TSWF Behavioral Health Specialty AIM Form User Guide January 2019

TSWF Behavioral Health Specialty AIM Form User Guide January 2019 Form Version: Jan-Apr 2019

Table of Contents Behavioral Health Specialty AIM form Introduction 2 General Information..... 3 Best Practice Procedures and Workflows. 4 Form Tabs Screening.. 5 Measures... 6 Suicide/Safety Assessment... 7 HPI... 10 Past History.. 10 Review of Systems (ROS). 11 Mental Status and Physical Exam.. 12 Treatment Plan and Care Notes.. 13 CPG Decision Support... 15 Patient Resources... 15 Using This Form.. 16 Adding Form to Favorites Instructions.. 17 Copy Forward Instructions 20 AHLTA Options. 24 1

Introduction to Behavioral Health Specialty AIM Form Background/History: The Tri-Service Workflow (TSWF) Team has created AIM forms to bring team care to MTF workflow, save provider and staff time through standardization of AHLTA templates, and enhance documentation of the patient encounter. The focus of TSWF activities is to facilitate improvements by evaluating clinical workflows and creating standardized structured documentation tools that mirror clinical processes. This is done through the use of AIM (Alternate Input Method) forms with the goal of improving care and documentation in AHLTA and not just the use of a form for its own sake. In 2012 a TSWF Behavioral Health form ( TSWF BH ) was created to support the needs of providers in the National Capital Area (JTFCM). In spite of only an initial local training and deployment, many providers across the MHS have been using this form, suggesting that a greater need for standardized documentation exists across the MHS. Since its initial deployment, the TSWF Team has been gathering Tri-Service input and lessons learned from users in order to improve the form. Based on this input, an entirely new form was created. In addition to addressing MHS system needs, the form was constructed to support the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury (DCoE) pathway of care for PTSD. Initial versions of this new form were alpha tested yielding several positive results. Users reported that the form helped them: construct more thorough treatment plans (77%), locate critical information in completed notes (69%), and perform more thorough suicide assessments (85%). Building on this alpha-form structure, a conclave was held in December 2013 that included Tri-Service and DCoE representatives. This resulted in the creation of the AIM form that is described in this User s Guide. Who is this form made for? The form is intended for specialty Behavioral Health clinics (not primary care), for initial and follow up appointments, for all diagnoses, and all types of Behavioral Health providers. The form has been evaluated in beta tests and pilots prior to release. In April 2014, a joint meeting (including representatives of the Services and Health Affairs) gave support for use of this form across the MHS by any clinics or Services that choose to use it. Furthermore, the form is designed to be consistent with data collected by the Behavioral Health Data Portal (BHDP). At the April 2014 meeting, the Services and Health Affairs recommended that the unique and helpful features of the TSWF-BH-Spec AIM form should be incorporated into the BHDP Note View feature. This incorporation is ongoing. The form went live on the AHLTA Enterprise in OCT 2014. Why would I want to use this form for my notes? This form and associated workflow was designed to standardize health documentation practices in the MHS. Standardization of documentation can result in the following: Integrating clinical support staff into the care of patients Obtaining more thorough and better documentation Guiding providers toward using evidence-based care Standardizing suicide and safety evaluations Improving the speed and efficiency of documentation Improving coding accuracy Building in items required for inspection Features of the Tri-Service Workflow AIM forms and associated workflows: The copy-forward process (see instructions on p21 of this Guide): o Maintains continuity of clinical information o Carries forward treatment planning and ongoing course of care o Improves note writing efficiency The forms include clinical clues and reminders VA/DoD CPG decision support is available right at the point of care 2

