New Haven/Fairfield Counties Ryan White Part A Program Substance Abuse Service Standard SUBSTANCE ABUSE

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SUBSTANCE ABUSE

I. DEFINITION OF SERVICE

CORE MEDICAL SERVICE

Support for Substance Abuse Treatment Services-Outpatient, provided by or under the supervision of a physician or other qualified/licensed personnel; may include use of funds to expand HIV-specific capacity of programs if timely access to treatment and counseling is not otherwise available.

Services limited to the following:

§ Pre-treatment/recovery readiness programs § Harm reduction

§ Outpatient drug-free treatment and counseling

§ Opiate Assisted Therapy (Does not include medications) § Relapse prevention

§ Services provided must include a treatment plan that calls only for the allowable activities and includes: 1. The quantity, frequency, and modality of treatment provided

2. The date treatment begins and ends

3. Regular monitoring and assessment of client progress

4. The signature of the individual providing the service and/or the supervisor as applicable

SUPPORTIVE SERVICE

Funding for Substance Abuse Treatment – Inpatient to address substance abuse problems (including alcohol and/or legal and illegal drugs) in a short-term residential health service setting

Requirements:

• Services to be provided by or under the supervision of a physician or other qualified personnel with appropriate and valid licensure and certification by the State in which the services are provided

• Services to be provided in accordance with a treatment plan

• Detoxification to be provided in a separate licensed residential setting (including a separately-licensed detoxification facility within the walls of a hospital)

• Limited acupuncture services permitted with a written referral from the client’s primary health care provider, provided by certified or licensed practitioners wherever State certification or licensure exists.

Documentation that:

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• Services provided meet the service category definition

• Services are provided in accordance with a written treatment plan

§ Assurance that services are provided only in a short-term residential setting

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II. DESCRIPTION OF SERVICE

Substance Abuse Treatment Services – Outpatient

SERVICES PERFORMANCE MEASURE/METHOD MONITORING STANDARD LIMITATIONS

Support for Substance Abuse Treatment Services-Outpatient, provided by or under the

supervision of a physician or other qualified/licensed personnel; may include use of funds to expand HIV-specific capacity of programs if timely access to treatment and counseling is not otherwise available

Documentation that services are provided by or under the supervision of a physician or by other qualified personnel with appropriate and valid licensure and certification as required by the State in which services are provided. Assurance that Ryan White funds are used to expand HIV-specific capacity of programs only if timely access would not otherwise be available to treatment and counseling

Maintain and provide to grantee on request documentation of:

• Provider licensure or certifications as required by the State in which service is provided; this includes licensures and certifications for acupuncture services

• Staffing structure showing

supervision by a physician or other qualified personnel

Services limited to the following: • Pre-treatment/recovery readiness

programs • Harm reduction

• Mental health counseling to reduce depression, anxiety and other disorders associated with substance abuse

• Outpatient drug-free treatment and counseling

• Opiate-assisted therapy • Neuro-psychiatric

pharmaceuticals • Relapse prevention

• Limited acupuncture services with a written referral from the client’s primary health care provider, provided by a certified or licensed practitioners wherever State certification or licensure exists

Documentation through program records and client files that:

• Services provided meet the service category definition

• All services provided with Part A funds are allowable under Ryan White

Assurance that services are provided only in an outpatient setting

Documentation that:

• The use of funds for acupuncture services is limited through some form of defined cap • Acupuncture is not the dominant treatment

modality

• Acupuncture services are provided only with a written referral from the client’s primary care provider

• The acupuncture provider has appropriate State license and certification

Documentation that services provided meet the service category definition and are allowable under Ryan White Part A funding

Provide assurance that all services are provided on an outpatient basis In cases where acupuncture therapy services are provided, document in the client file:

• A written referral from the primary health care provider

• The quantity of acupuncture services provided

• The cap on such services

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SERVICES PERFORMANCE MEASURE/METHOD MONITORING STANDARD LIMITATIONS Services provided must include a

treatment plan that calls only for allowable activities and includes: • The quantity, frequency, and

modality of treatment provided • The date treatment begins and

ends

• Regular monitoring and assessment of client progress • The signature of the individual

providing the service and or the supervisor as applicable

Assurance that services provided include a treatment plan that calls for only allowable activities and includes:

• The quantity, frequency, and modality of treatment provided

• The date treatment begins and ends

• Regular monitoring and assessment of client progress

• The signature of the individual providing the service and/or the supervisor as applicable

