Discharge Summary and Summary Statement

Discharge Summary and Summary Statement

Discharge Summary and Summary Statement

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Part 1: Using the revised treatment plan completed in Topic 7, complete a discharge summary for your client using the “Discharge Summary” template. This discharge summary should address the following:

1. What behaviors would indicate that the client is sustaining at a healthy baseline?
2. How would you determine if Eliza met her treatment goals? Discharge Summary and Summary Statement
3. What factors would determine if the treatment needed to be reevaluated, extended, or possibly referred to another clinician or setting?
4. Based on your assessment of current symptomology, does your client, Eliza, need wraparound services, outpatient references, and/or step-down services? (Recommendations should be based on the information gathered for second mandatory evaluation).
5. How would you encourage involvement in community-based resources?

Part 2: Write a 700-1,050-word summary statement about your client, Eliza.

Include or address the following in your summary statement:

1. Demonstrate whether or not the client met the goals of the treatment plan.
2. What specifically contributed to the success of the treatment plan or lack thereof?
3. What language would you use to communicate the outcome to the client?
4. How would you document the final session?
5. Include at least three scholarly references in your paper.

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Treatment Plan Reassessment

Carl B. Fletcher

Grand Canyon University: PCN-610

April 3, 2019
Treatment Plan Reassessment

A reassessment of the initial treatment plan is warranted due to the follow-up and worsening of the presenting symptoms identified in the initial plan. This reassessment, therefore, is based on the need to assess the effectiveness of the initial treatment plan and revisions to it to ensure a better approach to the presenting problems of the client. The changes are due to ineffective initial treatment planning or execution and hence the need for changes in the plan for more effective approaches to the client. The change in Eliza’s behavior was the continued alcohol consumption which escalated to the point where she was found passed out due to alcohol consumption.

The changes in Eliza occurred due to gaps in treatment planning and implementation. The initial treatment plan was designed for anxiety reduction, maintaining abstinence from alcohol, and increasing coping skills. Specifically, the treatment for abstinence was based on the need to identify negative consequences of alcohol and hence maintain abstinence through weekly group therapies. From the changes that have been witnessed since the institution of this program, it seems that the approach did not work to highlight the negative consequences as planned. The changes occurred probably due to the lack of commitment to identifying the negative consequences and learning from them.

The initial treatment plan and its components aimed at alcohol abstinence may have been compromised by the level of treatment being inadequate for Eliza’s diagnosis. In the initial treatment, it was identified that Eliza’s alcohol drinking was not a major problem and hence the treatment approach used was to prevent the client from getting into trouble with the administration for bringing alcohol to the dormitory. However, a reassessment of this treatment plan shows that her level of dependence on alcohol may have not been clearly identified. The current state shows that the dependence is higher than earlier predicted and hence a more thorough and focused treatment option is required.

The treatment plan will be changed from the current identification of negative consequences to commitment to recovery program. According to Batra et al. (2016), relapses in alcohol abstinence mainly occur due to the lack of further treatment after initial detoxification. Therefore, when using pharmacotherapy as the basis for changing the treatment plan for Eliza, there is the need to initiate a full recovery process which will effectively condition her for life without drugs. This will effectively contribute towards her health. This adjustment will further be accompanied by a reassessment of the other treatment options including anxiety reduction and coping skills. On a secondary level and after the initiation of the recovery program. Eliza will be assessed for effectiveness of the complementing treatment options. The reason for this adjustment in the treatment plan is to adopt a more effective approach to treating Eliza. This is ethical in that it enhances the beneficence of care as one of the principles followed in practice. Additionally, the reassessment allows the counselor to identify their areas of competence and refer the client to the necessary resources for effective treatment. Discharge Summary and Summary Statement

Moreover, the changes to the treatment plan mean one major change will be implemented in the client’s schedule; the move from group therapy to a more committed recovery group based on pharmacotherapy and alcohol recovery treatment. The change identified has been linked to the need to boost the efforts of the treatment plan to implement more thorough and focused treatment of the client when it comes to alcohol abstinence. This will be through pharmacotherapy and recovery therapy commitment. This change means that the resources used with the client will also change. The care accorded to her will also be changed and revved up for better treatment. This will also require an assessment for referral requirements. According to (), the main resource that is checked in making a referral is the human resource and their capability to competently deliver the required service. Therefore, the counselor’s qualifications and experiences running a full recovery program should be assessed. Secondly, the equipment to carry out the treatment should be checked. These include the relevant facilities for the recovery program and the relevant programs for the same.

When making the referral, a delicate task is communicating to the client need for referral and how the referral process will work to their advantage. This process is critical because it has to show that the counselor cares for the client and also gain approval from the client. Furthermore, it should protect the client from falling through the cracks and falling out of treatment. Having cultivated a relationship of trust with the client, the counselor has to establish continuity of care and show collaboration with referral parties so as to not only maintain the client’s confidence but also ensure effectiveness in maintaining treatment (Levy and Williams, 2016). The best approach is maintaining the confidentiality of the client and explaining to them why referral is the best approach. This would be through showing them that referral would improve the treatment and offer a more effective approach. The counselor should thus approach the client and explain the need for referral while showing that they will remain in contact and the counselor will follow closely on her treatment.

From the reassessment of the initial treatment plan developed for Eliza, the referral suggested will be mainly to a drug recovery practitioner. This referral is mainly due to the incompetence of the counselor in delivering that focused treatment to the client. This referral will be completed upon further review of the treatment plan for anxiety reduction and coping skills. Furthermore, various instruments may be used for assessing the patient and one such instrument is the Rapid Alcohol Problems Screen (Raps). This instrument is useful in assessing alcohol use disorders meeting the criteria for DSM-5 (Cherpitel and Ye, 2015). Using the assessment tool, the level of alcohol dependence and use disorder can be estimated for proper referral and treatment.

The initial treatment plan for Eliza failed due to inadequate treatment approach hence the need for a more rigorous treatment for alcohol dependence. The client’s alcohol use has escalated despite having been placed in therapy to identify the adverse effects of alcohol. This warrants the implementation of a recovery therapy for the client. Referral to professional drug recovery expert will be required to ensure that the client’s needs are effectively met in the treatment. Maintaining contact with and close monitoring of the client’s progress throughout the referral will be crucial for treatment completion.

References

Batra, A., Müller, C. A., Mann, K., & Heinz, A. (2016). Alcohol Dependence and Harmful Use of Alcohol: Diagnosis and Treatment Options. Deutsches Ärzteblatt International, 113(17), 301.

Cherpitel, C. J., & Ye, Y. (2015). Performance of the RAPS4/RAPS4-QF for DSM-5 compared to DSM-IV alcohol use disorders in the general population: Data from the 2000–2010 National Alcohol Surveys. Drug and Alcohol Dependence, 151, 258-261.

Levy, S. J., & Williams, J. F. (2016). Substance use screening, brief intervention, and referral to treatment. Pediatrics, 138(1), e20161211.