Identified Client Needs vs. Program Availability

Behavioral Health Programs

Cost, service availability, compliance, transportation, and access, are just a few of the reasons some clients don’t receive the needed services which could empower them and help them through recovery. Georgia psychiatric facilities have a lot of work to do, this is true, however what I find most concerning is the false hope given to clients and families as clients are stabilize and discharge back into the community with Inadequate, limited, and/or “No” supports in place.

During my employment at one of Georgia’s Psychiatric hospitals, and after having worked closely with local CSB’s in that region, clients and families, I was motivated to want to bring awareness to administration, community providers, staff and management on the importance of aligning treatment goals up with that of the caregivers of AMH, Forensic and DD client population.

Although my employment was brief, during my employment, I discovered that there was very limited collaboration or continuity between providers and family/caregivers. I believe that those in charge of the day-to-day care of clients become helpless after years of caring for clients, who are plagues with diagnosis and treatment which they do not understand. I believe that if these care givers had the skills and training needed to understand and identify the techniques we professionals utilize, the cost of inpatient care and treatment would decrease. This understanding isn’t an off the cuff idea, it comes from actual case information and research provided to me by families, clients and staff. However, because staff does not document unavailable needs, when identifying treatment services, the data needed to implement this untapped resource is unavailable.

During many of my interviews with loved ones, many family members claimed that it was the first time that they had been informed of the type (name) of their loved ones diagnosis, or the specific symptoms and behaviors associated with the mental health diagnosis (despite the client having numerous admission dating back 10 or 15 years. Most appeared elated and grateful in knowing that there where things they could do to identify triggers, decrease and avoid relapses and/or episodes.

Overall, the documentation standards of social workers (especially at the location in which I was responsible) was so ineffective and useless, that I was informed to check other discipline notes to truly understand the psychosocial history of clients.

As staffs from various disciplines gather together in front of a client to come up with treatment goals, it was and probably still is, common for teams to ignore certain client needs, simply because the service is unavailable. By “Unavailable” I mean that previous attempts to link clients to such services were either not offered in a particular region, or was not covered under state benefits, therefore, teams would simply move to the next (canned) treatment goal, without documenting that the need even existed.

From a BEST PRACTICE standpoint, and what I tried to get staff and administration to understand, is that “If it is not documented, IT DOESN’T EXIST”. Every social worker no matter what academic institution or whether at the undergraduate or graduate level, is taught this. Therefore, I found it hard to believe that they kept silent in treatment team meetings without advocating or documenting themselves.
One may ask, Why should such un-accessible services and needs be documented? The saying is, “If it isn’t written, then it didn’t/doesn’t exist”.

Documenting clients need is addressing the client’s needs… yes; this sounds redundant, but let’s takes a closer look at the implications here.

If a client needs a service and the service is non existing or scarce, the solution is to try and implement such services. Since most community based services is funded, let’s assume we need to try and obtain funding for it.

To lobby and/or try to get legislative support, one would have to be able to Identify the problem really exist; Assess the impact of the problem from a community or global perspective; prioritize the problem among other problems, and if one can show that it is beneficial and cost effective then maybe (and I do so maybe) additional support can be obtained.

In order to get anyone to support and assist in resolving the problem, one must be able to show proof (Verify) that such a problem is not perceived but actual a fact.

How do we prove something is real, by making it tangible; by having the raw data to back it up. Case examples! This is where Social Workers, Treatment teams, Community Services Board, and Administrators can support each other:

Case Example: “Service-X”

During a chart audit of several random charts, an auditor notices that soon after admission, several “Random” charts pulled, documented in either, an assessment, ISP, or progress note “Service-X” was a needed outpatient service for several clients upon their discharge. Wanting to rule out coincidence, the auditor pulled several additional charts and discovered that over 60% of all charts pulled (by different staff members and disciplines) identified the same outpatient service need “Service-X”.

In following the path of several charts, the auditor also finds numerous progress notes made by several different social services staff, of various failed attempts to link clients to “Service-X”. Thus, clients were discharged without the service in place.

The auditor decides to Document this in his/her findings, and shares the report with several department directors. The Social Services Director seeing the potential implications, decides to recruit several staff members (task force) to look into the possible trend and she/he documents this in his/her weekly department report (which he/she will present at the next Management Meeting –now this concern is also documented in the management meeting minutes).

