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85 Cards in this Set
- Front
- Back
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42 C.F.R. Part 2, confidentiality of drug and Alcohol Abuse Records
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federal regulations that mandate strict confidentiality of drug and alcohol patient information in federally assisted substance abuse treatment programs
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Addiction Severity Index (ASI)
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a rating scale that was developed to be used by clinicians to measure the severity of a client's substance abuse problems; the ASI measures 7 substance abuse-related problem areas: *medical condition *drug use *alcohol use *employment *illegal activity *social relations *psychological findings |
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Alcoholics Anonymous (AA)
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a worldwide organization of self-help recovery groups that support individuals in maintaining sobriety; AAA is based on a 12-step recovery process, and AA and other programs that follow the 12-step recovery process are sometimes referred to as 12-step programs
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CARF International (Commission on Accreditation on Rehabilitation Facilities)
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a voluntary accreditation agency that sets standards that promote "the delivery of quality services to people with disabilities" (CARF, 1994); CARF standards include a section devoted to alcohol and other drug treatment programs
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Center for Substance Abuse Prevention (CSAP)
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an agency of SAMHSA that provides national leadership for community-based substance abuse prevention programs; among other activities, CSAP administers a number of grant programs aimed at reducing the incidence of substance abuse
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clinical assessment
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a clinical assessment is conducted by a clinician for every client that enters a substance abuse treatment program; the clinical assessment is used as a basis for the client's diagnosis and individualized treatment plan
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Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision (DSM-IV-TR)
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a classification system and nomenclature of mental disorders developed by the American psychiatric Association with a stated purpose of providing "clear descriptions of diagnostic categories in order to enable clinicians and investigators to diagnose, communicate about, study, and treat people with various mental disorders" (APA, 2000, p.xxxvii); it is also used as a coding system for mental health disorders; each diagnosis is assigned a unique code number that is based on ICD-9-CM; DSM-V is scheduled to replace DSM-IV in 2013
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dually diagnosed
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clients with both a substance abuse disorder and a chronic mental illness are considered to be dually diagnosed; these clients typically have special treatment needs
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employee assistance programs (EAPs)
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substance abuse assessment and treatment programs established through a contractual arrangement between an organization and a substance abuse treatment facility to serve the employees within an organization
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individualized treatment plan (ITP)
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a written plan developed by the client's treatment team that is used to identify the type and frequency of services needed by the client; it includes measurable goals and objectives that address the problems identified in the clinical assessment and should be updated periodically usually every 6 months) as the client's treatment needs change
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intensive outpatient or partial hospitalization treatment
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"an organized outpatient service that delivers treatment services during the day, before or after work or school, in the evening, or on weekends
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Inventory of Substance Abuse Treatment Services (I-SATS)
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a listing of all known public and private substance abuse treatment facilities in the US and its territories
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involuntary commitment
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a legal process by which individuals who are deemed to be a danger to themselves or to others may be admitted to a substance abuse (or mental health) treatment program even though they refuse or cannot consent to the treatment
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medically managed intensive inpatient treatment
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substance abuse treatment programs that "provide a planned regimen of 24-hour medically directed evaluation, care, and treatment of mental sand substance related disorders in an acute care inpatient setting; they are staffed by designated addiction-credentialed physicians, including psychiatrists, as well as other mental health- and addiction-credentialed clinicians" (ASAM, 2001, p.4)
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National Registry of Evidence-based Programs and Practices (NREPP)
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sponsored by SAMHSA, NREPP is an online searchable database of treatments and interventions that have been demonstrated to be effective for substance abuse and mental health treatment and prevention programs
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National Survey of Substance Abuse Treatment Services (N-SSATS)
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an annual survey of all substance abuse treatment facilities known to SAMHSA; N-SSATS collects facility-specific information on location, characteristics, services offered, and utilization
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outpatient treatment
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"professionally directed evaluation, treatment, and recovery services...provided in regularly scheduled sessions" (ASAM, 2001, p.2)
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qualified service organization agreement (QSOA)
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an exception to the 42 CFR, part 2 Confidentiality of alcohol and drug abuse patient records that permits disclosure of patient record information to an organization providing services to the substance abuse program, such as laboratory, data processing, bill collecting, dosage preparation, legal, medical, or accounting services; the qualified service organization (QSO) has a written agreement to provide professional services to the substance abuse program, and that agreement requires the QSO to follow the 42 CFR regulations
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residential/inpatient treatment
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substance abuse treatment "services staffed by designated addiction treatment and mental health personnel who provide a planned regimen of care in a 24-hour live-in setting...they are housed in, or affiliated with, permanent facilities where patients can reside safely; they are staffed 24 hours a day; mutually and self-help group meetings generally are available on site" (ASAM, 2001, p.3)
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Treatment Episode Data Set (TEDS)
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one of the components of DASIS, TEDS collects from states uniform data that are client specific, but not client identifiable, including demographic and substance abuse characteristics
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Describe three different settings in which substance abuse treatment can take place.
