James Fitzgerald Therapy PLLC

Monitoring progress on a treatment plan is an essential part of effective mental health counseling. This process involves regular assessments of a client’s goals, challenges, and improvements to ensure that therapy remains aligned with their evolving needs. Therapists use progress notes, session summaries, self-report measures, and clinical observations to track changes in mood, behavior, and coping strategies over time. Client involvement in tracking their own progress is crucial for fostering self-awareness, motivation, and a sense of ownership over their mental health journey. By actively reflecting on their growth and challenges, clients gain insight into what strategies are working and where adjustments may be needed. Collaborative progress tracking also strengthens the therapeutic alliance, empowering clients to take an active role in shaping their treatment plan and achieving meaningful, lasting change.

Associations, regulators, organizations, commercial insurance companies, and government agencies, including CARF and TJC (accrediting agencies) recommend that patients should take an active role in establishing treatment plan goals and objectives. Some clinicians take time between sessions to write their treatment plans without consulting the client. A potential problem with this procedure is that it may leave out the client’s SNAPs (Strengths, Needs, Abilities, Preferences, and Values).

Typically, the first few sessions are spent on diagnostic interviews or assessments. The next few sessions are dedicated to developing the treatment plan, in which we review the assessment material from the initial sessions and collaborate on formulating the treatment plan (problems, goals, objectives, interventions, measures, and discharge criteria). This process increases your level of involvement in the treatment process and clearly saves time (You may have been asked to review this document as homework).

The first sessions are person-centered, strengths-based, culturally sensitive, and therapeutic, providing clear client understanding of the direction for therapy and a better understanding of the therapist’s and client’s goals for treatment. The amount of time we spend writing the treatment plan is determined by your current stage of change, level of motivation, insight and openness, capacity and ability, intelligence level, and cognitive functioning. It is advisable clinicians spend less time and effort writing treatment plans in the session with clients with severe cognitive deficits, active psychotic concerns, more severe and acute problems, or those with low motivation to be in treatment. In such cases clients typically need more direction from the therapist.

Medical Necessity:

Medical necessity is a coverage and payment concern. Medical necessity is not a clinical or patient care description. Medical necessity criteria include health care services that a Healthcare Provider, exercising prudent clinical judgment, would provide to a patient for the purposes of evaluating, diagnosing or treating an illness, disease or its symptoms, and that are: in accordance with the generally accepted standards of medical practice; clinically appropriate, in terms of type, frequency, extent, site, and duration and considered effective for the patient’s illness, injury or disease; and not primarily for the convenience of the patient or Healthcare Provider, Physician or any other Healthcare Provider, and not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease.

Generally accepted standards of medical practice mean: standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community; Physician and Healthcare Provider Specialty Society recommendations; the views of Physicians and Healthcare Providers practicing in relevant clinical areas — and any other factors.

Medical Necessity Requirements:

You must demonstrate symptoms consistent with a primary DSM- 5 TR diagnosis of a psychiatric disorder and/or substance use problem. You must be motivated & engaged, agree to comply with a therapy Treatment Plan & have a system in place to ensure follow through with your plan. Maintaining the current level of functioning throughout psychotherapy treatment is acceptable for justifying medical necessity. You must have a clinically significantly impairment level of functioning in areas such as self-care, work, family living, and social relations. Outpatient care will help increase level of functioning. You would experience increased intensity or duration of symptoms (with a diagnosis of mental illness and/or substance use) without an intervention or were not receiving treatment.

Psychotherapy Continuity of Treatment Episode “The Golden Thread”

• Each element in the therapeutic process and treatment episode should flow as follows:
• Intake and orientation: presenting problems, client history, integrated therapeutic approaches.
• Assessment and evaluation: biopsychosocial, self-assessment, outcome measures.
• Diagnosis and diagnostic justification: symptoms, behaviors, differential diagnosis, why treatment is medically necessary.
• Integrative summary and conceptualization: correlate diagnosis and problems to therapeutic orientation.
• Treatment plan creation: diagnosis, presenting problem, symptoms, behaviors, goals, objectives, interventions, progress, discharge criteria, medical necessity.
• Progress notes, Process Notes, and Psychotherapy Notes: diagnosis, problem, symptoms, behaviors, interventions, subjective, objective, assessment, progress, medical necessity.
• Unrelated to Therapy: missed and cancelled appointments; communication and correspondence; treatment plan revisions; case consultation: diagnosis, problem, reason for consult, follow up.
• Discharge summary: review of treatment, progress, developments, reason for discharge, recommendations, prognosis

Interactions must be clearly documented so that the connection between all aspects of clinical and administrative work flows logically from one record to the other. If the golden thread is maintained, documentation will support each decision, intervention, and note, contributing to a complete record of your mental health care that is respectful of your confidentiality, will protect your therapist from legal problems, get reimbursed by your insurance company, pass an audit of your therapist’s documentation processes, and reflect the integrity of the work you do with your therapist.

Medical Necessity and the Golden Thread

Collaboratively, we will treat each session as a scientific experiment. The hypothesis is the diagnosis. The diagnosis is supported by the evidence of behaviors that demonstrate the symptoms. The diagnosis is supported by the process of goals, interventions, and objectives. The process shows us the progress we are making (or lack thereof). Your current and recent progress in treatment justifies and informs the direction of future treatment. Justified medical necessity is the conclusion of the experiment. We will need to make sure that we communicate and document that continued treatment is medically necessary to address symptoms, reduce symptoms, stabilize symptoms, manage chronic symptoms, improve functioning, maintain gains, prevent de-compensation, and prevent higher level of care.

Diagnosis:

A diagnosis is not just a label. I use the diagnosis to group and describe a cluster of symptoms and behaviors in a manner that makes it easy to document and create targeted objectives and interventions specific to that diagnosis. If your symptoms indicate depression and I have diagnosed anxiety, and I use interventions for anxiety, we are not addressing the depression, it won’t get better, and it might get worse. Multiple diagnoses allow for interventions that target all your presenting problems, symptoms and unwanted behavior.

The following process outlines how to form a diagnosis. Mental Health Diagnosis should be described by code and name with ICD 10 Codes (not the DSM 5 Codes). In my integrative summary and your treatment plan, the symptoms you are experiencing and the behaviors you are engaging in must support the diagnosis. You must meet enough of the criteria listed in the DSM 5 TR, experienced as symptoms and behaviors, to support the diagnosis. For some diagnoses, there must be specific criteria met within the DSM 5 list to justify the diagnosis. I will ask you, or you will be prompted in the self-assessment outcome measure, to rate the symptom and behavior severity, frequency, and duration. I will ask you, or you will be prompted in the self-assessment outcome measure, to rate the level of impact the symptoms and behaviors have on your daily functioning. I will ask you, or you will be prompted in the self-assessment outcome measure, to list the domains that are negatively affected by the symptoms and behaviors.