GOAL
THE
PRIMARY GOAL OF THE NEBRASKA URBAN INDIAN HEALTH COALITION, INC BEHAVIORAL
HEALTH PROGRAM IS TO PROVIDE CULTURALLY AND LINGUISTICALLY COMPETENT
BEHAVIORAL
HEALTH TREATMENT SERVICES TO NATIVE AMERICANS/ALASKA NATIVES AND OTHERS WHO
PRESENT THEMSELVES FOR SERVICES AT COALITION FACILITIES.
Objective 1 :
Outpatient Behavioral Health
Provide outpatient behavioral health (substance abuse and mental health to a
target population of
American Indians/Alaska Natives. (This is not to exclude non-Native
Americans/Alaska Natives).
Activity 1: Accept requests for evaluations
in order to determine eligibility for services and the
appropriateness for
this level of care.(Eligibility for Regions V and VI reimbursement is
determined by
information obtained for Magellan Registration and client’s area of
residence. Appropriateness
for this level of care is determined by client’s ability to meet the
criteria for Level I
outpatient substance abuse services.)
Level
1 outpatient services are for individuals assessed as meeting the diagnostic
criteria for
a substance-related disorder as defined by the current Diagnostic and
Statistical Manual of
Mental Disorders or other standardized and widely accepted criteria, as well
as the
dimensional criteria for admission. See Appendix A.
Person Responsible: Counselor
Documents: Initial Screening Form
Magellan Registration
Completion Date:
Initial Contact (phone or in-person)
Mode
of Program Coordinator Review
Evaluation: Region VI Program Review
Quality Assurance Committee
Activity 2: Accepting
referrals
The following persons will be given priority status for
admission to this facility:
American Indians/Alaska Natives
Other Racial/Ethnic Minorities
Pregnant women/children
Persons receiving Supplemental Security
Income and Social Security Disability Income
Mental Health Board Commitments
Other persons given priority include:
HIV+ individuals
IV Drug Users
Person(s) Staff Counselors
Responsible: LADC Supervisor
Documents: A comprehensive substance abuse evaluation
completed within the previous 6 months and signed by a certified
counselor. The evaluation completed by another agency must be contain the
results of assessment tool use (i.e. a SASSI (Substance Abuse Subtle
Screening Inventory)), describes the 5 (five) axis including the global
assessment of functioning score that indicates the client is appropriate for
an outpatient level of care. If not available, this program will
complete a comprehensive substance abuse
evaluation.
Completion
Date: Evaluation must be received within 7 days of
initial client contact.
If evaluation is completed by the
admitting counselor it is to be completed by the third session.
Mode
of LADC Supervisor
Evaluation: Quality Assurance Committee
Activity 3: Admit
clients and open a client file.
All client files will be kept in the order specified by the
face sheet and kept in the Medical
Records room in a file separate from other patient records. The file cabinet
will be kept locked at
all times. The file room door will be locked at the end of each day. All
documents will be secured in
the file.
Each client file must contain, when applicable, the following
information: dates of admission
and discharge, name of client, gender and date of birth, demographic
information (including
address and telephone number), physical description of client or client
photo identification,
admission assessment information and determination of eligibility for
admission, health
screening information, individualized service plans, physician orders,
medications and any
special diet, significant medical conditions, allergies, person to contact
in an emergency
(including telephone number), fee agreement, documentation of care and
treatment provided,
client’s response to care and treatment, change in condition and changes in
care and
treatment, discharge and transfer information, client rights, and referral
information. For
outpatient services this information is obtained using the documents
listed below. The substance
abuse evaluation must identify client strengths and needs.
It is preferable that a photo be taken of each
client. However, if the client objects, the
counselor should provide a physical description.
