Market Education

Integrated Clinical Summary in the TIER Workflow System

The Integrated Clinical Summary is an important form within TIER^®. The purpose of the Summary is to facilitate development of the master (comprehensive) treatment plan based on review and analysis of key assessment findings and client – family – staff input on prioritized problems or needs that will be carried forward to the treatment plan versus deferred to late in treatment or discharge/continuing care planning. An underlying principle of the Summary is derived from the JCAHO requirement that not all problems or needs identified in assessments must be carried forward to the treatment plan provided that there is justification in the Summary to support why problems/needs are deferred. The TIER^® Summary form includes a scale to categorize the status of problems. The scale documents whether problems are carried to the treatment plan, deferred to later in treatment, or deferred to discharge/continuing care

The Integrated Clinical Summary is not meant to be an extensive document nor a replication of information already documented in the treatment team assessments. Rather it is meant to be a formulation of the following elements as a “bridge” or “crosswalk” to the master treatment plan:

• A thorough description of the prioritized core problems/needs including those to be addressed during primary treatment versus deferred for discharge/continuing care planning

• Intensity versus severity of core problems/needs and their implications for treatment including special alerts and precautions

• Expectations of treatment and ability of patient/client to meaningfully participate and gain from involvement in treatment

• (For Chemical Dependency) Patient motivation toward recovery, relapse potential, and specific relapse prevention triggers

• Expectations of treatment and nature of family participation in treatment

• Assessment of obstacles toward discharge

• Assessment of patient/client strengths/resources that can be maximized during treatment

• Clinical strategies and/or rationale for development of the master treatment plan

• Full DSM-IV diagnosis with all five axes

• Beginning development of continuing care plan