[Transcript] Episode 517: Intake, Assessment, and Diagnosis with Dr. Maelisa McCaffrey of QA Prep

 

Evan Dumas

You’re listening to Group Practice Tech, a podcast by Person Centered Tech, where we help mental health group practice owners ethically and effectively leverage tech to improve their practices. I’m your co-host, Evan Dumas.

 

Liath Dalton 

And I’m Liath Dalton, and we are Person Centered Tech.

 

Liath Dalton 

This episode is brought to you by Therapy Notes. Therapy Notes is a robust online practice management and electronic health record system to support you in growing your thriving practice. Therapy Notes is a complete practice management system with all the functionality you need to manage client records, meet with clients remotely, create rich documentation, schedule appointments and bill insurance all right at your fingertips. To get two free months of Therapy Notes as a new Therapy Notes user go to therapynotes.com and use promo code PCT.

 

Evan Dumas 

Hello and welcome to Episode 517: Intake, Assessment and Diagnosis with Dr Maelisa McCaffrey of QA Prep.

 

Liath Dalton 

Today, we are once again joined by the marvelous Dr Maelisa McCaffrey of QA Prep and author of Stress-Free Documentation for Mental Health Therapists: The Complete Guide to Progress Notes, Treatment Planning, and Medical Necessity.

 

Liath Dalton 

And Melissa is also one of our favorite CE presenters. And your courses are always very popular with the PCT community, and we’re going to be having you doing a training that is really focused on a particular area of documentation that is different to just the general progress notes and everything that entails.

 

Liath Dalton 

So what we’re talking about is specifically how to manage documentation for intakes and assessments, which is, you know, it’s its own sort of component of the documentation picture, but needs to be managed differently. So let me start by asking what are the kind of top questions or misconceptions that you end up addressing about how to document intakes and assessments?

 

Dr. Maelisa McCaffrey 

Yeah, yeah. And I will say this is one of my favorite topics. Personally, I love intake, and diagnosis specifically. So while it’s not the most common thing that I get questions about. Typically, questions about progress notes is one of my favorite things to talk about. So I’m very excited to do this training and even talking about today, right?

 

Dr. Maelisa McCaffrey 

So the first, I would say, the first, you know, misconception, is that the same misconception I would give you about any documentation related thing is that there’s one way to do it, right? Or that there’s one right way to do it. And there isn’t.

 

Dr. Maelisa McCaffrey 

Just like with progress notes or treatment planning or even therapy itself, there is not one right way to do it. It really will depend on how you work and on what works for your schedule, what works for how you practice, etc. So there’s that, and that, I think, is an important foundation, because those are important things to consider, you know, what works well for you.

 

Dr. Maelisa McCaffrey 

But beyond that, the most common problem is the practical, logistical, time management aspect of intake. Because this is a time where there are a lot of things that you are required to review with people.

 

Liath Dalton 

Right.

 

Dr. Maelisa McCaffrey 

Ethically, there are, you know, we ethically, all of our ethics codes, NASW, APA, ACA, etc, everyone says that we have to review informed consent, that we need to, which is not necessarily limits to confidentiality. So that we need to review, you know, what therapy will be and what that will look like, that we need to get consent from someone to treat them, that we need to review limits to confidentiality, that we need to review payment procedures, like all these are things that we are explicitly told we need to do as soon as possible, right?

 

Dr. Maelisa McCaffrey 

So we all kind of know to do those things. And then there’s the legality of how those principles of reviewing those things have turned into these massive forms that we all have.

 

Liath Dalton 

Mhm.

 

Dr. Maelisa McCaffrey 

And that we’re all terrified of, you know, being sued or having to review all these things. And so now we have this giant chunk of paperwork that we’re trying to manage, along with actually just getting to know somebody and have them tell us in their deepest, darkest secrets. And so those things are often in conflict.

 

Liath Dalton 

Yes.