Person
Responsible: Counselor
Completion
Dates: By the end of the day on which Second Session
occurs
Documents: Magellan Intake Form (if not completed at
screening; to be entered at website as soon as completed)
BSAP version of the Addiction Severity
Index Structured Clinical Interview
Emergency Contact Release
Release(s) of Information
(Confidentiality)
Receipt of Client Orientation (including
advising the client of the parameters of
confidentiality according
to 42CFR (Appendix B)
Agreement to participate in treatment
follow-up
Fee Agreement/Sliding Fee Scale/Income
Documentation
Client photo (preferred) or physical
description
Treatment Contract (if starting
treatment)
Chemical Dependency Evaluation Documents
(if no evaluation is provided) – Am I an
Addict, SASSI-3 (Substance Abuse
Subtle Screening Inventory), South Oaks Gambling
Screen, Beck Depression Inventory
Health/Infectious Disease Screening
Indian Health Service Treatment
Application (if requesting referral to inpatient substance
abuse treatment with an IHS facility)
Outcome Base Measurement
(Admission/Discharge)
Voter
Registration
Mode
of
Evaluation: LADC Supervisor
Quality Assurance Committee
Activity
4: Determining Client Fees
The provider will assist the client in
completing forms to determine fees and payment methods
for services. The three informs include: the Financial Information Form,
Payment Agreement for Services and the Sliding Fee Scale. The client will
need to provide proof of income which may include: pay stubs, rent
receipts, or documents from social service agencies. The client will be
informed of the fees before being assigned a Primary Counselor. Clients
cannot be denied services based upon their inability to pay. Clients may be
offered the opportunity to have a payment plan developed which may include
volunteer service.
Person
Responsible:
Provider/ Staff support
Mode
of Evaluation: Quality Assurance Committee
Accounts Receivable
Region VI
NE. Dept.of Health and Human Service.
Activity 5: Complete
Orientation with all clients. Assign Primary Counselor.
The counselor will provide orientation to
each client. The information will include:
·
Coalition’s philosophy/goals of treatment
and staff responsibilities.
·
Provider credentials
·
Client Rights
·
Explanation of Confidentiality/Privacy/HIPAA
regulations
·
Client Grievance Procedures
·
Participation in Outcomes Assessment
The
admitting counselor and indicate by initials and signature that they have
read, or had read to
them, and understand the information provided. The client will be given a
copy of the
orientation packet. The counselor must document in the admission SOAP note
that this occurred.
The admitting counselor will review the client orientation documents and
take the client on a tour
of the facility advising him or her of the location of the restrooms,
office spaces, fire escape routes
and the location of the storm shelter. The client will also be informed of
the discharge from
treatment criteria or referral to a higher level of care (see Appendix C),
the estimated length of stay
in this program based upon the client’s needs, and the fact that this
facility is a smoke
free, drug/alcohol free and violence free establishment.
Person
Responsible: Counselor
Completion
Date: Upon Admission
Documents: Treatment Contract
Client Orientation Packet
SOAP note
Agency Program Description (Appendix
C)
Mode
of
Evaluation: Program Coordinator
LADC Supervisor
Quality Assurance Committee
Activity 6: Target
Behaviors for Treatment Plan Formulation.
Treatment plan development will begin with the admission
session. The counselor and the
client will work to identify behaviors in need of development or change to
assist the client to
maintain abstinence from substance use and life-limiting behaviors. An
initial treatment plan
to address immediate needs will be implemented with the client at the first
treatment session. A
more comprehensive treatment plan will be implemented at the fourth
session.
Person
Responsible: Counselor
Client
Documents: ASI (Addiction Severity Index)
Substance Abuse
Evaluation
Completion Initial Plan: First Session
Date: Comprehensive Treatment Plan: Fourth
Session
Mode
of
Evaluation: LADC Supervisor
Quality Assurance Committee
Activity 7: Complete
Treatment Plan on all clients.
Comprehensive treatment plan development will be completed
when the assessment process
is finished. The treatment plan must specify the care and treatment
necessary to meet the
client’s assessed needs; include referrals for needed services that this
facility does not provide;
identify client strengths and possible barriers to completing treatment;
contain specific goals and
the measurement the client will use to achieve reduction or elimination of
substance abuse; specify
the extent and frequency of care and treatment (i.e., weekly sessions);
specify criteria to be met
for termination of care and treatment (i.e., completion of all goals and
objectives); define
therapeutic activity; document client participation in the development of
the treatment plan by
client signature and date(s) of participation or justification for the lack
of the client’s signature;
and estimate the length of stay and the plan for discharge.
Person
Responsible: Counselor
Client
Documents: AccuCare Computer Program Treatment Plan
Completion
Date: By the Fourth Session.
Mode
of
Evaluation: LADC Supervisor
Quality Assurance
Committee
Activity 8: Evaluation
of care and treatment (treatment plan review).
