only needs a small amount of information which doesn’t help.The form also asks for progress, then separating for issues-really, this makes no sense. I think we should change this and I will be working on it.
- For a short list example: James attended his psychiatrist appointment this month and his meds were changed to …… to address ….., TCM left message for psychiatrist informing Dr. Happy of his current progress status and faxed a copy of the STM to her office prior to the appointment, he saw his outpatient therapist Suzy Fixit as scheduled, his Plus therapist as planned on the service plan 2x per week individual, 1x collateral per week, he went to the Happy Time community program the TCM set up for him 2x, he continues receiving speech therapy and placement in his BD classroom at school, his mother utilized the food pantry the TCM referred her to, and he remains on a wait list for a TCS. TCM continues to follow up on that status.
or…
- James missed his psychiatric appointment this month due to mother having transportation issues. TCM is helping reschedule, and has provided her resources for other other modes of transportation for the future. Mother was educated on the policy of the psych office that he may be dropped as a client if he misses another appointment. He saw his outpatient therapist Joe Helpme as scheduled. Plus therapist utilized the collateral sessions with his mother and school as indicated on the plan (1x per week), yet missed two sessions this month of individual of the 2x per week scheduled due to James not answering the door to let provider in the home. Team is addressing this issue by continuing to create rapport with him, and educate him on how attendance will help him progress with his plan. James refused to attend the Happy Time community program as he stated it was “lame” so team is working with him to be open to the program. Plus therapist is planning on taking him to decrease his anxiety regarding attending that he is hiding behind his “lame” comments. He remains in a BD classroom for support, yet attendance has been an issue. Team again believes this is due to anxiety issues related to his diagnosis and are addressing in the plan. Family has not followed up on food resources provided by the TCM, and team will assess why this is not being accessed.TCM continues to attempt to contact the CDW, and will be contacting their supervisor if future attempts are not successful. TCM attempted to attend court date on 1/20, but mother confused the dates and it was not the correct time/court. TCM working with mother on documenting appointments utilizing a calendar.
- Goal update section. This section allows for brief updates on each of the clients goals. It needs to be both positive activity and problems in achieving progress. If your goal data changes on the STM it should be noted here. If there is no progress, or minimal, then it should be discussed why there is little improving and what the team is doing to address the lack of progress. There should be clinical input here from the BHP, and other therapeutic providers indicating what they are changing, adjusting, doing to address…..you get the idea.
- TCM plan for the upcoming month. This should be specific, and should change each month. Stock statements (TCM will contact the family as needed and provide resources as needed for example) are not specific enough. This area really means-why does this client/family need TCM? This section can be based on the current status of the family needs, issues with accessing services, etc. It should also be reflected in your objectives on the STM. Examples could be:
- TCM will continue to attempt to reach CDW, and will follow up with his supervisor if needed. Will work with mother on utilizing a calendar to help her organize her appointments. Will attend next court date to keep team and court informed of progress. Will work with school on scheduling an IEP review meeting to address his lack of attendance to help develop a plan. Will continue to encourage mother to utilize Food4U program. Will continue educating mother on importance of attending psych appointments, and will help her schedule a Medicaid cab prior to appt. Will reinforce with James that he needs to attend his therapy appointments and will talk to him about why he is missing appointments.
- I hope this explanation clarifies what the form really wants. I understand that it may look like a lot in this descriptive format, but it is really just documenting what you are already doing. I welcome suggestions or questions.