 

Dr. Maelisa McCaffrey 

And so the most common struggle, practically, is managing that. And so how do I manage getting to know someone in the limited time I might have, with having all these forms signed and then asking them all these questions I have to ask everybody, and then doing a mental status exam? And then, how do I document it all? And then do I have to have a diagnosis by the end of 45 minutes with this person?

 

Dr. Maelisa McCaffrey 

And the answers to all of those questions can vary depending on whether or not you work with insurance, and how that works. But the key here is that you know one of the most important parts of an intake is getting to know someone.

 

Liath Dalton 

Right.

 

Dr. Maelisa McCaffrey 

If not the most important part, right? And so, because sometimes that even means you do the intake and you refer someone out, because you learn that you wouldn’t actually be the best fit, but you still need to have a good conversation with someone in order to determine that.

 

Dr. Maelisa McCaffrey 

And even if, for some reason, someone didn’t want to continue in therapy, I think, as a profession, and then as a professional, we all want people to have a positive experience, even if it’s just that one intake session. Like, I want them to feel like, even if they know I’m not the best fit, or whatever doesn’t happen, that they still feel like seeing a therapist was a positive thing, right? And so that’s, I don’t think, something that we would always talk about as part of this conversation, and yet, something we all understand we want to be a part of the process.

 

Dr. Maelisa McCaffrey 

And so me sitting with my laptop in front of me and typing a bunch of things out and asking people details about every substance they might have ever used may not be conducive to that experience.

 

Liath Dalton 

Mhm, mhm.

 

Dr. Maelisa McCaffrey 

And so, you know, very practically, like one of the things that I tell people, and that that I did and continue to do in my practice, because it was so helpful, is to do as much of that paperwork offline as possible. And to have people do as much paperwork ahead of time, and, so that I can remove as much of that process as possible.

 

Dr. Maelisa McCaffrey 

And this is where, as with most things, actually talking to the client about this process makes it more successful. So if I tell someone, you know, “Okay, well, I have a bunch of paperwork I’ll need you to fill out,” and then I just send them a bunch of links to fill out some forms. It may or may not go well, but I tell someone, “You know, I have a bunch of paperwork I need you to fill out. It might feel like a lot. It is a lot. Just to give you a heads up, it’s six pages long, and there’s a couple different forms, but the better that you’re able to complete this paperwork, the less we’ll have to do paperwork when we first meet.”

 

Dr. Maelisa McCaffrey 

And 99% of people, they get that. Like, we all know what it’s like, and none of us want to pay a professional right to sit there and do paperwork with us. I mean, across the board, right? So if you can, it’s okay to very practically talk to people about those things and set the stage.

 

Dr. Maelisa McCaffrey 

And then, you know, think about at intake. It’s, it’s both that balance of your ethics and legal obligations and customer service. So what I mean by that is, I would do things like have an email that says, okay, you know, as we talked about, because I would have this conversation with them. But then I would say, you know, here are the forms to fill out. It’ll take about 25 minutes to fill out this form. It’ll take about two minutes to fill out this form, about five minutes to fill out this form. And that is something that enhances their experience, because they know, oh, okay, yeah, she did say that one would take a while, so I’ll wait to do that.

 

Dr. Maelisa McCaffrey 

Or they know, oh, this one’s only going to take a couple minutes. I can, like, click on this and fill this and fill this out really quickly, and it improves their ability to get this done. Well, you know, because I’m setting that up to I’m setting up the situation for success. And so doing all of that and having as much of that stuff done ahead of time really saves you, the clinician.

 

Dr. Maelisa McCaffrey 

And then, once you meet with someone, you also have a frame of reference to start from.

 

Liath Dalton 

Right.

 

Dr. Maelisa McCaffrey 

So you’re able to look at, you know, their description, their answer to the question, you know, what are you hoping to gain from therapy? Or what are you seeking from therapy? Now you have their literal words that you can use, and it helps build rapport more quickly, because you’re starting with some common language, which I think is really, really helpful.

