| name | treatment-planning |
| description | Use when developing treatment plans, writing SMART goals, determining appropriate level of care, implementing measurement-based care protocols, or adapting treatment based on patient progress. Provides SMART goals framework, ASAM/LOCUS criteria guidance, and treatment monitoring strategies. |
Treatment Planning
Description
This skill provides frameworks and tools for developing evidence-based, collaborative treatment plans. Includes SMART goals methodology, level of care guidance, and measurement-based care approaches.
Clinical Context: Effective treatment planning translates assessment findings into actionable, measurable interventions. These frameworks support collaborative goal-setting and progress monitoring while maintaining clinical flexibility.
Available Frameworks
| Framework | Purpose | Key Components |
|---|
| SMART Goals | Behavioral health goal setting | Specific, Measurable, Achievable, Relevant, Time-bound |
| Level of Care Guidance | Matching symptoms to treatment intensity | Criteria for outpatient, IOP, PHP, residential, inpatient |
| Measurement-Based Care | Using assessments to track progress | Baseline, regular monitoring, treatment adjustment |
Response Style
- Start with the Quick Reference table below.
- Ask if the user wants the detailed guidance and examples.
Quick Reference
| Step | Action | Tools |
|---|
| 1 | Review assessment results and severity | PHQ-9, GAD-7, PCL-5, AUDIT-C/DAST-10 |
| 2 | Select level of care | OP, IOP, PHP, residential, inpatient |
| 3 | Write SMART goals and monitoring plan | SMART + outcome tracking |
Interactive Mode (Lightweight)
Use this mode when the clinician asks to build a plan step-by-step.
- Confirm readiness, target problems, and recent assessment results.
- Ask one domain at a time (goals, objectives, interventions, timeframe).
- Propose SMART goals and check for clinician approval.
- Identify level of care considerations and monitoring plan.
- Summarize the plan and offer documentation-ready bullets.
Usage
This skill can be invoked when you need to:
- Develop treatment goals with patients
- Determine appropriate level of care
- Create measurement-based care plans
- Write treatment plan documentation
- Monitor and adjust treatment based on outcomes
Example requests:
- "Help me write SMART goals for this patient"
- "What level of care does this patient need?"
- "How do I implement measurement-based care?"
- "Guide me through treatment planning"
Framework Details
SMART Goals Framework
Purpose: Structure goals to be clear, achievable, and measurable for behavioral health treatment.
SMART Criteria:
- S - Specific: Clear, concrete behaviors or outcomes
- M - Measurable: Quantifiable progress indicators
- A - Achievable: Realistic given patient's current functioning and resources
- R - Relevant: Aligned with patient's values and treatment needs
- T - Time-bound: Specific timeframe for achievement
Examples:
Well-Formed vs. Poorly-Formed Goals:
- Poor: "Feel less depressed."
Good: "Reduce PHQ-9 from 16 to <10 within 8 weeks through weekly CBT and activity scheduling."
- Poor: "Stop having panic attacks."
Good: "Complete 3 interoceptive exposure exercises per week and reduce GAD-7 by 4 points in 6 weeks."
- Poor: "Sleep better."
Good: "Average 7 hours of sleep on 5 nights/week within 6 weeks, tracked with sleep diary."
Common Goal Areas:
- Symptom reduction
- Functional improvement
- Coping skills development
- Relationship enhancement
- Recovery maintenance
Goal-Writing Guide (Detailed):
- Start with baseline data (PHQ-9, GAD-7, PCL-5, AUDIT-C/DAST-10).
- Name the target behavior/outcome in observable terms.
- Set a time frame that matches acuity and resources.
- Define measurement (score change, frequency, duration, or functional milestone).
- Use patient language and confirm buy-in.
Examples by Domain:
- Depression: "Increase daily activity to 5 days/week; PHQ-9 decrease by ~5 points in 4-6 weeks."
- Anxiety: "Practice 10 minutes of relaxation daily; GAD-7 decrease by ~4 points in 4-6 weeks."
- Trauma: "Complete grounding skills plan; PCL-5 decrease by 10-20 points over 8-12 weeks."
- Substance Use: "Reduce drinking days to 1/week; AUDIT-C moves from hazardous to low range in 8 weeks."
Level of Care Guidance
Purpose: Match symptom severity and functional impairment to appropriate treatment intensity.
Level of Care Continuum:
-
Outpatient (OP):
- 1-2 sessions per week
- Stable, lower acuity symptoms
- Adequate social support
- No acute safety concerns
-
Intensive Outpatient (IOP):
- 9+ hours per week, multiple days
- Moderate symptoms affecting functioning
- Needs structure but can maintain community living
- Some safety concerns manageable with increased support
-
Partial Hospitalization (PHP):
- 20+ hours per week, weekdays
- Significant symptom severity
- Marked functional impairment
- Needs daily clinical monitoring
- Alternative to inpatient or step-down
-
Residential Treatment:
- 24-hour structured environment
- Severe, persistent symptoms
- Unable to maintain community living safely
- Needs constant supervision, not acute medical
-
Inpatient Psychiatric:
- 24-hour medical management
- Acute safety risk (suicide, homicide, grave disability)
- Severe symptoms requiring medical monitoring
- Brief stabilization focused
Decision Factors:
- Symptom severity and acuity
- Suicide/violence risk
- Functional impairment
- Social support availability
- Previous treatment response
- Co-occurring conditions
- Patient preference (when safe)
Decision Tree (Quick Guide):
- Imminent risk or inability to care for self -> Inpatient
- Severe symptoms with unsafe home environment -> Residential or PHP
- Moderate impairment needing structure -> IOP
- Mild to moderate symptoms with stable supports -> Outpatient
Additional Indicators for Higher Level of Care:
- Recent suicide attempt or escalating self-harm
- Severe functional impairment or inability to complete ADLs
- Psychosis or severe substance withdrawal risk
- Failure to improve with appropriate outpatient treatment
Measurement-Based Care
Purpose: Systematically use assessment data to guide treatment decisions and track outcomes.
