Program Requirement Four (4): Scope of Services – Person-Centered and

Program Requirement Four (4): Scope of Services – Person-Centered and Family-Centered Treatment Planning A. The CCBHC directly, or through a DCO, provides person-centered and family-centered treatment planning, including but not limited to, risk assessment and crisis planning (CCBHCs may work collaboratively with DCOs to complete these activities). Person- centered and family-centered treatment planning satisfies the requirements below and is aligned with the requirements of the applicable section of the Affordable Care Act, including person receiving services involvement and self-direction. Note: Refer to the program requirement related to coordination of care and treatment planning. B. The CCBHC develops an individualized treatment plan based on information obtained through the comprehensive evaluation and the person receiving services’ goals and preferences. The plan shall address the person’s prevention, medical, and behavioral health needs. The plan shall be developed in collaboration with and be endorsed by the person receiving services; their family (to the extent the person receiving services so wishes); and family/caregivers of youth and children or legal guardians. Treatment plan development shall be coordinated with staff or programs necessary to carry out the plan. The plan shall support care in the least restrictive setting possible. Shared decision-making is the preferred model for the establishment of treatment planning goals. All necessary releases of information shall be obtained and included in the health record as a part of the development of the initial treatment plan. C. The CCBHC uses the initial evaluation, comprehensive evaluation, and ongoing screening and assessment of the person receiving services to inform the treatment plan and services provided. D. Treatment planning includes needs, strengths, abilities, preferences, and goals, expressed in a manner capturing the words or ideas of the person receiving services and, when appropriate, those of the family/caregiver of the person receiving services. E. The treatment plan is comprehensive, addressing all services required, including recovery supports, with provision for monitoring of progress towards goals. The treatment plan is built upon a shared decision-making approach. F. Where appropriate, consultation is sought during treatment planning as needed (e.g., eating disorders, traumatic brain injury, intellectual and developmental disabilities, interpersonal violence and human trafficking). G. The person’s health record documents any advance directives related to treatment and crisis planning. If the person receiving services does not wish to share their preferences, that decision is documented. Note: Refer to Program Requirement Three (3) requiring the development of a crisis plan with each person receiving services.