 

Liath Dalton 

Absolutely one, one question, that, kind of circling back to the informed consent component of things and the ethical and legal obligations around that. I, first, wholeheartedly agree that if all of the actual paperwork itself can be done offline, meaning outside of session, like, usually that’s going to mean it’s done online, but outside of session, that there still is a component of talking about the contents of that.

 

Liath Dalton 

And I worry that there are some instances in which, if it is all done and taken care of outside of session, that some of the really important parts that should be discussed in relationship are not getting addressed at intake. So just curious on your thoughts about that piece, and how to kind of manage okay, yes, I’ve got everything I need signed, but these are some pieces that we still need to have a brief but meaningful conversation about in the actual intake session, and how you manage that.

 

Dr. Maelisa McCaffrey 

Yes, absolutely. And so that’s where you know, like I know Roy and I did a training on informed consent years ago, and really emphasized this method called layering. Where there are all these things that we want to talk about with clients, and there are, like I mentioned earlier, those few things that we we explicitly are told we need to prioritize as first things and discuss, and to do so as soon as possible, right? And so yes, those we need to have in our forms, and get our forms signed. But more importantly, we need to actually talk with people about them.

 

Dr. Maelisa McCaffrey 

So absolutely, we have to talk with people about the limits to confidentiality. We have to talk with them about, and really, these are the things I would prioritize, limits to confidentiality, talking with them about what therapy looks like with you, and getting their consent and what you expect of clients. And because, whether or not someone has been in therapy before, you might have very different expectations or ways of doing things than someone else does.

 

Dr. Maelisa McCaffrey 

And then fees. It’s really like payment and scheduling are, you know, payment specifically, we’re all told that we need to discuss with people, for obvious reasons. But payment and scheduling are often the things that will create ruptures.

 

Dr. Maelisa McCaffrey 

So I often think of it in that way, like, what are the things that are often either confusing or really important or might create a rupture? And so, you know, from a practical perspective, yes, could someone wanting to subpoena records and have me show up for court and all of that, could that be a potential issue? Sure. It’s not nearly as likely as someone who forgets what your cancellation policy is, or doesn’t know what it is, and needs to cancel a session because, like, their kid is sick today, right?

 

Dr. Maelisa McCaffrey 

So that is highly likely to be something you will manage with every one of your clients at some point. So.

 

Liath Dalton 

Right.

 

Dr. Maelisa McCaffrey 

So looking from a practical perspective at like, okay, what are the issues that come up, and making sure that I address those. And you don’t need to spend a ton of time, right? Like just mentioning, hey, I just want to reiterate my, you know, here’s my cancelation policy. If you have questions about it, let me know. You know, these don’t have to be long, drawn out conversations, but they are, you know, and you can literally preface it by saying there’s a few quick things I want to go through before we get started today and talk about those limits to confidentiality, etc.

 

Dr. Maelisa McCaffrey 

And then the rest of it, kind of like we talked about in this informed consent training with layering, are things that you can either go into more in depth as needed, in that first session. So for example, if someone does say, related to payment, that they want to use their insurance or that they want a superbill, then I would bring up the additional aspect of that is another potential confidentiality problem, right?

 

Dr. Maelisa McCaffrey 

Because now insurance might have access to your records, and just making sure people are aware that that’s a thing.

 

Liath Dalton 

Right.

 

Dr. Maelisa McCaffrey 

And then, that might not be something that comes up right away. Maybe someone’s paying privately. You don’t need to discuss that in the first session, but six months later, they say, hey, I just got this new insurance, you know we switched insurances, and now I have this available, and so they want to talk to you about it.

 

Dr. Maelisa McCaffrey 

So all of these issues that were required and should be talking about initially, also could come up over time. And so they’re all likely to be things that we might need to revisit, but initially we can just kind of do, like a quick conversation and assess when we need more detail. And when you do need more detail, or if, whether that’s that session or six months later, that’s when you can talk more about it.

 

Liath Dalton 

Exactly. And when you’re talking about layering, you also literally mean that with the documents themselves, right?

 

Dr. Maelisa McCaffrey 

Yes.