Maintain program records and client files that include treatment plans with all required elements and document: • That all services provided are

allowable under Ryan White • The quantity, frequency and

modality of treatment services • The date treatment begins and end • Regular monitoring and assessment

of client progress

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Substance Abuse Treatment – Inpatient

SERVICE PERFORMANCE

MEASURE/METHOD

MONITORING STANDARD LIMITATION

Funding for Substance Abuse Treatment-Residential to address substance abuse problems

(including alcohol and/or legal and illegal drugs) in a short-term residential health service setting

Documentation that:

• Services are provided by or under the supervision of a physician or by other qualified personnel with appropriate and valid licensure and certification as required by the State in which services are provided • Services provided meet the

service category definition Assurance that services are provided only in a short-term residential setting

Maintain, and provide to grantee on request, documentation of:

• Provider licensure or certifications as required by the State in which service is provided; this includes licensures and certifications for a provider of acupuncture services

• Staffing structure showing supervision by a physician or other qualified personnel

Provide assurance that all services are provided in a short-term residential setting

Requirements:

• Services to be provided by or under the supervision of a physician or other qualified personnel with appropriate and valid licensure and certification by the State in which the services are provided

• Services to be provided in accordance with a treatment plan

• Detoxification to be provided in a separate licensed

residential setting (including a separately-licensed

detoxification facility within the walls of a hospital)

Documentation that:

• Services are provided by or under the supervision of a physician or by other qualified personnel with appropriate and valid licensure and certification as required by the State in which services are provided • Services are provided in

accordance with a written treatment plan

Assurance that services are provided only in a short-term residential setting

Maintain program records that document: • That all services provided are allowable under

this service category

• The quantity, frequency, and modality of treatment services

Maintain client files that document: • The date treatment begins and ends • Individual treatment plan

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III. NATIONAL FISCAL MONITORING STANDARDS (HRSA issued April 2013):

SERVICE PERFORMANCE

MEASURE/METHOD

MONITORING STANDARDS LIMITATIONS

SECTION D: Imposition & Assessment of Client Charges

1. Ensure grantee and subgrantee policies and procedures require a publicly posted schedule of charges (e.g. sliding fee scale) to clients for services, which may include a documented decision to impose only a nominal charge

Review of subgrantee policies and procedures, to determine:

• Existence of a provider policy for a schedule of charges. A publicly posted schedule of charges based on current Federal Poverty Level (FPL) including cap on charges

• Client eligibility for imposition of charges based on the schedule

• Track client charges mad and payments received

• How accounting systems are used for tracking charges, payments, and adjustments

Establish, document and have available for review:

• Policy for a schedule of charges Current schedule of charges

• Client eligibility determination in client records

• Fees charged by the provider and the payments made to that provider by clients • Process for obtaining, and documenting client

charges and payments through an accounting system, manual or electronic

2. No charges imposed on clients with incomes below 100% of the Federal Poverty Level (FPL)

Review of provider policy for schedule of charges to ensure clients with incomes below 100% of the FPL are not charged for services

Document that:

• Policy for schedule of charges does not allow clients below 100% of FPL to be charged for services

• Personnel are aware of and consistently following the policy for schedule of charges. Policy for schedule of charges must be publicly posted.

3. Charges to clients with incomes greater than 100% of poverty are determined by the schedule of charges. Annual limitations on amounts of charge (i.e. cap on charges) for RW services are based on the percent of client’s annual income, as follows:

• 5% for clients with incomes between 100% and 200% of FPL • 7% for clients with incomes

between 200% and 300% of FPL • 10% for clients with incomes

greater than 300% of FPL

• Review of policy for schedule of charges and cap on charges • Review of accounting system for

tracking patient charges and payments • Review of charges and payments to

ensure that charges are discontinued once the client has reached his/her annual cap.

Establish and maintain a schedule of charges and policy that includes a cap on charges and the following:

• Responsibility for client eligibility

determination to establish individual fees and caps

• Tracking of Part A charges or medical expenses inclusive of enrollment fees, deductibles, co-payments, etc.

• A process for alerting the billing system that the client has reached the cap and should not be further charged for the remainder of the year

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IV. SUBSTANCE ABUSE SERVICE COMPONENTS Outpatient Substance Abuse

Program outcome:

§ Numerator: 75% of clients enrolled in SA TX/program who decrease or maintain sobriety under treatment after accessing SA TX Services. § Denominator: All clients enrolled in Outpatient Substance Abuse Therapy Program

Indicators:

§ Number of clients attending SA services who are engaged in treatment.* § Number of clients who have addressed at least 2 treatment goals.