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• Outpatient Substance Abuse Facility – clients receive regularly scheduled outpatient substance abuse treatment • Intensive Outpatient Substance Abuse Facility – clients spend at least nine hours per week in substance abuse treatment but do not stay overnight. • Medically Managed Intensive Inpatient Substance Abuse Treatment Setting – clients are treated for substance abuse under the direction of a physician, which includes all services of an acute care hospital. |
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Define the role of a case manager versus the role of a counselor in substance abuse treatment settings.
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A case manager differs from a counselor in his or her relationship with the client; the case manager provides assistance with obtaining and coordinating services for clients rather than actual therapy.
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What is Alcoholics Anonymous?
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An organization of self-help recovery groups that utilize a twelve-step program.
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How does AA relate to substance abuse treatment?
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It supports individuals in maintaining sobriety.
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List the key elements that should be included in an individualized treatment plan.
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• Identifying Information • DSM-IV-TR diagnoses (DSM-V to replace DSM-IV-TR) • Strengths of the individual • Justification or reason for treatment, including duration and frequency of the problem • Proposed treatment process, including type of service and frequency • Treatment goals and objectives that are measurable, with target achievement dates |
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Name two voluntary accreditation organizations that set standards for substance abuse treatment facilities.
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• The Joint Commission • CARF |
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What standards are used for outpatient centers?
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One standard is 42 C.F.R. Part 2, Confidentiality of Drug and Alcohol Abuse Records, The Joint Commission and CARF also set standards for substance abuse facilities. The government standards that are most frequently applied to substance abuse treatment programs are state Medicaid guidelines. Facilities treating Medicare clients also have to comply with the applicable Conditions of Participation. Also these centers follow the standards outlined in a Joint Commission accreditation program manual, the Comprehensive Accreditation Manual for Behavioral Health Care (CAMBHC). In addition, CARF has two standard manuals for substance abuse programs: Behavioral Health Standards Manual and the Opioid Treatment Program Standards Manual.
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What standards are used for Inpatient programs?
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Inpatient standards are the same as in outpatient centers, and include The Joint Commission’s Comprehensive Accreditation Manual for Hospitals (CAMH). And also include CARF’s two standard manuals for substance abuse programs: Behavioral Health Standards Manual and the Opioid Treatment Program Standards Manual.
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Define involuntary commitment.
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A legal process by which individuals who are deemed to be a danger to themselves or to others may be admitted to a treatment program even though they refuse or cannot consent to the treatment.
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What are the basic steps to obtain an involuntary commitment?
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These steps represent a typical series of events in the overall process: • A petitioner, law enforcement officer, or other responsible person files a petition that states that the client meets the criteria for involuntary admission (i.e., he/she is a danger to himself or herself or to others). • The client is detained for an evaluation by a physician or other qualified clinician for a period of time that may vary from state to state. • The clinician certifies that the client meets the standard for involuntary commitment. • The petition and the certificate are filed with the court and a hearing date is set. • The court determines whether or not the client meets the standard for involuntary admission. • The court will require that the client be admitted if the client meets the standard for involuntary admission. • The court will require that the client be admitted if the client meets the standard (this admission may be to an inpatient or outpatient program, depending on the needs of the client and the state guidelines). |
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detoxification
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medical treatment to remove or reduce the substance out of their system
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What are the required elements for an authorization to release information from an alcohol are drug program?
