Community Mental Health &
Substance Abuse Services
of St. Joseph County
Subject:
Individualized Treatment Planning
Consumer Planning
Application:
Policy &
Procedure
33.02
All Departments
Effective
1/1/14
Reviewed
Revised
Approved
PURPOSE
To establish and outline the policy and procedure of individualized treatment planning for persons receiving
substance abuse services at Community Mental Health & Substance Abuse Services of St. Joseph County or
CMHSAS-SJC.
POLICY
The Michigan Mental Health Code establishes the fundamental and legal right of all individuals served to have an
individualized treatment plan, or plan of service, developed through a person-centered planning process. (see policy
33.01 for an outline of person-centered planning) The creation of the individualized treatment plan or ITP must be a
product of the active involvement and informed agreement of the person served. Active participation of the person
served in establishing the planned goals and objectives of substance abuse treatment is expected and required. It
helps to facilitate motivation to participate in treatment, ensure the identification of the appropriate level of care, and
establish true and/or realistic needs and expectations of treatment. Individualized treatment planning requires an
understanding that each individual is unique and that each plan reflects the individual’s unique needs, wants, desires,
and strengths. The ITP forms the foundation and guiding focus of the services provided. It is the basis of their
consent for treatment and the vehicle through which treatment or services are authorized.
PROCEDURE
The Administrative Rules for Substance Abuse Programs in Michigan, promulgated under PA 368 of 1978, as
amended, state “a recipient shall participate in the development of his or her treatment plan” [Recipient Rights
Rules, Section 305(1)].
CMHSAS-SJC, as a member of the Southwest Michigan Behavioral Health or SWMBH alliance and Coordinating
Agency or CA, will maintain approved national accreditation as a substance abuse treatment provider. Accreditation
standards require evidence/documentation that persons served participated in the planning of their substance abuse
treatment and/or services.
Individualized treatment planning begins at the time the person served enters treatment, either directly or based on a
referral, and ends when the person served is discharged. Treatment planning is a dynamic process that evolves
beyond the first or second session when the required ITP documentation is completed. Throughout the treatment
process, as the needs of the person served change, the ITP is updated, revised or amended to meet the changing
needs. Regardless, the ITP is entirely redone on an annual basis.
The ITP is not limited to the person served and the clinician(s) providing services/treatment. The person served can
request any family member, friend or significant other to be involved in the treatment planning process. Once the
ITP is completed, the person served, clinician(s) and other individuals involved must sign the document indicating
an understanding and acceptance of the plan and the overall expectations of treatment.
Establishing Goals & Objectives
The initial step in developing an ITP involves the completion of a primary assessment and substance use disorder
assessment. This comprehensive bio-psycho-social assessment includes current and historical information about the
person served. From this assessment, the needs and strengths of the person served are identified; this forms the
foundation for the creation of the goals and objectives that will be the focus of treatment. The identified strengths
(i.e., good physical health, dependable transportation, stable employment, secure housing, willingness to actively
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participate in treatment, a recovery support network, etc.) can be used to help the person meet their treatment goals
and objectives. Identifying strengths of the person served can provide motivation to participate in treatment and may
take the focus off possible negative situations that surround the person served getting involved in treatment (i.e.,
legal problems, work problems, relationship problems, etc.).
Writing the Plan
The mutually agreed upon goals and objectives for substance abuse treatment are entered into the person’s electronic
medical health record. The goals and objectives are written in the person’s own words, as much as is possible. Each
goal/objective ought to be connected to a need that was indentified in the assessment. It is understood that new or
previously unidentified needs may arise during the treatment planning process. Goals are positive statements
describing something that the person desires to achieve. Objectives are the discrete individualized steps that the
person is going to make to attain their goals. The objectives are written in such a way that they can be observed or
measured with a targeted date for completion. This is important so that progress, of lack there of, can be tracked and
objectively measured.
Establishing Treatment Interventions
ITP interventions are tactics or strategies that will be used to assist the person served in being able to accomplish the
objectives in the plan. Interventions are generally evidence based clinical techniques that are discussed with the
person served and mutually agreed upon. Establishing treatment interventions includes a discussion of what action
the person served is willing to take to achieve an objective and what action the clinician will take to assist the person
served in achieving their objective/goal.
Framework for Treatment
The ITP provides the framework for the content, quality, and quantity of the treatment to be provided. Individual
and/or group sessions that the person served participates in must address or be related to the goals and objectives in
the ITP. All service notes will indicate the goal and objective from the ITP that were addressed during the treatment
episode. Service notes are also the place where any adjustments or changes to the ITP will be discussed and
documented. If a change to the ITP is mutually decided on, the ITP will then be updated, revised or amended to
reflect the change noted in the service note.
Individualized Treatment Plan Progress Reviews
Individualized treatment plan progress reviews, also called formal progress reviews, are completed every three
months from the effective date of the ITP or last completed formal progress review. The reviews are a
comprehensive summary of progress made, or not made, on all the ITP goals and objectives. Input for the review
will include all clinicians and treatment providers involved in the care of the person served and other individuals the
person being served has involved in their ITP. The need for or pertinency of all goals and objectives is reviewed at
this time; some goals and/or objectives may be discontinued. Formal treatment plan reviews are an important part of
the treatment process both clinically and administratively. Authorizations, length of stay, medical necessity/level of
care, and discharge are all tied to formal ITP progress reviews.
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