Key Principles:
- Baseline Assessment: Establish starting point with validated measures
- Regular Monitoring: Consistent re-assessment (weekly, monthly)
- Collaborative Review: Share results with patient
- Treatment Adjustment: Modify interventions based on progress
- Outcome Tracking: Document change over time
Common Measures:
- PHQ-9 (depression)
- GAD-7 (anxiety)
- PCL-5 (PTSD)
- Functioning scales
- Quality of life measures
Implementation Steps:
- Select appropriate measures for presenting problems
- Administer at baseline
- Set review schedule (e.g., every 4 sessions)
- Graph progress with patient
- Discuss results and adjust treatment
- Document in clinical notes
Using Measurement to Guide Treatment:
- Reliable change indices
- Clinically significant change
- When to intensify treatment
- When to step down care
- When to change approaches
Implementation Guide (Detailed):
- Select measures aligned with primary problems (1-3 tools max).
- Baseline at intake and repeat every 2-4 weeks or every 4 sessions.
- Share results with the patient and document clinical interpretation.
- Adjust treatment if no meaningful improvement after 4-6 sessions.
- Escalate level of care if scores worsen, risk increases, or function declines.
Clinical Interpretation
Translating Assessment to Plan (Examples):
- Mild severity: Low-intensity interventions, psychoeducation, brief therapy.
- Moderate severity: Structured therapy (CBT/DBT), weekly visits, consider meds.
- Severe or complex: Combined treatment, close monitoring, consider higher level of care.
- Positive safety screens: Immediate safety plan and risk-focused interventions.
Treatment Plan Development Process:
- Review assessment findings
- Identify primary problems/diagnoses
- Discuss patient's goals and priorities
- Determine appropriate level of care
- Develop SMART goals collaboratively
- Select evidence-based interventions
- Establish progress monitoring plan
- Set review timeline
Matching Interventions to Goals:
- Evidence-based practices for specific diagnoses
- Patient preferences and values
- Cultural considerations
- Available resources
- Therapist competencies
Safety Protocols
Treatment planning must address safety:
- Document suicide/violence risk assessment
- Include crisis plan in treatment plan
- Identify early warning signs
- Specify emergency contacts and procedures
- Plan for means restriction if indicated
- Schedule more frequent contact if needed
When to revise treatment plan:
- Emergence of safety concerns
- Significant symptom worsening
- Major life changes or stressors
- Lack of progress over reasonable timeframe
- Patient request or preference change
Safety Protocols (Expanded):
- Use ASQ or C-SSRS for any positive PHQ-9 Item 9 or clinical concern.
- Document intent, plan, means, protective factors, and prior behaviors.
- Include a written safety plan for any elevated risk.
- Arrange same-day evaluation for moderate to high risk.
- For imminent risk, activate emergency services and do not leave patient alone.
Limitations & Considerations
These are support frameworks, not rigid requirements:
- Treatment plans are collaborative documents
- Patient autonomy and choice essential
- Cultural factors shape goal priorities
- Social determinants affect achievability
- Flexibility within structure
- Clinical judgment guides application
Cultural Considerations:
- Individualism vs. collectivism in goal-setting
- Family involvement expectations
- Traditional healing integration
- Language and communication style
- Structural barriers to care access
- Cultural concepts of distress and recovery
Common Challenges:
- Patient and clinician goals may differ
- Insurance limitations on level of care
- Limited availability of appropriate services
- Social determinants limiting goal achievement
- Balancing structure with flexibility
Additional Limitations and Considerations:
- Resource constraints may limit ideal level-of-care placement.
- Insurance authorization may require justification and measurable goals.
- Patient readiness and preference affect pacing and intervention selection.
- Cultural factors influence goal relevance and engagement.
References
SMART Goals:
- Doran GT. There's a S.M.A.R.T. way to write management's goals and objectives. Manage Rev. 1981;70(11):35-36.
- Bovend'Eerdt TJ, Botell RE, Wade DT. Writing SMART rehabilitation goals and achieving goal attainment scaling: a practical guide. Clin Rehabil. 2009;23(4):352-361.
Level of Care:
- American Society of Addiction Medicine (ASAM) Criteria
- LOCUS (Level of Care Utilization System) for psychiatric services
- Mee-Lee D, ed. The ASAM Criteria: Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions. 3rd ed. Carson City, NV: The Change Companies; 2013.
Measurement-Based Care:
- Scott K, Lewis CC. Using measurement-based care to enhance any treatment. Cogn Behav Pract. 2015;22(1):49-59.
- Fortney JC, Unützer J, Wrenn G, et al. A tipping point for measurement-based care. Psychiatr Serv. 2017;68(2):179-188.
Additional References:
Status: ✅ Implemented
Priority: MEDIUM - Phase 3
Last Updated: 2026-02-03