The assigned staff was asked to strategically pull all the client charts which identified “Service-X”” as a needed outpatient service and to document the number of clients who were and were not linked to “Service-X” upon discharge. The staff decided that to minimize the daunting task of looking at every single chart, they would strategically focus on several areas, Discharge packets, progress notes and transition notes within a specified time frame.

By the end of their assignment, the staff reported in their summary report, that over 80% of the charts pulled, identified “Service-X” as an outpatient service need, and that only clients from Region 8 were linked, while those in Region 5 were not.

The information was then shared with top CSB administrators in Region 5 who collaboratively joined together with the local inpatient unit and the task to obtain funding to implement ““Service-X” was initiated, Utilizing appropriate documented data, facts and testimony to support the need for additional funding at the state/legislative level.

If the inpatient staff had not been consistent in their documenting “ALL” identifiable service needs of the clients they were assigned (despite the availability of such services), No one else would have been able to take the necessary steps that they took, Ultimately leading to implementing a service need of not only the client but of that community. Consequently, resulting in staffs’ inability to transition Region 5 clients back into the community in an efficient and timely manner; the communities’ inability to advocate and/or implement a service need of their community, and finally the inability to fill a service gap in Region 5 by requesting and lobbying for additional services and/or funding. However, because so many took the initiative to report their findings, the issue was able to travel through the appropriate channels, thus empowering staff, clients, communities and organizations.


Not many people willingly go looking to create more work for themselves, especially if they already have an overloaded caseload. Consequently this is why some clinicians intentionally do not document identified service needs.

These types of individuals may even go as far as to ignore a client’s direct request for a specific outpatient services. Despite a client’s ability to be an active participant in the creation of his/her Individual Service Plan (ISP), there are some clinicians who by their clinical training and experience, are aware of specific service needs of clients (i.e: a client with a known hx of SA, admitted with a positive drug screen) but because it requires additional work, (utilizing creative thinking to find alternatives, collaborating and partnering with CSB’s to explore options, frequent documentation and/or having to transition a willing client into another service area where needed services are available) the clinician intentionally fails to document or make the team aware of this information.

Others may not be compelled to identify and/or document unavailable services needs, simply because they feel they will be held accountable for not linking the client – and may be seen to either the treatment team, their supervisor and/or the client as being inefficient – when in fact they are actually helping everyone by identifying such challenges.


By inpatient staff documenting available and unavailable outpatient service needs of their clients (which should be a Best Practice Approach), they not only help their client, but they in turn help themselves, the Community Service Boards (CSB’s) they refer to and other stake holders as this exemplifies the Client Centered Approach to treatment & services.

It is imperative that inpatient directors and managers, train, support and encourage staff to be more diligent in documenting the needs of the clients being served. This allows not only the clients voice and needs to be heard and identified, which empowers them and gives them a better chance at recovery, it demonstrates a higher standard of excellence for the clinician and their profession.

For staff development and human resource departments, working closely with department heads on how to support and encourage due diligence in documenting is key, identifying and implementing discipline specific standards’ in documentation and holding department heads accountable for the adherence of their staff, Collaborating and working closely with IT to explore how technology can be integrated into work flow procedure and/or electronic documentation to help stream line the process, decreasing the risk of staff reverting back to old documenting habits.

I recall raising the issue and trying to raise support to implement electronic documentation utilizing a program already in place, and under utilize by the social services department. However, my support retired prior to getting it started and I resigned soon after.

After several readmission and episodes later, caregivers, clients and (depending on how bad the episode was) the community treatment staff throws their hands up in defeat and label the client as non-rehab-able. I have even witnessed several well known community providers refuse to accept clients back into treatment despite stabilization success.

Common claim made by a well known CSB on several occasion:
“That client is no longer with our program – he/she was banned from the program because he/she posed a threat to our staff during an episode which took place 3-4 years ago”.

Having spearheaded a recidivism project and trended the data at one of Georgia’s oldest and largest psychiatric campus, I believe that that the problems many clients face do not stem from their inability to pay for treatment or from receiving inadequate services while admitted to an inpatient treatment facility! No, the biggest gap in services occur POST discharge from an inpatient facility.

2009 Program outcomes revealed that community outpatient programs/treatment failed at providing comprehensive services to clients after discharge resulting in over 70% of the readmissions. Findings also revealed that most programs that included an ACT team had fewer readmissions than those without such programs (this included both Adult mental health and forensics clients).

Another finding which seems to take a back seat to all other findings, but that I believe warrants a spotlight is the support and services provided to the families and care givers of clients (AMH, DD/MR) regarding awareness, access and training.