§ Urine or comparable drug screening test results showing decrease in drug use or maintenance of sobriety; if not feasible, RWCA client self-report decrease in drug

use or maintenance of sobriety.

*Engaged= individual invested in treatment and attends a minimum of 50% of appointments Service Unit(s):

§ Treatment Visit (A visit that is not a counseling session or a dosing visit. Ex: visit for random drug screen) § Individual Level Treatment Session (An individual visit where the Treatment Plan is discussed)

§ Group Level Treatment session (A group counseling session)

§ Medication Assisted Treatment Visit (A visit where medication for substance abuse treatment is dispensed) Inpatient Substance Abuse

Program Outcome:

§ Numerator: 75% of clients enrolled in inpatient Substance Abuse treatment/program who complete their recommended length of treatment stay

§ Denominator: Total number of clients who enter inpatient Substance Abuse rehabilitation program Indicators:

• Number of clients who completed recommended length of stay

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Standard of Care Outcome Measure Numerator Denominator Data Source Goal/Benchmark I. Organizational

A. Staff licensure and accreditation: As per Connecticut State Statutes and DMHAS regulations,

professional staff will be licensed, certified, or supervised by a licensed Drug Treatment professional. A. Verification Drug Treatment staff is currently licensed, certified or license-eligible Verification that all

unlicensed/ certified staff is supervised by a licensed Drug Treatment professional. A. Number of Drug Treatment Staff licensed, certified or license-eligible Number of unlicensed/ certified staff is supervised by a licensed Drug Treatment professional A. Total number of Drug Treatment staff Number of unlicensed staff A. Administrative records of agency A. 100% of all agencies providing drug treatment services have licensed, certified or certified-eligible staff

100% of all agencies have unlicensed/ certified staff supervised by licensed professional B. Continuous Quality Improvement (CQI) including Ongoing professional staff training in HIV-specific topics

B. At least 10 hours of HIV-specific training per year for each professional staff member serving RW clients

CQI plan updated annually ensures ongoing improvement of services B. Number of professional staff with evidence of attending 10 hours of training during year Number of

agencies with CQI Plan updated annually B. Total number of professional staff serving RW clients Total number of Drug Treatment agencies B. Employee files contain training certificates or proof of attendance Agency CQI Plan B. 100% of professional staff serving RW clients will attend at least 10 hours of HIV-specific training annually

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II. Outpatient

Process Outcome Measure Numerator Denominator Data Source Goal/Benchmark

D. Intake/Assessment: charts will contain a completed intake and assessment (per DMHAS regulation schedule).

D. New client charts will have an individual intake and assessment completed and documented no later than 14 days after clients’ first face-to-face visit with a substance abuse

professional. Assessments contain a supervisor’s signature.

D. Number of new client charts with assessment completed within 14 days of first face-to-face visit D. Total number of new clients

D. Chart audit D. 100% of new client charts have an intake and assessments completed and documented no later than 14 days after clients’ first face-to-face visit with a substance abuse professional. Assessments contain a supervisor’s signature. E. Treatment Plan compliant with DMHAS regulations * Engaged client = individual invested in treatment and attends 50% of appointments

E. Treatment is delivered with an individualized treatment plan, addresses adherence, indicate suggested treatment frequency by type; estimated end date documented; is

co-constructed with client, and signed by client within 30 days of admission E. Number of clients with a treatment plan completed within 30 days of admission Number of clients with clients with constructed, co-signed treatment plans Number of clients with treatment plans addressing adherence every 6 months E. Total number of clients

E. Chart audit E. 100% of client charts have treatment plan

completed and documented no later than 30 days of admission.

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II. Outpatient

Process Outcome Measure Numerator Denominator Data Source Goal/Benchmark

E. Treatment Plan compliant with DMHAS regulations

For methadone or suboxone treatment, client charts will document contact with the client’s medical provider within 72 hours of initiation of methadone/ suboxone to inform the provider of the new prescription or client refusal to authorize this communication.

Treatment Plans are reassessed every 6 months and signed by the client; estimated end date must be documented or rational for continuation with note of frequency of intervention/plan. Number of client charts with methadone/ suboxone treatment document medical provider contacted within 72 hours of treatment initiation Number of clients with treatment plans reassessed every 6 months Number of clients on methadone/ suboxone Total number of clients For methadone or suboxone treatment, 100% of the client charts will document contact with the client’s medical provider within 72 hours of initiation of

methadone/suboxone to inform the provider of the new prescription or client refusal to authorize this communication.

