Review assessments from referring facilities and note problems/issues that require further attention and integrate this information into patient’s current course of treatment.
Contact referral source and other key individuals no less than weekly to gather additional information as necessary and to update on progress.
Complete ASAM Forms (admission, continued stay, transfers and Discharge) for each level of care. Documenting Criteria.
Gather comprehensive diagnostic information through psychosocial assessment interview.
Develop an Integrated Summary, bringing together information from all assessments to identify problem areas that may affect treatment and/or need to be addressed in treatment planning.
Develop a comprehensive problem list that reflects patient’s individual issues as described in the assessments and Integrated Summary and ensure that the list is carried to the treatment plan.
Present psychosocial and diagnostic information to treatment team in a clear, concise manner.
During first session with patient, review initial treatment plan, including case management issues and be sure that patient and staff assignments and responsibilities are understood and in progress.
Formulate a comprehensive treatment plan with patient that effectively addresses patient issues and is completed within established time frames.
Develop clearly stated treatment goals and objectives that are measurable and that are patient driven.
Develop interventions that will accomplish goals and objectives and state the planned frequency of interventions.
Participate effectively in multidisciplinary treatment plan reviews, demonstrating adequate preparation and understanding of patient issues, progress, areas of resistance, positive and negative strategies, etc.
Document the patient’s progress accurately as it relates to treatment goals and objectives.
Continue treatment planning process throughout patient’s stay in treatment, opening new problems and developing or revising treatment plans as necessary.
Assist patients in gaining group process skills.
Track patient’s clinical problems in group.
Utilize experiential techniques effectively.
Create atmosphere in which self-disclosure is facilitated.
Conduct educational and process groups (lectures/videos/discussions) effectively.
Adhere to time schedules.
Provide individual counseling to patients at least one (1) times per week.
Assist patients gain insight into problems.
Assist patients in understanding treatment goals.
Give patient a clear picture of where he/she stands with regard to progress toward recovery as seen by the therapist and the multidisciplinary treatment team.
Enforce program rules and regulations in a firm but fair and respectful manner.
Confront counter-productive behavior appropriately and with respect.
Bond with patients and elicit respect.
Adapt to different types of patients.
Identify patient strengths and weaknesses and be able to document and work on them, per the treatment plan, throughout the course of treatment.
Maintain healthy boundaries with patients at all times.
Understand and apply the program’s clinical philosophy.
Maintain regular contact and open communication with families.
Assist families in identifying the problems and issues they need to work on.
Assist families in finding resources to help themselves.
Link patient with internal and external resources as needed to meet patient needs.
Maintain contact with referral source and other key individuals, per the guidelines of the agency.
Assist patient in managing outside stressors (legal, financial, vocational, etc.) according to the best interests of the patient’s progress in recovery.
Demonstrate good strategic and problem-solving skills and utilizing morning meeting and group supervision to staff a case, if needed.
Be effective in finding needed resources and working in tandem with Case Management.
Maintain clinical records according to program policies and those of licensing and accrediting agencies.
Ensure that documentation is timely, consistent, clear and articulate and never copy/pasted from another note or another chart.
Keep clinical records secure at all times.
Use good clinical judgment in moving patient through treatment levels and ensuring there is supportive documentation in the Medical Record.
Prepare patient to maintain recovery post-discharge.
Develop a continuing care plan that meets patient needs for ongoing support following discharge.
Conducts Family Therapy as ordered by Doctor or Director.
Demonstrates ability to work with Substance Abuse clients.