The Practice of Therapy

Gordon Brewer: Well, hello everyone and welcome to the podcast, and I'm really happy for you to get to know today, Dr.
Tiana Kelly. Welcome, Tiana.
Tiana Kelly: Yes. Thank you. Thanks for having me. I'm super excited to be here and, you know, have some good conversation.
Gordon Brewer: Yes, yes. And I, I, I think the topic people are gonna find very interesting today. It's not something I've covered in a while, but just around compliance things. But before we get to that, tell folks a little bit more about yourself and how you've landed where you've landed.
Tiana Kelly: Yeah. So I'm Dr. Tiana Kelly. I have a doctorate degree in prevention science. I'm also a practicing licensed professional counselor here in the state of Pennsylvania working with move Forward counseling. We have we meaning Allison Pigeon and I have kind of sidestepped a little bit and started doing some consulting work.
Because as part of my role at Move Forward Counseling, I. I have taken on the compliance program, really kind of developed it and maintain it at this point in time, and so we're trying to branch out even further and help some other private practices with developing, you know, their, their private practice as a whole, but also their compliance
Gordon Brewer: services.
Right, right. Well, I think as we were talking about and that I'm so glad you're here and 'cause I think you're gonna have a lot of knowledge to give us, but I think when I think of compliance and probably most people think of compliance is hipaa. But also, I'm sure there are other compliance issues.
I'm thinking like employment issues, all of those kinds of things as well. But so tell us what, what do you feel like are important things for us to remember? Because I think when we think about compliance, people kinda get a little squirrely, as I like to say, just to, oh no, I'm gonna get in trouble with all this stuff if I don't comply.
So, yeah.
Tiana Kelly: Yes. And you're so right. You know, you hear that word compliance or even, you know, when I'm working with therapists at our practice I can only imagine what it feels like to get an email from the compliance officer. You know, I try to do a lot to offload the fear and just. You know, for the most part, let everyone know like, you're doing a good job, you, you've got this.
But it's still, it's just that word, right? It's really fear loaded. But I think it is important to really consider how compliance is more than just hipaa. And I agree with you. You know, as I got started with this, I thought like I'd really be doing kind of like HIPAA 1 0 1, day in and day out in my compliance role.
But it is so much more than that, you know, of course it is hipaa, that that is by and large what's driving a lot of our. Standards and requirements within our practices. But, you know, it, it, compliance really kind of sneaks its way into every element of our private practice, whether we like, sit and think about it and acknowledge it or not.
I mean, even just down to like policies and procedures and how those are written and, you know, do you have different procedures for. For instance, for therapists to follow, for clients to follow. If there's a complaint, a grievance, like is all of that laid out? You know, that's a piece of compliance documentation that is a big piece of compliance.
Mm-hmm. And a big piece that you know, every single day, whether you're the practice owner or the therapist, you are dealing with that. And then, you know, to touch on like some of the, the HIPAA stuff, I would say of course, like. Having an understanding of PHI and what we can do with it, what we can't do with it, what we need to do with it.
You know, for instance, if clients request access to their records, like it, it's the day in day, day out operations from admin is handling stuff with compliance. Therapists, of course are handling things with compliance and then practice owners, you know, for sure are handling different areas of compliance.
Gordon Brewer: Right. Right. What would you say are some of the, when, when I think about, when we think about documentation, what are some of the essentials around compliance with just documentation, other than, you know, keeping the information private and following the hipaa, HIPAA guidelines and that kind of thing.
Tiana Kelly: Yeah.
You know, one of the biggest things, and it seems like one of the, like the easiest to control, but yet the hardest across the board for therapists is timeliness with our documentation. And we know how this goes, right? We get to the end of the workday and it's like, ah, we had a, a day of talkers and we just couldn't get to the notes, and I'm exhausted, and so I'm gonna put them off until tomorrow.
And then we start the day and we don't get yesterday's notes done and it just. Piles up and piles up and piles up and we don't realize, I mean, just exactly what that could mean for the practice, right? Especially if you're an insurance based practice, that could mean that practice does mean that practice is not getting paid if they're not able to submit for claims where notes aren't done.
So that's a big piece, you know, that's within the control of therapists and to a degree within the control of the practice owners, right. Setting some policies around how, what's your timeframe for when notes are to be completed? Typically, 24 to 48 hours is what we see. Another big piece though, is.