Engaged* clients address at least 60% of treatment goals that are agreed upon with clinician. These are reviewed with clients every 6 months at a minimum. 100% of client charts document reassessment of the Treatment Plan every 6 months and signed by client. F. Access to & Maintenance in Medical Care: RW clients’ ongoing participation in primary HIV medical care

F. Each client is assessed and verified for

engagement in HIV medical care and assisted with establishing linkages to care if not currently receiving it. This is assessed initially, then reassessed and documented every 3 months.

F. Number of clients

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II. Outpatient

Process Outcome Measure Numerator Denominator Data Source Goal/Benchmark

G. Risk Reduction Counseling: to prevent secondary transmission of HIV

G. All clients will receive risk reduction counseling a minimum of twice yearly

G. 100% of clients receive risk reduction counseling at a minimum of twice a year G. Total number of clients

G. Chart audit G. 100% of clients receive risk reduction counseling at a minimum of twice a year H. Referral to Support Services H. Substance Abuse providers routinely coordinate all necessary services along the Continuum of Care. H. Number of clients with referrals to support services H Total number clients with documented need for referral

H. Chart audit H. 100% of closed cases state the reason for closure and a closure summary with a supervisor’s signature indicating approval. I. Discharge of Client for Services I. Upon termination of active substance abuse services, a client case is closed and contains a closure summary documenting the case disposition.

I. Number of client charts with closure summary

I. Total number of closed charts

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III. Outpatient

Outcome Outcome Measure Numerator Denominator Data Source Goal/Benchmark

J. Decreased use of drugs and alcohol frequency or mainten-ance of decreased drug use

J. Clients demonstrate decreased drug use frequency or maintenance of decreased drug use in a 6 month time frame through urine or blood drug screens or self-report

J. Number of clients show decreased drug use frequency or maintenance of decreased drug use in a 6 month time J. Number of clients J. Chart audit or other site data system J. 70% of clients show decreased drug use frequency or maintenance of decreased drug use in a 6 month time frame demonstrated through urine or blood drug screens or through self-report K. Efficacy of

Services: clients are satisfied with their treatment

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IV. Inpatient Outcome Measure Numerator Denominator Data Source Goal/Benchmark L. Inpatient Treatment (not detoxification treatment); Indicators documented for admission to this level of care will identify moderate to severe impairment in 3 or more areas of

functioning including medical, withdrawal level, readiness for change, relapse potential, and environment.

L. An 8-hour treatment day will address the coping, motivation, biopsychosocial needs of the client.

L. Number of Inpatient Drug Treatment Agencies that address coping, motivation, biopsychosocial needs of clients L. Total number of Inpatient Drug Treatment agencies L. Admission criteria; Treatment protocols L. 80% of an 8-hour treatment day will address the coping, motivation, bio-psycho/social needs of the individual in care.

M. Intake/Assessment M. New client charts will document an individual intake and biopsychosocial assessment completed within 3 days of admission. Assessments contain a supervisor’s signature.

M. Number of new client charts with assessment

completed within 3 days of admission

M. Total number of new clients

M. Chart audit M. 100% charts will have an individual intake and biopsychosocial

assessment documented with 3 days of admission N. Treatment Plan N. Charts will have a

treatment plan initiated within 72 hours of admission. N. # of charts with treatment plan initiated within 72 hours N. Total number of clients

N. Chart audit 100% of charts will have an initiated treatment plan within 72 hours of

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IV. Inpatient Outcome Measure Numerator Denominator Data Source Goal/Benchmark P. Treatment Team: client clinical progress occurs through team meetings

P. Charts will show summarization of patient clinical review by treatment team at least 2 in 30 days.

P. Number of charts documenting at least 2 team clinical reviews in 1 month P. Total number of

clients P. Chart audit 75% of charts will show summarization of patient clinical review by

treatment team at least 2 in 30 days. Q. Discharge Summary: closed cases at termination will reflect a summary of patient progress

Q. Charts will contain a Discharge Summary that includes: Name, Date of Admission, Date of Discharge,

Medications, Summary of participation,

Referral at discharge, Signature and Date of Clinician

Closed charts will have a completed summary within 72 hours of discharge.

Q. Number of closed charts that contain Discharge summary Number of charts with Summaries completed within 72 hours of discharge Q. Total number of closed charts

Q. Chart audit 100% of closed charts will contain a Discharge Summary

80% of closed charts will have a documented a summary within 72 hours of discharge.

