Documenting a Change in Treatment

A change in treatment is documented in the Care Plan section of an Initial Assessment note or a Follow-up note in CMTS. Note: You must first create a care plan before you document a change in treatment in the care plan.  To create a care plan, open an Initial Assessment or Follow-up note and scroll down to the section called Care Plan. There are different categories, e.g. depression, anxiety, housing, etc. Let’s say you want to create a depression care plan. Choose that as the category. CMTS will ask you to designate a tool for measuring success (e.g. PHQ), as well as a score that indicates success (e.g. 9). Now you need to tell it what type of treatment the patient is receiving. This is an Action Step. Click on the dropdown menu under Action Step and choose the type of treatment. If it's behavioral activation, click that. If it’s medication, click that and make sure you have entered anti-depressant medication(s) in the Medications section so that the registry knows what types of meds the patient is taking for treatment of depression. 

Now let's say your patient has been in treatment for several weeks but is not improving and the team decides on a change in treatment. Document that in a Follow-up note. This can be as part of a session with the patient or not. Either way, you open up a Follow-up note in CMTS and scroll down to the Care Plan section. Click ‘update’ and choose the next Action Step that corresponds with the change in treatment for that patient. It could be the addition of Problem-Solving Treatment, or a change in medication, or something else. Whatever it is, when you choose a new Action Step, CMTS tracks that as a change in treatment. Remember, it's up to you to make sure that the change in treatment actually occurs, but when you follow the above steps, the change will be successfully documented in CMTS. 

Additional information: How to quickly see who might need a change in treatment

As you treat the patient and document his or her PHQ-9 scores over time, CMTS will track to see if the score is decreasing. This can be viewed in the patient’s individual record or you can use the Caseload Statistics report to quickly see which of your patients are improving (or not) and how long they have been in treatment. The quickest option would be to go to the NYS Medicaid Reporting Metrics Report and see who currently meets the criteria for needing a change in treatment. 

The number ‘5’ in the red circle indicates the number of patients who have been in treatment for 10 weeks or more and have not improved significantly (the denominator). The number ‘3’ above it indicates the number of patients who haven’t improved significantly but have had at least one change in treatment (the numerator). You want to focus on the other 2 that haven't improved and haven't had a change in treatment. If you click on the ‘5’, CMTS will take you to the list of patients who have not improved after 10 weeks or more of treatment. This way you can quickly find the two that haven't had a change in treatment. It can be useful to use this list as a starting point for the weekly case review with the psychiatric consultant and to quickly see who might benefit from a change in treatment.