By Maria Fuentes, FPA-C, Family Peer Support Training Specialist, NYU McSilver/PeerTAC

If you are new to Medicaid Billable Peer Support Services, you may wonder about the requirements for documentation and how to master the art of documenting these services. Some of us love the idea of our thoughts being written down as they tell the life story of a person’s recovery. When done well, this is exactly what Peer Support Services documentation focuses on, telling a story. 

In the beginning, peer support providers might not understand how to pick out what is important to include in the story or what not to include. Every word the person said seems to be imperative to tell. But with good coaching and practice, it gets easier to see what fits and what doesn’t fit in the person’s recovery story through the lens of our Peer Support Services. 

If you are already familiar with clinical documentation, there are some important differences between the way a clinical record is written and the notes written by the peer support provider. Ann Rider, a national leader, psychiatric survivor, and mental health peer advocate, created a presentation in 2019 that is specific to Medicaid Billable Peer Support Services describing these differences. 

Medicaid Billable Documentation: Clinical Records vs. Peer Support Notes

Clinical Records	Peer Support Notes
•Use the language of diagnoses, symptoms, medications •Focus on symptom management and compliance •Include the problems •Use the provider’s goals for compliance •Are often about compliance	•Use the language of ordinary human experience •Focus on recovery and resiliency •Include the person’s strengths •Use the person’s goals for recovery •It’s all about the person!

Peer Support Service notes may be about the same person as the clinical record but they have a different focus (recovery) and use different language. Nonetheless, the purpose of peer support notes is not so different from that of clinical documentation. Both types of documentation have the same foundation of recording and preserving important information about the services a person is receiving, and the progress that person is making while you are working with them. Peer Support Service documentation requires us to learn and understand the basics of documentation of services from the peer lens, and (fun fact) to be comfortable with it. Once we are comfortable with documenting the services we are providing, then we are able to help the people we work with to get comfortable with it as well. As Peers (whether providing or receiving support), we meet each other wherever we are, and that makes a difference. 

For the purpose of documenting Medicaid Billable Peer Support Services let’s highlight that in most cases, every service in the notes should link directly to a goal from the treatment plan that was mutually created with the person receiving services and their treatment team. The treatment plan may have been created before or during the time a person starts to receive Peer Support Services. In any event, peer support providers should be working with the treatment team to coordinate peer services with the goals on the treatment plan. The peer support provider may also help the treatment team make adjustments to the treatment plan, if necessary, based on new or different recovery goals (or challenges with meeting those goals) discussed during peer support sessions.

In some cases there may be a single event where the person or family needs support from the peer support provider that would not link directly to a goal on the treatment plan. This event and the reason for the services would be documented in the Peer Support Services notes. 

A famous illustration of the documentation process is called the golden thread. It refers to the flow from assessment (by the clinician) to treatment plan (by the clinical treatment team) to progress notes (by the different providers, including peer providers) to discharge plan. The golden thread helps those who are writing different documents to tie the important elements together. It helps those who are reading different documents to understand how services are connected. 

For peer support providers, the image of a “goal-den” thread helps focus their notes on the person’s goals and how their services support those goals. This image may be a more digestible way of looking at documentation and how it fits the peer “PEERspective” in a more seamless way. 

The PowerPoint (A.Rider, 2019) points out the importance of these many parts of documentation for peers stating; “The record of a person’s time with your agency is the pivotal chapter in their life story. It’s the transitional chapter, the one that moves it from despair to hope.”

In writing about these important steps in a person’s recovery story, peer support providers are contributing to a living document of the person’s recovery journey and how it was supported by the services provided by the agency. As well, person-centered language is the best way for peer support providers to document the person’s goals, and their interactions with the people they are supporting. The ease of documenting their services when using these skills to “tell the person’s story” makes a difference in how peer support providers learn how to document overall. It is no different when providing individual services or while working alongside clinical service providers. 

We have to remember that when peer support providers offer services in Medicaid mental health settings, they have to follow OMH guidance for the work they do to be billable. If a reviewer (who determines whether the service that was provided is billable or not) can follow the “goal-den” thread so it connects every peer support service provided to a service goal, then it is easier to determine that the work done by the peer support provider satisfies the requirements for Medicaid billing.

Learning the documentation of Peer Support Services should be a collaborative process, which can be accomplished with a supervisor or with a more experienced peer support provider. Using the supervision session as a regular time to meet each other, supervisor and supervisee, where they are (in their learning process) can set the stage for building positive relationships and supporting the peer support provider to learn these skills from the beginning. 

Documentation can also be a collaborative process between peer support providers and people receiving support services. Collaborative Documentation refers to writing the progress note with the person during the peer support service session. When creating collaborative documentation, it helps the person to be more involved in telling their own recovery journey and taking ownership for the next steps. 

There is much more to learn about documentation! CTAC, a partner of PeerTAC, has a self-learning training series called “Documentation Done Right” which can help peer support providers (and all providers!) understand the basics of documentation and create the foundation about which we spoke. 

References:

CTAC (2021). Documentation Done Right Series, Community Technical Assistance Center (CTAC) https://www.ctacny.org/series/documentation-done-right-series/ 

Hyams, K. (2019), Peer-centered language,
https://practicetransformation.umn.edu/wp-content/uploads/2019/01/clinicaltips_personcenteredlanguage.pdf 

NYS OMH (2022). Mental Health Outpatient Treatment and Rehabilitative Services Guidance on Youth, Family, Adult, and Older Adult Peer Support Services 
https://omh.ny.gov/omhweb/clinic_restructuring/part599/mhotrs-peer-support-services-guidance.pdf

Rider, A. (2019). Peer Support Notes Clinical Records, Holding the Hope 
https://holdingthehope.com/wp-content/uploads/2019/03/Ann-Rider-PTP-Documenting-Peer-Support.pptx

Note:

Material contained within this article is informational only and is not official guidance. Providers should refer to state guidance documents for official guidance.