And again, kind of sounds simple, but when we are moving throughout the day to day, we're, we're moving too quickly often, just like, Hey, note is done. Let me admit the next client. Let me bring them, you know, back from the waiting room. Proofreading, you know, we, we move so quickly and so much of the time when I'm in there doing chart audits, I, I catch such silly errors and some of them it's.
It's like, oh, okay. You know, that would really just be a moot point. It's not a big deal. Some of it is like, oh, actually in this note you are misgendering the client, or it's not even the client's right name. And like that kind of stuff is pretty detrimental. If the client were to see that, what kind of upset with that cause?
So. Proofreading again, I think is a, a big mistake that comes up. That is something simple, easy within our control takes, you know, a couple, couple extra seconds after you're finished the note to just take a glance at it and make sure it is as accurate as it can possibly be. Mm-hmm. And you know, if I had to list like kind of a third one, I would say.
This is more for like maybe the practice owner standpoint of things, though you could do this as a therapist for yourself in your own notes or your own documentation. Like not, not doing chart audits, not going in there and seeing like what are the trends amongst your therapists and, you know, what are their weak points?
What are their strong points? Where do we maybe need to offer more training or consultation around to make sure that we're hitting all of the areas that our payers or that HIPAA are requiring of us.
Gordon Brewer: Sure, sure. Yeah. And I think one, one of the things too that and I don't want to get us too far on a rabbit trail, but I know with the, a advent of, you know, AI and being able to use AI to help with our notes what are your thoughts on that?
Tiana Kelly: Yeah, this, this is a question that's coming up. Oh my goodness, so often, and. I love it because I, I do wanna challenge myself, challenge us as a whole to, you know, advance with the times. I don't wanna be that person that's like, no, it has to always be this way. However, I feel like we just, we just don't know enough yet, or at least I don't know enough yet.
Like, where is that information stored? Who eventually, you know, within cyberspace, like who could have access to that? How secure is it? I want those. Answer or those questions answered before I start to feel comfortable mm-hmm. With using AI for documentation. But, you know, going back to that proofreading piece, if it is something that you're already doing, 'cause you know, lots of EHRs have built it in and we just kind of have to roll with it.
If, if that's the case, you really, really need to go back and make sure that what is written in there is. Factual. It is actually what happened. And that's what I fear is, you know, we're already moving so quickly that when we write our notes, we misspell the client's name or we use the the wrong client's name and we're not even picking that up.
So when AI allows us to move even faster, are we then taking that time to go back and check and make sure for accuracy? I mean, it is. Mm-hmm. It is our ethical requirement and our legal requirement to do so.
Gordon Brewer: Right. Right. And, you know, another, another area that I think we're probably seeing a little bit more of and, and I guess it depends on where you're located, but the whole thing around medical necessity, particularly if you're an insurance based practice.
Tiana Kelly: Yes. And that Yes. An insurance based practice. And, you know, I, I get that question a lot for self. Self pay, cash pay cash pay based practices too, of just like what should go in the notes for, for those practices. And, you know, I, I kind of follow the same guidelines as for insurance based practices, just because it's, I mean, that's what's going to be really sound, that's what's gonna give us the, like to stand on is if our documentation does include, for instance, that those medical necessity pieces.
But the really tricky part is. You know, our insurance manuals will spell out kind of what needs to be. In our documentation and in our notes, but they also spell it out in kind of a vague way, like saying, you know, you have to document medical necessity. And it's like, well, what does that mean? Mm-hmm.
So I will often, you know, kind of follow the, the, the guidebook or the standard of making sure that when you're assigning that diagnosis, you are documenting some symptoms to back that up. And when I'm working with our therapist, I'll often say like, if you're struggling with that, you know you're assigning A-P-T-S-D diagnosis.
Pull out the DSM, make sure that hey, yeah, there are some criteria here that are being met and, and document that, right? Mm-hmm. Just document the list of symptoms and, you know, kind of like going through all of our diagnostic criteria. How long have the symptoms been going on? Are they actually meeting, you know, the six month timeframe, the three month timeframe, whatever it might be.
And then how is this impairing the client? In what ways are they limited as a result of these symptoms? So I kind of look for those three big pieces. Of course, there's always ways to like add more information, but like bare bones, I think that's a great starting point to make sure that there's some medical necessity captured.
Gordon Brewer: Yeah. Yeah. That's yeah, and I think it's just a matter of, you know, tweaking your language a little bit with, with your notes as far as being it at least my understanding of it is, is that you want it to be symptom focused in your, in your subjective, you know, portion of a note.