 

Liath Dalton 

And, which I find so important. That you don’t just have just one massively long intake document that has subheadings for each of these important things. These are distinct documents because these are distinct issues and considerations, and having them all kind of quenched together minimizes how important each one is, first of all. And one of my takeaways too, is it makes it a lot less feasible to do those quick references and go through things conversationally as well.

 

Dr. Maelisa McCaffrey 

Yeah, and it makes it easier if you, for example, see couples and kids and adults and have different fees for all of those, and if you have different policies you want to review for all of those different types of clients, if you have things separated out, it makes it easier to send them off to the correct people and also to update as needed.

 

Liath Dalton 

Excellent point. So the strategy for managing intake really is around the time management and centering the relational components, right? How, how about for assessments?

 

Dr. Maelisa McCaffrey 

Yes. And so to me, like intake and assessment is kind of the same thing, and that’s part of the confusion with this topic is that, so when I say, have people fill out the paperwork ahead of time, I mean, yes, like informed consent, or consent for services, or whatever types of document, you know, Notice of Privacy Practices, Good Faith Estimate, all all the things you need to do, and a biopsychosocial assessment form, so a big old form that has all types of deep questions about this person and covers all of their history and all the things, right? And have them fill that out ahead of time, and then you can review it, and then you can add more details as you’re actually doing your assessment, right?

 

Dr. Maelisa McCaffrey 

So as you’re doing your intake session and you’re doing your assessment, you’re looking at all of those things. And I don’t think that you, as the clinician, then need to have a whole other intake assessment form you’re doing. The client already filled out all that data. And one of my I have two black and white rules that I teach in QA Prep, and one of them is never write anything twice.

 

Dr. Maelisa McCaffrey 

So always thinking through this is a huge, this rule applies to intake more than anything else, intake and assessment. Especially if you are in a private practice setting, you don’t have to write the same thing five times. You can put see intake assessment, or see client form, or, you know, whatever, wherever that information is, you can always reference where that information is. See diagnosis summary, you know? Whatever that might be.

 

Liath Dalton 

Right.

 

Dr. Maelisa McCaffrey 

Whatever you call it. You don’t need to have it rewritten out five different times. And this happens so often, because people are using an EHR, and maybe the EHR gave you these templates, or has this treatment plan template that you’re trying to fill out. And people think, Well, my EHR has this and so I have to do – no, you don’t. You get to tell the EHR what to do, not the other way around.

 

Dr. Maelisa McCaffrey 

And you are the clinician. You can make this determination, and if it’s a required field, which is sometimes the case, you can just do, like I said, and just put, you know, see whatever other document, or even put not applicable, NA.

 

Liath Dalton 

Right.

 

Dr. Maelisa McCaffrey 

Right, like, just because it’s a required field, or you can just put none or whatever, but you don’t have to rewrite everything over and again. Instead, focus on getting to know the client, talking to them about what they want from therapy, talking to them about, you know, any follow up items you saw on that, on the forms that they filled out, like if they did say that they’ve, you know, experienced some type of massive crisis, or that they are, you know, actively, like suicidal or in some kind of unsafe environment, right, you’re going to talk about those things.

 

Liath Dalton 

Right.

 

Dr. Maelisa McCaffrey 

As your first priority. So talk about all of those things, but then that way you can let the conversation flow a little bit more, because you can kind of start off with whatever it is that they said they are there to do, and literally read off their answer from that question, and then you just do what you do as a therapist, which is have a conversation and gather that data.

 

Dr. Maelisa McCaffrey 

And I don’t think that getting a sense of why someone is there is the most difficult thing for most clinicians. I think what becomes difficult is managing the paperwork, part of it, which we’ve already talked about, and then thinking, I have to have a diagnosis at the end of the session. And sometimes that’s true. Sometimes you do want to have a diagnosis at the end of that session if you’re working with insurance. So I know that’s a real concern, and sometimes you don’t have enough information at the end of that session to make an accurate diagnosis, and that’s that’s okay.