General Information on Form Use ------------------------------ (Sequence of Clinical Workflow) -------------------------------- o Form Structure: - Mirrors clinical workflow - Facilitates use of clinical support staff (technicians, medics, corpsman, etc.) for screening and intake documentation - Allows for BHDP data entry (Screening, Measures and Suicide/Safety Assessment are items also found in BHDP, therefore information can be copied and pasted into these tabs. This option of limited parallel charting serves as a failsafe measure for when BHDP latency occurs.) - Provides decision support from VA/DoD CPGs and other national level recommendations - Improves documentation efficiency (especially for follow up notes) - Carries important information forward from one appointment to the next via the copy-forward process [REMINDER: any information you want carried into subsequent notes must be placed into the yellow fields as these are the only fields that copy forward when selecting PMH/Auto Enter (see specific instructions on p22)] - Is intended for - Behavioral Health Clinics (not primary care clinics) - Adult patients - Initial Evaluation (full form) - Follow-Up appointments (primarily on last tab) - Prescribers and therapists While the original TSWF BH AIM form is being used by many clinics, TSWF will not make any updates or changes to that form. The TSWF BH-Spec AIM form replaces the TSWF BH form as the Tri-Service approved BH form for use in specialty care clinics. NOTES: -Because of the unique structure of this form, one should never copy forward a primary care note or non- TSWF BH-Spec form into this form. Doing so will create errors in documentation. Within the copy-forward process, many BH clinics are selecting the HPI tab in addition to the PMH tab in order to save time from having to re-type the narrative in subsequent visits. However, the provider needs to be sure to document that the current encounter s narrative has been reviewed. This User Guide is a comprehensive AIM form reference that walks through all of the tabs on the TSWF BH-Spec AIM form. If you need initial training on the use of AIM forms, please contact your clinical systems trainers. Training is also available at: www.tswf-mhs.com If you have questions or feedback about this User Guide, please contact us via the following link on Milsuite: https://www.milsuite.mil/book/groups/tswf. The TSWF repository for training/educational materials and updates: www.tswf-mhs.com 3

Best Practice Procedures and Workflows Patient *in failover mode Patient Signs In Patient Enters Data on Paper Intake* Clinical Support Staff (and/or Provider) Based on manning, clinic workflow needs, and leadership preference Data Entered into AIM form Note is Opened Provider Provider Reviews/Edits Documentation Continues Encounter Documentation in AIM form Completes and Signs Note Recommended Documentation Workflow a. Clinical support staff (CSS) copies forward previous essential HPI and PMH encounter information (up to a week prior to the visit) via the Open, Not Checked-In option. b. On the day of the visit the CSS checks the patient in, and reviews/updates all copy-forward information (e.g. past history, etc.) in the note with the patient. c. The CSS performs Screening (on Tab 1 of form or paste screening data from BDHP into form), Past History, etc. if desired by clinic leadership and workflow. CSS closes (not signs) note. d. The provider then takes ownership of the note (i.e. edits S/O portion of the note) and reviews all copied forward information and everything entered by the CSS. e. The provider then completes the rest of the documentation and signs the encounter. Transferring patient data from BHDP Utilize the Snipping Tool to copy information (text or graphical) from BHDP Note View into Add Note OR: Text can be copied and pasted into the specifically built textboxes in the BH Spec AIM form that can easily be copy-forwarded into subsequent notes. o Individual Measures (C-SSRS, PHQ-9, GAD-7, PCL-5, ISI, AUDIT) AIM Scoring Boxes (found on the Measures Tab) PLEASE NOTE: A comprehensive visual change log has been created to assist users in identifying the changes made with each version s update. Click here to access this presentation. 4

Screening Tab Visit the TSWF website for training/educational materials and updates. Access any TSWF form from the Navigator via this link. This ribbon is where BHDP data can be copied and pasted. MilSuite link AHLTA users can ask questions and provide input. Link to BHDP Dashboard Chief Complaint box for presenting problem. This is also a good place to paste the patient narrative, problems and difficulties that is produced by the BHDP narrative. Important information throughout the form is in red. Patient Demographic Information and Occupational History will copy-forward from appointment to appointment. Link to launch to an external website. Tobacco, alcohol, and illicit drug use screening questions are copy-forward fields. The lower portion contains items for the initial appointment only. Some textboxes contain prepositioned text. Typing an x within brackets denotes a selection. This particular field contains some pre-positioned x s for select questions. Small boxes throughout the form allow free text entry. A red X indicates this section will be included in the note. AHLTA automatically marks this X after text has been entered. Clicking on the X after typing in the box will reset the box to its default text by erasing what has been entered. The Undo button (at the top of the page) can be clicked if this was done accidentally. 5