Tiana Kelly: Exactly. Yes, exactly.
Yeah. And again, like we have the DSM at our disposal. I know it's a big hefty book. Or if it's, you know, you have a digital copy, you're scrolling, scrolling, scrolling and things like that, but it's there, right? We don't have to play a guessing game. We don't have to, you know, figure out, oh, what would this diagnosis be?
We have a general idea. We can go right to that reference material and see and make sure and double check. And I, I think that. You know, not only helps our documentation, but also obviously helps like our care of the client. If we aren't giving them an accurate diagnosis, we might be treating them completely inaccurately.
Gordon Brewer: Mm-hmm. Yeah. Yeah. What, how much how much pressure do you think we need to make on ourselves around being able to show progress with a client? And all of those kinds of things. Mm-hmm. Because I know, I'm sure a lot of us have had long-term clients that have been coming for years, and really more of their, the more of the focus is on, you know, just personal growth and having someone that they trust that they can talk to about their life and what's going on in general.
And yeah, the, the, I'm sure those are questions that come up for people as well.
Tiana Kelly: Sure. Yeah. It's like the million dollar question, right? How do we, how do we still continue to justify with medical necessity some of those clients that, that are here for more of just the personal growth and for like maintenance.
And, you know, I don't have the best answer for that because obviously like our, our insurance companies, again, if you're an insurance based practice, are going to want to see like. The impairments, right? The symptom. Mm-hmm. They're gonna wanna continue to see, unfortunately, I'm just gonna put it bluntly, like some struggle.
And. Not all clients are gonna be in that space, especially in outpatient, outpatient, private practice. Mm-hmm. I mean, that's, that's kind of the, the gist of who we see are, are people who are generally stable. Maybe sometimes they're going through some life stuff and we help them through, but they stay in services to just maintain.
And you know, with that, I, I definitely have a couple of those clients myself. And I think it is about just making sure that you're documenting, like when things do come up. It gives you a little bit of a leg to stand on. Right. So documenting, like what, what are the symptoms that came up as a result of whatever that stressor is?
Mm-hmm. I also think it's helpful too. Like you, you know, you're documenting the progress and you're documenting the maintenance, but nobody's perfect a hundred percent of the time. Right? So whatever those goals are, if there's a, a little point in time where maybe they're having trouble or there's some barriers there to that maintenance goal or to that personal growth goal.
Document those barriers because it's mm-hmm. At least showing you, you know, they're not able to. You know, continue to grow or grow at the pace that they want because of X, Y, and Z. So documenting the barriers can be a good way to continue to sort of justify the treatment. Mm-hmm. Which feels icky, right?
It feels icky as therapists. Because we, we wanna help people when they're going through the broad spectrum of different things, when they're at a great point in life and when they're not so great point in life.
Gordon Brewer: Right. Right. So as, as you think about, you know, just kind of the whole world of co compliance, what are some other things that come to mind for you?
And just thinking about things we need to be ca as I like to say, have on the radar.
Tiana Kelly: It's gonna be kind of like a catchall, but I think it's like trying to be aware of what you don't know. So going to that like constant evolution of just learning and seeking out trainings and for practice owners, like providing your therapists with training, you know, not just on the newest modalities and things like that, but also on like what are some of the trends in documentation what are.
Some of the things we need to be aware of in terms of keeping PHI. Private and secure. So this goes back to, you know, we're all supposed to be taking some kind of like HIPAA training on a, on a regular basis. So I think continuing with that so that we, we do continue to learn and understand and learn again and, you know, relearn, relearn, relearn all of these different facets.
'cause especially is, I mean, you could spend a lifetime truly trying to understand every piece of it. And so I think that there is, you know, if there are like HIPAA breaches. A lot of the times I like to think it comes from just like not knowing, not that that's an excuse, and we don't, we don't get to use that as an excuse.
But it, it happens. You just don't know. I didn't know that doing that was going to lead to a HIPAA breach, or I didn't think about, I wasn't aware of how that could lead to a HIPAA breach. So I think just continuously seeking out more information, even though it's not the most glamorous. Is helpful for all of us.
Gordon Brewer: Right, right. Well, I know, I know in the past when I've talked with people about HIPAA because it does, it is an anxiety producer for a lot of people, and we've always, we've al always heard the, the term HIPAA compliant, but I've also heard it said that maybe a better way to to frame that is saying things are HIPAA secure.