V. DATA REPORTING

Part A service providers are responsible for documenting and keeping accurate records of Ryan White Program Data/Client information, units of service, and client health outcomes.

Reporting units of service are a component of each agency’s approved workplan. Please refer to the most current workplan, including any amendments, for guidance regarding units of service.

Summaries of service statistics by priority will be made available to the Planning Council by the Grantee for priority setting, resource allocation and evaluation purposes.

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Substance  Abuse  Tool   1   2   3   4   5   6   7   8   9   10   STRUCTURE  (“WHO”)  

STAFF  

1   Verification  Licensure  Substance  Abuse  staff  currently  licensed,  certified,  or  license-­‐eligible                                           2   Verification  Supervision  of  all  unlicensed/certified  staff  is  supervised  by  a  

licensed  Substance  Abuse  professional                                           3  

Documentation  of  Training  At  least  10  hours  of  

HIV-­‐specific  training  per  year,  10  hours  of   Substance  Abuse  Training  and  5  hours  of  co-­‐ occuring  disease  for  each  professional  staff  

member  serving  RW  clients                                          

INFRASTRUCTURE  

4  

Model/Tools/Program  Design  outlined  

Documentation  that  Program  Design,  Model   used  provides  supporting  tools  or  instruments   to  assess  progress,  outcomes  and  have  some   scientific  basis  for  use  

                                       

5  

CQI  Plan  updated  annually  ensures  ongoing  

improvement  of  services.  Plan  exists,  has  EMA-­‐ wide  components  and  is  updated  on  a  yearly   basis  

                                       

6  

A  Crisis  Intervention  Policy  in  place  to  assist  a  

client  in  life-­‐threatening  situations  including  not   limited  to  suicidal,  homicidal,  child  abuse  or   neglect  issues  

                                        PROCESS  (“How”)  

INITIAL  ASSESSMENT  

7   Documentation  of  Presenting  Issue  Chart  shows  that  some  system  for  Presenting  Issue  is   recorded  -­‐-­‐  AXIS,  DSM,  etc.  

                                       

8  

Suggested  Therapy/Treatment  Chart  states  

suggested  therapy  given  Presenting  Issue  -­‐-­‐   defined  by  Individual,  Group;  Level  of  Care  (OP   SA  Counseling,  Psych  referral,  IP  SA  Counseling,   Detox,  Hospitalization)  

                                       

9  

Methadone/  Buprenorphine  Clients  Only  

Document  contact  with  medical  provider  within   72  hours  to  inform  the  provider  of  new  Rx  or   client  refusal  to  authorize  contact  

                                       

10   HIV  Risk  Reduction  Counseling  HIV  Risk  reduction  counseling  a  minimum  of  twice  yearly                                          

11  

Suggested  Treatment  Frequency/Duration  

Estimated  #  of  sessions  by  type  (individual,   group);  estimated  end  date  (documented)  or   rationale  for  continuation  with  note  of   frequency  of  intervention/plan  

                                       

12   Treatment  Plan    Treatment  Plan  Addresses  adherance;  Signed  by  client  within  30  days  of  

intake                                           13  

Goals  Set  Documentation,  signature  and  date,  

where  appropriate,  that  treatment  goals  are  set   with  client  and  therapist/clinician.    Date   documented  for  review/reassessment  

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CARE  STATUS  

27  

Goals  Met  Documentation  that  goals  are  met,  

dated.  Further  treatment  plan  outlined.                                           28  

Active  Care  Status  documentation  that  client  is  

in  active  HIV  medical  care  or  that  efforts  are   being  made  to  attach  or  re-­‐attach  client  to  care  

                                       

29  

HIV  Regimen  documentation  of  core  

components  of  HIV  medical  regimen  including  if   on  ART,  annual  documentation  of  CD4  and/or   viral  load,  and  every  6  mos  visit  to  HIV  medical   doctor  (or  reason  that  client  is  not  compliant   and  efforts  to  attach)  

                                       

CARE  STATUS  

31  

Referral  of  Follow-­‐Up  (if  indicated)  

Coordination  necessary  services  in  Continuum                                           32  

Satisfaction  Survey  Standardized  Ryan  White  

Part  A  satisfaction  surveys  or  DMHAS  surveys  

offered  to  client  annually                                           FISCAL  MONITORING  REQUIREMENT  

34  

Sliding  Fee  Scale  Providers  maintain  current  

sliding  fee  scale  in  accordance  with  HRSA  

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