Measures Tab Order of screenings matches what s found in BHDP All text boxes in yellow will copy-forward to the next visit. For each sequential visit, add a line with the updated scores to keep a running log. The PHQ-9 perfectly mirrors the Pfizer Inc. version. Clinical cues are found throughout and give relevant information. Arrow buttons will expand and collapse ribbons. Pediatric Screening measures are included. 6

Suicide/Safety Assessment Tab This tab contains 4 ribbons: Columbia Suicide Severity Rating Scale (C-SSRS) Risk Level and Safety Plan Comprehensive Suicide Assessment (Intake and as needed) Air Force Suicide Assessment For the Columbia Suicide Severity Rating Scale (C-SSRS), cues on the right give instructions on how to ask the questions. 7

Suicide/Safety Assessment Tab, cont. Select the appropriate Risk Level. This adds a summary statement in the encounter (example shown here). Add additional information such as actions taken by clicking the little square icon to open the text field. Risk Level and Safety Plan is found on the Suicide/Safety Assessment tab. Risk Assessment and Actions from DoD CPGs. 8

Suicide/Safety Assessment Tab, cont. COMPREHENSIVE SUICIDE ASSESSMENT consistent with VA/DoD CPG guidelines Air Force Suicide Assessment 9

HPI Tab Do NOT delete the TSWF AIM form identifier as it is integral to the copyforward process. Start the note below this text. Instead of copying and pasting your HPI to future notes, you can select HPI in addition to PMH when completing the copy-forward process (see page 22 for specific instructions). Past History Tab Initial Encounter Full Past History First Follow - Up Encounter - delete any text you do not want to appear in subsequent encounters (click the red X ) 10

ROS Tab Select All Normal and document specifics by exception. Additional ROS can be found by clicking open this ribbon. Free text option for documenting ROS. 11

Mental Status and Physical Exam Tab Safety Questions must be documented here even if free texting MSE. Two options are provided for MSE free text documentation. More common physical exam elements in psychiatry reminder: look for these items in medical/psychiatric patients. 12

Treatment Plan and Care Notes Tab Standardized Treatment Plan Structure.Flexible Progress Note Options Appointment Notes Written with Treatment Plan in View This valuable copy-forward field contains a list of interventions that offers a concise overview of all the therapies the patient has or has not received. Within each intervention, document any details of the technique/process. This field ultimately provides continuity and situational awareness for the entire BH clinic. Progress Note (Ribbon is closed by default) You can use this box for the bulk of your session or progress note. WILL NOT COPY-FORWARD PRESCRIBERS ONLY (Ribbon is closed by default) Document medications by opening the Medication Ribbon. 13

Treatment Plan and Care Notes Tab, cont. Treatment Team Information Treatment Plan Always Copies Forward and is visible when writing follow-up notes. Defines Terms and Lists Items to Include in Treatment Plan. A Comprehensive Treatment Plan ribbon with four copy forward text boxes is included. 14

CPG Decision Support Tab CPG Decision Support Depression Substance Use Bipolar Disorder PTSD Trauma Suicide Assessment Patient Resources Tab Web links to Patient Resources 15

Using This Form Tab Using This Form - (Ribbons are closed by default) This tab is designed to highlight the most important information from this User Guide and be easily accessible to providers and clinical support staff at the point of care. Information includes: General AIM form Tips and Tricks S/O Default Settings Prepositioned Text Form and Structure overview Best Practice Procedures and Workflow Copy-Forward Process Transferring Patient Data from BHDP 16

TSWF Behavioral Health Specialty AIM Form: Adding Form to Favorites Instructions 17

The preferred method of accessing TSWF AIM forms is to have the Navigator in your Favorites. Loading from the Navigator will take you to the most current version of the form. Alternate Method: Add the specific TSWF AIM form to your Favorites 1. Open Tools 2. Select Template Management 3. Click Expanded Search to locate TSWF AIM forms 4. In Template Name line type TSWF 5. From Owner Type dropdown list select Enterprise 6. Click Search button 18