Treatment plans will be evaluated to determine continued
appropriateness for client need
and response to care and treatment.
Person(s)
Responsible: Counselor
Program Coordinator
Documents: AccuCare Treatment Plan Review
Completion
Date: At no more than 90-day intervals
Mode
of
Evaluation: LADC Supervisor
Program Coordinator
Quality Assurance
Committee
Activity 9: Staffing
Review/Input documentation.
Staffing with counselors and the LADC supervisor will be
conducted on each client
participating in outpatient treatment services. The information obtained
will be used for
further treatment planning and guidance.
Person(s)
Responsible: LADC
Supervisor
Program
Coordinator
Staff
Counselors
Documents: Staffing Form
Completion
Date: By fourth
treatment session
Mode of Program
Coordinator
Evaluation: LADC
Supervisor
Quality
Assurance Committee
Activity
10: The counselor will assess the client’s progress on a monthly basis
and provide a copy of this report
to the client and any party authorized by the client to receive the
information.
Monthly progress reports are used to chart the client’s progress.
This assessment is to be shared with the client and a
copy
given to the client. A Release of Information (ROI) is required if the
information is to be provided to any other party. The probation/parole
departments and other social services agencies (i.e., Child
Protective Service workers) generally require a report at regular intervals
to track a client’s progress. A release of information from the client is
still required.
Person(s)
Responsible: Counselor
Documents: Progress Report Form
Release of
Information signed by the client
Completion
Date: The fifth working day
of each month
Mode of
Evaluation: LADC Supervisor
Program
Coordinator
Activity 11: Complete Aftercare Orientation,
Referral Services, and Discharge planning on clients being
discharged from program. Files of discharged clients will be secured in a
manila folder
and kept locked in the client file cabinet.
A ‘Continued Service Criteria’ checklist will be completed on
all clients prior to
discharge planning to determine if a discharge from this program is
appropriate (see Appendix D).
Discharge will occur when the client has
completed all of the established goals and objectives
of the treatment provided and have demonstrated the ability to maintain
abstinence at a less
intensive level of care (see Appendix E). A discharge plan will be developed
with the client and
must include: a relapse prevention plan (which includes triggers and
interventions for the client
to activate); a client plan for follow up, continuing care, or other post
care and treatment
services; documentation of referrals made for the client by this facility;
the client’s plan to
further his/her recovery; the client’s signature and the date; and the
counselor will complete
a discharge/treatment summary with the client. This summary must include a
description of
the client’s progress under his or her treatment plan, the reason for
discharge, and
any recommendations for the client. This summary will be signed by the
client and the
primary counselor during the last session. This document will then be
reviewed and signed by
the LADC supervisor and mailed to the client no more than 10 days
following discharge.
LADC supervisor will countersign this document.
Person
Responsible: Primary Counselor
Client
LADC
Supervisor
Completion
Date: Initial
Discharge Report: Last treatment session
LADC
Supervisor Review: No more than 10 days following discharge
Documents: Relapse
Triggers/Prevention Plan
AccuCare Discharge Summary
Mode of
Evaluation: LADC
Supervisor
Quality
Assurance Committee
Activity 12: Discharge
and referral for clients being discharged from outpatient services due
to an identified need
for a higher level of care.
A
client identified as not meeting the treatment contract agreement
(abstinence, keeping appointments, completing assignments) or completing the
goals and objectives of the treatment plan will be referred to a higher
level of care. If possible, the counselor will discuss the options for
referral with the client prior to discharging the client.
Person
Responsible: Counselor
Completion
Date: When client need is identified or after the
third missed session without contact from the client.
Document: AccuCare
Discharge Report
Mode of
Evaluation: LADC
Supervisor
Quality
Assurance Committee
Activity 13:
Complete follow-up on all clients.
Utilizing the information known at the time of discharge a phone call will
be made to or a
written form with an agency-addressed envelope will be sent to clients
having completed the
substance abuse program to assess his or her current needs and to
ascertain if recovery is
being maintained.
Person(s)
Responsible: Program
Coordinator
Agency
Secretary
Completion
Date: 30 (thirty) days; 90 (ninety) days; 6 (six)
months; and 1 (one) year following discharge.
Document: Follow-up
form
Mode of
Evaluation: Quality
Assurance Committee