After 12 ½ months of trending readmission data which spanned across 10-15 years, providing group therapy to clients enrolled in a readmission track curriculum, collaborating with administrators at several local CSB’s and participating in weekly treatment team meetings for clients readmitted, program outcomes revealed that the biggest gap in the recovery model was the support provided to care givers and families. Only 2% of families and caregivers of clients in the program understood the dynamics of the specific diagnosis and treatment options available to them and their loved one.

My findings, however never came to the attention of those in a position to make a difference, or not that I was aware of. Instead, when the results of the program were presented, I was told that the information was irrelevant. Yet, a few months later in a Department Of Justice (DOJ) investigation report, several of the same concerns were identified, and action initiated. I was later promoted and transferred to another unit without mention of the program outcome report, which I guess was my boss’ way of saying I had done okay. With the DOJ investigations continuing and haunted by the findings of the program, I felt my hands were tied, and outside of traditional lobbying for changes and funding, I recall advocating to my staff of social workers and other administrative staff, a need to raise the bar in clinical documentation.

In conclusion, this “Best Practice Approach” of documenting available and unavailable service needs of the clients being served, would ensure that the program and service offering currently being used, are indeed, client centered, yielding better program outcomes because they are truly the needs of the clients. This little task of properly documenting clients need while not filtering it by program availability, would give a true picture and empower staff, families and clients by providing the services they need.

What seems like more work in the beginning has the possibility of yielding so many positive outcomes and benefits at the Micro, Macro and Mezzo levels, that if I had to leave readers with one important fact, it would be…

If you were a client in recovery and your success of recovery and stabilization was riding on your linkage to a particular service what would be your expectation of the team assigned to you?

If not for yourself, do it for the clients who depend and need your clinical and professional expertise. DOCUMENT, DOCUMENT, DOCUMENT….

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5 replies. Join the discussion

I have NOT had a psychiatric hospitalization since
1991. I guess Washington State handles 'community
release' differently than the State of Georgia, where
the original 'author' was from.

I always received the services I needed (and there
were many). Does 'CARE' really vary so much on a
'state-by-state' basis?

'THEY' scoffed at what 'they' called 'ObamaCare'
but isn't THIS just one more example of 'why' WE
NEED 'Universal Health Care' / single payer?

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Thanks for sharing. Your essay emphasizes that clients who are able can attend self-help meetings: Recovery, Inc., NAMI Connections, DBSA and any other community groups that deal with mental health. We have two in Louisville, KY connected with Catholic parishes: Health and Hope and Ups and Downs. Also Southeast Christian Church has one. And patients/consumers can always go on line to share their thoughts and concerns.

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Thanks for the comments... I wish there was more I could do... I see so many clients go without the services and care that they need, that it becomes unbearable to watch or partake in.

Those who care and try to make a difference stand out like a soar thumb and are seen as the exception as oppose to the rule. We are ostracized for simply doing our job, and after a while, we either become part of the problem or we burn out or move on... I always choose to move on...

(Not great for the resume, but I would rather do as much as I can for those I can... while I am there, and then move on, than to remain in a setting where such lackadaisical care and services are provided and end up losing hope or worse become like those around me).

I am a true believer that if helping people/others is not your thing, then you should not be in the field-Look for a new job!

I believe that if we made our attempts (work habits)personal, as if we were caring for our own loved one's, than the care and services we provide would not be as bad as it is…

One Day I Hope To be Able to hear God say... I did Ok.. and that I made a difference in the lives of at least one... Thanks again for your comments

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Once upon a time, I 'lived and worked' in New York
State. It was during the 'early 1960's'. I had 'just
completed my M.A. in "Speech Pathology". I was
working at "AHRC", teaching 'ADL' to TMR Adults
in a 'sheltered workshop'.

In today's 'culture'; you are expected to 'write-up'
"IHPs" (Individualized Habilitation Plans) for each
AND every 'client'.

It 'worked' in the 1960s --- don't see why it wouldn't
'work' NOW.

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What I would like to see is that we get a copy at the time of our meetings be it Dr. Social Worker, Regional Center etc. that would be like minutes at an important meeting. I see the need for so many services and then there are alot of service providers but remember that many are for profit. The squeaky wheel may get the services quicker, and I believe it is so they shut us up so they can continue to provide half a-- services and milk the system. I am running into this all the time. It is time for CHANGE. DOCUMENTS provide proof we have been asking continually for a need that is not met. I deal with Dual Diagnosis of Developmental Delay and Mental Health issues.

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