 

Dr. Maelisa McCaffrey 

So yes, you do also want to manage asking some targeted questions about that, and here’s where I found success with calling those situations out when they do feel awkward. So it’s okay to say, for example, you know, I know this feels really premature, but we actually have to make these treatment goals together by the end of this session, because Medicare requires it, and we have to write them in this weird way called SMART goals. Have you ever heard of SMART goals? You know.

 

Dr. Maelisa McCaffrey 

But it’s okay to, like, blame the insurance company for the fact that you have to do a lot of stuff very quickly.

 

Liath Dalton 

Right.

 

Dr. Maelisa McCaffrey 

And and call out, you know, that people have to have a diagnosis. And you know, if you are worried about people being concerned about their diagnosis, ask them about it. You know, I’m thinking at this point I would include this as your diagnosis. You know, how does that make you feel? Do you have any questions about what that means? Do you want to look at that together? And letting people be a part of that. But also, you know, I really do think it’s okay to just blame the insurance company for the awkward situations.

 

Liath Dalton 

Absolutely. Do you, if you’re doing a session for an insurance based client, um, when do you bring that up? Do you kind of preface the session with like, here’s something that has to be an outcome of what the session entails, and I just want you to be fully aware of that so that lessens how awkward it feels or doesn’t feel like it’s coming as a surprise at the midway through or at the end of our time together?

 

Dr. Maelisa McCaffrey 

Yeah, I think it’s best to talk about the diagnosis part of things when you’re talking about payment. So as soon as they say they want the superbill or or if you know you are contracted with insurance and you already know that’s a thing going in, you’re still going to review that as part of their informed consent and make sure that they are aware that one, their insurance company can access their records at any time, and two, they you will be required to give a mental health diagnosis, and all of their treatment is literally contingent on them having a mental health diagnosis. So I think that’s the best time to bring it up, because it’s more about, like, the payment part of it, and this is a requirement.

 

Dr. Maelisa McCaffrey 

And then you can have that, then you can just ask them, you know, do you have any questions about that? Were you aware? And some people don’t care, and some people do, right? And so it may just be a like, then you move on, and it really isn’t a big deal to them, and maybe they’ll ask you about it at random sometime later because they’re applying for life insurance. And maybe you’ll have a more in depth conversation about it then, right? Or maybe it’ll never come up, or maybe that will literally be a big deal. And they’ll say, oh no, I’m I’m a police officer, like, I don’t want that at all. And you’ll say, okay, well, then we probably want to change to not using your insurance, and I don’t have to give you a diagnosis, would you prefer that? And you know, so talking with them about it in that way.

 

Liath Dalton 

And how to manage when it is an issue is something that you will be addressing in your training that is specifically focused on intake and assessment, right?

 

Dr. Maelisa McCaffrey 

Yes, yeah. And we’ll talk about, you know, some quick tips for, I do think it’s it’s helpful to have some things as frames of reference, and have a couple of tools in your toolbox for being able to diagnose quickly and maybe messily if needed, and how to make those adjustments later. It makes you feel like either you’re not good at that or the situation just doesn’t warrant giving a good diagnosis in a quick way. You know, we’ll definitely talk about, what do you do if you need to extend your intake process for multiple sessions, which is very normal, you know, right?

 

Liath Dalton 

Well, we are looking forward to your offering that and hoping to equip clinicians in the community to be able to manage this aspect of things as effectively and with as little stress as possible.

 

Liath Dalton 

So we’ll look forward to that training presentation, the live version of which will be offered on June 9. So check out the show notes, everybody, for links to the upcoming trainings that Melissa is doing through PCT, and you can see all the details and register.

 

Liath Dalton 

Thank you, as always, Melissa, for your time and for your insight and just the way that you approach these aspects of practice with so much care and practicality.

 

Dr. Maelisa McCaffrey 

Awesome. Thank you.

 

Liath Dalton 

This has been Group Practice Tech. You can find us at personcenteredtech.com. For more podcast episodes, you can go to personcenteredtech.com/podcast, or click podcast on the menu bar.