7. In the Search Results list: Right click on the TSWF-BH-SPEC- (Department of Defense) AIM form 8. Select Add Favorite (Do not use Save As, as the form will not get updated properly see below) Do not use Save As when adding this template to your favorites list. Do not set this form as your default encounter template unless you have specific instructions on how to do it from your local clinical systems trainer. Save As will break the link to the Enterprise and keep the form from updating properly; setting as a default will also break the link if not done properly. We suggest cleaning out old and un-used templates from your favorites to help you quickly find the ones you most often use. 19

TSWF Behavioral Health Specialty AIM Form: Copy-Forward Instructions 20

Copy Forward Instructions 1. In Appointments view; Double-Click on the Patient. (This takes you to this Current Encounter view.) DO NOT OPEN S/O The copy-forward process is integral to the Tri-Service Workflow. Following these steps will ensure that the appropriate data you enter in today gets reused as efficiently as possible. REMINDER: only information placed in the yellow fields throughout the form will copy forward!! 2. Select the Previous Encounters module from the Folder List. Consider including cancelled/lwobs visits when reviewing this module. 3. Click on the most recent and compatible TSWF encounter listed (e.g., includes <<Note accomplished in TSWF BH-SPEC>> in the HPI section). 4. Click the Copy Forward icon on the tool bar. 21

AHLTA returns to the Current Encounter 5. Select S/O DO NOT MAKE ANY EDITS WITHIN THE COPY-FORWARD TEMPLATE! - If the Copy-Forward Template is not automatically loaded; select it from the Template drop down menu. 6. Select PMH tab to copyforward. In some cases, HPI may be selected as well. Many BH clinics have selected HPI to copy forward to save time from having to re-type the narrative. However, the provider needs to be sure to document that the current encounter s narrative has been reviewed. 7. Click AutoEnter. TSWF Copy-Forward process All copy-forward items are located on the PMH tab in this view, and are ONLY in the yellow colored fields throughout the AIM form. Critical Assumptions You MUST complete copy-forward and open the TSWF AIM form before editing the content. You MUST copy-forward from a TSWF BH Spec-AIM form. 22

8. Select TSWF BH-Spec AIM form 23

AHLTA Options Access by opening up any clinical encounter or tel-con to this screen. Click on the OPTIONS tab. Line 1-will default to your name Line 2-as directed by your MTF-in the LIVE system, AHLTA s default is PHYSICIAN/WORKSTATION Line 3-as directed by your MTF Co-signer-as directed by your MTF AUTO CITES- recommend checking Allergies and Questionnaires (if used). Uncheck anything else. VITALS/LABS/RADS-this will automatically place ANY vitals/results in your note for the time period you selected-ie for the last 7 days. We recommend leaving all these unchecked. WARNING-THIS FUNCTION WILL AUTOMATICALLY PLACE INFORMATION IN YOUR NOTE REGARDLESS OF WHO ORDERS THE LABS. Individual labs/rads can be added to the encounter when viewing those results. A/P Active Order Default- recommend checking all the boxes 24

S/O Default- We recommend unchecking both of these boxes. Having them checked can cause unexpected behavior in the forms. Disposition Follow Up Discussed with Default: Defaults to Patient. Option to override for exceptions is located in the DISPOSITION tab E&M Calculator Defaults: If the user is primarily using CPT codes, recommend changing SERVICE TYPE to Other Unlisted E&M. Note: There doesn t have to be any E&M code if there is a CPT code in the AP module. Do NOT check AUTO PRINT or SENSITIVE Include ICDCM/DoD Unique/CPT4/HCPCS codes in encounter note- check this box. This will place the codes on the signed encounter. No action required by user. Warn me if no procedure documented- for primary care, do not check this box. Auto Save- recommend unchecking this box. This used to be helpful but auto-saving freezes up AHLTA for a moment and it s really just not needed. 25