Rather than HIPAA compliant because unless it's changed. When they wrote the, the HIPAA law, what was it, 19 97, 95, something like that. Mm-hmm. They, they told you what needed to be done, but they didn't say how. And so, yeah. And so it we're kinda less, there, there's a lot of room for interpretation with that.
And I think probably the biggest thing is just for a lot of people to just, just use your common sense in thinking about, okay, how do I keep things private? Because, you know, confidentiality is the cornerstone of, of our profession as mental health providers. And so just thinking about it in that way I think is, is really important.
Yeah.
Tiana Kelly: Yeah, I, I wholeheartedly agree, and I like that switch from HIPAA compliant to HIPAA secure. I, I was once in a training that talked about how there's truly nothing that is HIPAA compliant, like, quote unquote, HIPAA compliant. And it's like, what do you, okay, what do you do with that? Right?
What do we do with that? Mm-hmm. Because there's so many different, you know, programs and things like that out there that are marketed HIPAA compliant and we, we kind of go with it 'cause we trust that and we trust that marketing tactic, but we don't maybe really even know what that. Company, what that brand means by HIPAA compliant.
Mm-hmm. So we do have to kind of do a little bit of our own investigating to make sure, you know, are they using encrypted channels and you know, do they have VAAs where they need to have VAAs and things like that. Mm-hmm. And I think, you know, bottom line, we were talking about documentation and moving too quickly and.
Even, you know, this area in figuring out like, what, what is truly HIPAA secure or HIPAA compliant? I think the theme here is just like slow down, right? Mm-hmm. We need to slow down and really pay attention to what we're doing, the decision, the decisions that we're making to make sure that we are ensuring that confidentiality and our client's privacy.
Right,
Gordon Brewer: right. Yeah. It's you know, it's, it, it's, it, it can be, I think we can overcomplicate the whole HIPAA stuff and also the compliance stuff and that, you know, you just. You just follow a and this might be something you wanna speak to Tiana, is follow a procedure or a process with what you do so that you don't let things fall through the crack.
You you wanna say some more about that? About setting up processes or systems and processes, as we like to say around all of that?
Tiana Kelly: Yeah. Yeah, that's a really good point. And you know, a lot of times those processes, those procedures, the way the way we do things come from. Recognizing we've been doing things wrong.
And a lot of times, especially if you're in, you know, a group practice, if you're running a group practice, you're needing to pay attention to, like, what are those things that like, ooh, I, I didn't know that we've been doing it this way and we actually should be doing it this way. And what's your default after that to make sure that everyone is.
In compliance, it's establishing some policy around it. And then, you know, as the practice owner, once you have that policy in place that says, you know, we're gonna do X, Y, and Z and this is how we're going to do it, you, you're, you know, in a sense, you're much more covered than if you don't have that policy, right?
Because you can at least say, Hey, my employees are all aware, this is the way that this specific process is supposed to go. They signed off on that, on that handbook, and. It's not that you're like, it's not that you get off free at that point, but it, it gives you, you know, a, a much stronger sense of security just to be able to say like, Hey, we do have a policy and, and a procedure for this.
This is the expectation. And you know, from there. Who knows where it goes. Right. That's just dependent on the situation. But yeah, developing some really strong policies is a key piece in compliance.
Gordon Brewer: Yeah. And I think being particular for practice owners, it's it's important to establish on the front end, when you hire someone, what the expectations are. I mean even, you know so what, you know, having something in place around, I don't like the word consequence, but it, that's kind of what I'm talking about. What are the consequences if if an employee doesn't stay on top of their documentation or isn't getting it done, that kind of thing.
You know, what is the, what is the procedure around that?
Tiana Kelly: Yes. Yeah. And we do definitely need some form of consequence, right? Something that says like, Hey, we're holding you to this expectation, to this standard, and if you don't, this could be the repercussion of that. And I think, you know, within that. Like within that scenario, you know, every, obviously every therapist is human.
They go through things and I think it's very important and can help to offload the fear around like that compliance word and compliance practice. It's very important to remember that, that you know, your therapists are human and your practice owner is human. And especially if it's a therapist that you haven't seen a particular behavior.
Like they haven't engaged in that behavior before, or it's not typical of them before jumping to those consequences. It's like, let's have a conversation. What's going on here? Mm-hmm. Or if it is a pattern, have that conversation first. Right. I noticed that, you know, every single note, it's five days late.
