PSYCHOSOCIAL REHAB SERVICES
Also offered are Psychosocial rehabilitation (PSR) services (reimbursed by all Medicaid Plans) for clients to address independent living needs or skills, such as social skills, money management, budgeting, and other interpersonal activities that the individual lacks due to an emotional or behavioral problem/disability.
PSR can be done individually or in groups.
Our PSR progress notes are designed to guide you through the documentation process and include the information generally expected for a complete clinical record. Rather than providing step-by-step instructions for how to complete every field, we ask that you review the note carefully and use your professional clinical judgment when determining what information is appropriate to document for each individual client and session.
Documentation should accurately reflect the service you provided, the client's presentation and response, the interventions used, and the client's progress toward treatment goals. Because every client and every session is different, there is not one “correct” way to complete a progress note. Your documentation should be individualized and should support the clinical decisions you made during the session.
If you are unsure what a field is asking for, how something should be documented, or whether additional information is needed, please ask us. We are always available to provide clarification and guidance. The goal is not to follow a script—it is to create an accurate, clinically appropriate record of the service you provided.
Below is some information about PSR that we gathered, that might be useful if needed:
Must Check all 3 (when you do a treatment plan) in order for PSR to be medically necessary:
The easiest way to understand the difference is:
PSR = TEACHING & PRACTICING SKILLS
TCM = CONNECTING & COORDINATING SERVICES
PSR is about helping the client learn, practice, and improve skills they need to function more independently because of their behavioral health needs. Think: “I am teaching the client HOW to do something.” Examples include:
PSR is NOT simply doing something FOR the client. The clinician should be actively teaching, demonstrating, coaching, practicing, reinforcing, or evaluating the client's use of a skill. For example: PSR: “Practiced with the client how to communicate concerns appropriately to the teacher and role-played different responses.”
TCM is about helping the client access, coordinate, and maintain the services and resources they need. Think: “I am helping CONNECT the client to something or COORDINATE their care.” Examples include:
For example: TCM: “Contacted the school counselor to coordinate available academic support services and followed up regarding the client's referral.”
Ask yourself:
Am I TEACHING or PRACTICING a skill with the client? → PSR
Am I CONNECTING the client to a resource/service or COORDINATING their care? → TCM
And remember: the service should be driven by the client's documented behavioral-health needs and treatment goals—not simply by something that would be generally helpful to the client.
If you go to SUBMIT DOCS, therapists, and then Progress Notes, you will see that you can select PSR from the drop-down menu for service. Once that's done, the note will auto-populate the fields required for PSR in each note.
Check off the SKILL(S) that were taught today to the client.
Then there are 2 main narrative fields in the PSR note:
HOW were the skills taught?
Describe what YOU did to teach or strengthen the skill. Include the teaching method or intervention used. Examples: explained, demonstrated, modeled, role-played, practiced, coached, prompted, provided feedback, used worksheets/activities, rehearsed real-life situations, or reinforced previously learned skills.
What did the client do / How's their progress?
Describe the CLIENT'S participation, response, and ability to use the skill. What did they practice or demonstrate? How much assistance did they need? Note any progress, difficulty, or continued need for skill development. Examples: practiced the skill independently, required prompts, completed a role-play, identified appropriate responses, demonstrated improvement, struggled to apply the skill, or continues to require coaching.
TAKE A LOOK AT THESE 2 EXAMPLES ON HOW TO WRITE A PSR NOTE:
PSR specialist taught the client emotional regulation and appropriate communication skills by reviewing how to recognize early physical and emotional signs of frustration. The specialist demonstrated controlled breathing and pausing before responding and modeled appropriate ways to express feelings without yelling or arguing. Role-play scenarios involving common situations at home and school were used to practice these skills. The specialist provided verbal prompts, corrective feedback, repetition, and positive reinforcement throughout the exercises.
Client actively participated in the skill-building exercises and identified situations at home and school that commonly lead to frustration. Client practiced recognizing signs of becoming upset and demonstrated controlled breathing and pausing before responding. During role-play scenarios, client practiced expressing feelings and needs appropriately rather than yelling or arguing. Client initially required several verbal prompts but improved with repetition and feedback and completed the final scenario with minimal assistance.
Clients are limited to a max of 20 units (or 5 hours) per week of PSR. Not every single client should have 20 hours. Every treatment should be individualized, otherwise it raises red-flags. -- NEVER bill the same amount of units every time.
PSR requires a prior-authorization, so please plan ahead. Submit the Auth Form here after your Tx Plan is updated.
Without it, we don't know that we need to submit an auth for you.
Please make sure you have an updated TxPlan (within the past 3 months) on file for the client -- see tx plan section below for details on how to complete it, and who completes it.
Every client getting PSR services, needs to have an assessment done. The assessment must be performed by a LICENSED mental health counselor. The assessment must be done in house; we cannot accept other agencies. Even if you are self-referring the case, a licensed counselor must do the assessment. When the referral is accepted, a licensed mental health counselor will be assigned to do the intake. Do not start services until you receive the intake assessment from them.
Every client that gets PSR, needs an assessment and treatment plan done (this is NOT the same as a TCM assessment or service plan),
@ For clients who are also getting therapy with us, the assigned therapist will add PSR objectives to the current treatment plan. It is important that you keep active communication with them. You'll be asked to complete your PSR area on the treatment plan and sign it as well
@ If the client is NOT currently getting therapy with us, then let Andrea know about it, so that we can arrange for an assessment and master treatment plan to be done before you provide any services. If you have the experience, you can complete these and a licensed supervisor will sign off... track of your deadlines and do a TPR every 3 months. A Treatment Plan Review must be done every 3 months to re-authorize the service.
These are sample PSR goals/objectives:
(___) Pre-vocational, job training, matching, and/or support
(___) Budgeting and money management
(___) Maintenance of the living environment
(___) Training in appropriate use of community services
(___) Structured activities
(___) Social skills training
(___) Symptom management, medication management, treatment options
(___) Food planning and preparation
(___) Transportation
(___) Daily living skills
(___) Establishing social supports
(___) Reducing isolation and withdrawal tendencies
