How Headway defines clinical quality
The Headway Clinical Team promotes clinical excellence on the Headway platform. Headway is focused on getting patients into the right care, at the right place, and at the right time. Our expectation is that clients receive evidence-based, safe treatment that meets recognized standards of care and matched to their individual needs.
We aim to partner with our providers in identifying and encouraging quality improvements for Headway’s care delivery, always with the overall goal of improving the quality of healthcare patients receive through Headway.
Resources for quality documentation
The Clinical Team has compiled a rubric that represents essential elements of each new patient intake note for therapists. Incorporating the elements from this rubric when completing intake chart notes and drafting documentation can help ensure that our providers demonstrate the appropriate quality of healthcare delivery.
This documentation standard helps ensure that each patient’s behavioral health conditions are adequately communicated throughout their journey in the healthcare system and helping our providers protect their own practice liability.
How Headway evaluates clinical quality
At Headway, we evaluate the quality of intake notes based on a detailed rubric, with a strong emphasis on risk, safety, and psychosocial assessment factors. When deficits or areas for improvement are identified, a member of the clinical team may reach out via email or request a meeting for further review. In some cases, we may also require a re-review of the documentation to ensure that all clinical standards are met.
Therapist intake rubric
The reason for seeking treatment, focus on current issues/concerns/problems/ symptoms which you will be helping with. This section may include psychiatric diagnoses received, life transitions, recent stressors, other relevant events.
Documentation of a client's use of substances (nicotine, alcohol, illicit substances) should be present. If the client denies past or present substance use, this should be documented. If the client endorses substance use, a basic overview of the use & timeline should be present.
The client's general medical history must be present (hospitalizations, chronic illnesses, etc). If the client reports they are in good health, the documentation must identify that there are no acute medical issues.
A client's medication history must be present in the documentation, including timelines of taking the medication. If there is no medication history, this should be documented.
The documentation should list the client's social supports (family, friends, community groups, etc). If the client has no social supports, this should be documented.
Elicitation of a client's history of trauma (abuse, neglect, violence, assault) should be present. If the client indicates no trauma, this should be documented. If the client indicates trauma, a basic overview of the trauma & timeline should be present.
A mental status exam of a client’s appearance, cognition, speech, mood, thought process, thought content, judgment/insight should be present.
An accurate risk assessment of homicidality or suicidality must be present on every piece of intake documentation.
Disclosure of the client's history of self-harm should be present. If the client indicates they have never self-harmed, documenting that they have not engaged in self-harm suffices for this question. If the client indicates they have self-harmed in the past, the nature of the self-harm and timeline should be present.
Disclosure of the client's history of harm to others should be present. If the client indicates they have never harmed others, documenting that they have not engaged in harm-to-others suffices for this question. If the client indicates they have self-harmed in the past, the nature of the self-harm and timeline should be present.
If a client indicates suicidality or homicidality, a safety plan must be present in the documentation.
Diagnostic criteria must be documented that is consistent with DSM-5 criteria and supports the diagnosis billed, including the symptoms, frequency of symptoms, duration of symptoms, and the client's functional impairment.
An intake note should include the intended modality (which should be an evidence-based practice) and general notes about the intended course of treatment.
The note should indicate when the next session between the provider and client is intended to occur. This can be general (next Thursday, next week) or specific (April 21st).
The note should be signed within 72 hours of the date of service.
Headway Academy educational offerings
The Clinical Team offers short, easy-to-digest courses to assist in quality care delivery. We put together a learning pathway that includes the following courses (click the links below to be redirected to each individual course):
| Course | Description |
|---|---|
| Golden Thread [5 minutes] |
This course dives into the Golden Thread concept, a crucial element that ensures continuous and consistent documentation across all client interactions. Through a short video lesson, participants will explore how to construct a client chart that stands up to insurance audits and enhances the quality of care. The course covers the creation and integration of intake assessments, treatment plans, progress notes, and discharge summaries. By the end of this course, therapists and prescribing level clinicians will not only be adept at weaving the Golden Thread through their documentation, but also at elevating their practice's standards and safeguarding against compliance risks. |
| Clinical Consultation and Intake for Mental Health Therapists [10 minutes] |
Unlock the fundamentals of conducting effective mental health intake sessions with our comprehensive course designed specifically for non-prescribing mental health professionals. This course will guide you through the critical steps of initial client consultations, helping you to establish a strong therapeutic alliance and gather essential information for accurate diagnosis and effective treatment planning. |
| Differential Diagnosis [10 minutes] |
This course enhances your diagnostic skills in differential diagnosis. You will learn the foundational principles of differential diagnosis, focusing on symptom history, frequency, and functional impairment. |
| Risk Assessment and Safety Planning [10 minutes] |
This brief course is designed for mental health professionals who aim to refresh their expertise in identifying, assessing, and managing risks associated with mental health conditions. With a focus on promoting patient safety and well-being, the course equips participants with the necessary tools for effective risk management in their practice. |
| Medical Necessity [10 minutes] |
Navigating the complexities of medical necessity can be challenging for healthcare providers, but it is crucial for ensuring insurance coverage and delivering appropriate patient care. This comprehensive 10-minute course provides a clear and concise overview of what constitutes medical necessity, based on accepted medical standards and criteria. |
| Write compliant intake notes, treatment plans, and progress notes [15 mins] | Understand insurers' expectations and industry standards so you can confidently document your sessions. |
Continuing education for clinical quality
Headway offers Continuing Education Units (CEUs) through our partners Violet and PESI. You can learn more about our offerings here: Using Violet and PESI for continuing education with Headway.