What's happening? Not, might look like, like, okay, you just had a couple sessions today, right here together. Let's sit and write the notes. And have them do it in front of you to see where are they struggling and can you offer some kind of like corrective action and mm-hmm. Some guidance before moving into that consequence piece.
And I think that that really helps therapists feel like seen and feel like, okay, you get it. Like this work is hard and there's some struggles and, and trying my best, I just needed a little bit of help. Right,
Gordon Brewer: right. Yeah. And I think one of the biggest struggles I see, particularly with newer. Newer folks, people that are just coming in, you know, maybe pre-licensed or newly licensed people in, in our professions is they want to overdo their session notes.
In other words, they're putting a blow by blow detail of everything that happened in the session. And that's not, you know, that's not necessary. And I, I tell my folks that, you know, writing a, writing a progress note really shouldn't take you any more than five or 10 minutes. Mm-hmm. And just being able to complete that note, particularly if you're using an EHR and I'm put in a, a, an un a bias plug here for Therapy Notes, who's a sponsor of this podcast, but using an EHR like therapy notes.
And there are others out there too that do similar, similar kinds of things. They've got the templates that you can use. Mm-hmm. And, and it, it's really designed to be, keep you from having to do too much work in completing a progress note. You know, lots of check boxes and around interventions and all that kind of thing.
Tiana Kelly: Yeah. Yes, and I think, you know, we are, it's, it's a rough time to be a therapist, but it's also a nice time, right? Because we do have those kinds of tools at our disposal to make those things just a little bit easier for us. And I totally agree with you. You know, especially with, with newer therapists, early career professionals, we do tend to see that over documentation.
We also tend to see it just depending on where they've worked and whenever I'm consulting with like our, our therapists that we're onboarding, that's my first question to them 'cause it helps me to get an understanding of, mm-hmm. Okay. This is your style and where is it coming from? Right. If your notes are right, three paragraphs.
Long, I wanna work with you to trim that down because you're just, you're working too hard at that point. Mm-hmm. Unless it's like a crisis session, of course. But you know, if I know that they've come from, for instance, community mental health, where, you know, in a, in a PHP for instance, where you, you do have to document like every single thing that happened throughout the day, then I know where it's coming from.
I know, you know, if they continue to struggle with the tips that I'm giving them, that this is gonna be a process because they've just worked maybe the last two years documenting. Every single thing. And again, I think that that's really seeing them for like their humanness, that this isn't going to just be something they can, you know, implement, you know, two or three tricks for, and they're gonna get it right.
Gordon Brewer: Right. Right. Yeah. And I think it's you know, it's important I guess as practice owners and all to have, you know, give some guidance on that and, and really and I think particularly like you said, asking questions about what is their previous experience, whether that's none or. Lots of experience working in community mental health, which is a whole different ball game.
You know, I remember when I was working in, in, in that realm, it was just, you know, we got obsessed with documentation because of the utilization reviews, contracts, and all that kinda stuff.
Tiana Kelly: Yes, yes. It really is. It's challenging to go from, you know, a, a more intense acute setting, P-H-P-I-O-P, community mental health, to like an outpatient private practice.
And I, I remember my own experiences. I started off in PHP and it was that like document every single thing that happened throughout the entire, you know, six hour day and then getting into outpatient private practice and just being like. Now what do I write? And it, it was a little bit of a training period for me.
My notes probably if I went back in the beginning, were much longer than they are at this point. So, you know, from the therapist perspective, like have some patience with yourself. You were just trained for, you know, certain amount of time to write them one way, and now you're adjusting and adapting to what the new setting you're in might require.
Gordon Brewer: Right. Right. Yeah. That's great. Well, Tiana, I've gotta be respectful of your time and I'm sure we could spend all day talking on this topic for sure. But tell folks how they can get in touch with you and find out more about the work you're doing with Allison and the consulting and stuff.
Tiana Kelly: So if you would like to get in touch, check out our services.
We are in the process of launching our website. It is www.privatepracticebydesign.com. And on there, you know, you'll, you'll find some information about us, our services and ways to get in touch with us.
Gordon Brewer: Awesome, awesome. And we'll have links here in the show notes, in the show summary for people to get to that easily.
So, well, Tiana, thanks, thanks for being on the, on the episode. This. Of this podcast and hope we get to have another conversation again here soon.