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*The name or general designation of the programs making disclosure *The name of the individual or organization that will receive the disclosure *The name of the patient who is the subject of the disclosure *How much and what kind of information will be disclosed *A statement that the patient may revoke the consent at any time, except to the extent that the program has already acted in reliance on it *The date, event, or condition upon which the consent expires if not previously revoked *The signature of the patient (and/or other authorized person) *The date on which the authorization is signed |
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What are the settings for substance abuse treatments?
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*Outpatient *Intensive Outpatient *Residential Inpatient *Medically Managed Intensive Inpatient *Substance Abuse Education and Prevention Program *Self help Recovery Groups *Aftercare |
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Diagnostic categories:
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Substance abuse Substance dependence |
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Terminology:
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Alcohol and other drug dependence, psychoactive substance dependence, drug addiction, alcoholism, or chemical dependency Clients or individuals receiving services |
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Evolution of substance abuse treatment
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1950s - residential treatment and AA Now most treatment is outpatient |
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Level I: Outpatient Treatment
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Regularly scheduled sessions (e.g., individual therapy) Examples: mental health center, hospital-based outpatient center, freestanding treatment center Lasts up to a year or more |
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Level II: Intensive Outpatient or Partial Hospitalization Program
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Minimum of 9 hours per week within structured program Evening programs allow work or school to continue Partial hospitalization usually a day treatment |
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Level III: Residential/Inpatient Treatment
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Consumers with sub acute medical, behavioral, or emotional problems; typically lack social supports Examples: live-in facilities such as halfway and quarter-way houses |
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Level IV: Medically Managed Intensive Inpatient Treatment
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Clients with acute problems, require full range of medical and support services Examples: acute care general hospitals, acute psychiatric hospitals or units, and specialty hospitals |
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American Society of Addiction Medicine
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ASAM
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Educational Programs/Early Intervention
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For “at-risk” persons Center for Substance Abuse Prevention grants |
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Self-Help Recovery Groups
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“Twelve-step” programs of which Alcoholics Anonymous (AA) is prototype Other types of support groups often use a form of cognitive behavioral therapy |
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Types of Clients
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*Generally from all ages and socioeconomic backgrounds *Adolescents *Women *Employee Assistance Program (EAP) *Dually Diagnosed *Court-Referred |
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Types of Caregivers
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*Physicians *PAs and NPs *Nurses *Counselors *Case Managers *Recreational Therapists |
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Regulatory Issues CARF International |
Behavioral Health Standards Manual Opioid Treatment Program Standards Manual |
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Regulatory Issues The Joint Commission |
Hospital-based programs: Comprehensive Accreditation Manual for Hospitals (CAMH) Community-based programs: Comprehensive Accreditation Manual for Behavioral Health Care (CAMBHC) |
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Regulatory Issues Medicaid |
Medicaid (varies from state to state) |
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Documentation
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*Legal/Administrative Documentation *Clinical Documentation -Clinical Assessment -Individualized Treatment Plan (ITP) |
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Reimbursement and Funding
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*Client Fees *Private Insurance *Medicaid-one basic tenet of Medicaid is that it provides for reimbursement of care that is "medically necessary" *Medicare-covered for a preset number of days or visits *Other Government Funding -grants and contracts -at some centers may provide 75-100% of funding |
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Information Management
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*Flow of Information -Intake -Assessment -Development Treatment Plan -Documentation of Care -Documentation of Discharge Summary -Development of Continuing Care Plan -Aftercare |
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Coding and Classification
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DSM-IV with DSM-V as scheduled replacementDSM designed to be compatible with the current clinical modification of ICD
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Coding and Classification
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*Multiaxial Format Axis I – Clinical disorders Axis II – Personality disorders, mental retardation Axis III – General medical conditions Axis IV – Psychosocial and environmental problems Axis V – Global assessment of functioning |
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Data Sets
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Purpose: To substantiate the need for federal block grant money
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Data Sets
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*SAMHSA developed Drug and Alcohol Services Information System (DASIS) -Treatment Episode Data Set (TEDS) -National Survey of Substance Abuse Treatment Services (N-SSATS) -Inventory of Substance Abuse Treatment Services (I-SATS) |
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Electronic Information Systems
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*Electronic information systems vary greatly from facility to facility *Public community treatment programs are working together to develop standardized electronic records *Electronic records improve efficiency in the intake process for clients and throughout the course of treatment. |
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Quality Assessment and Improvement
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*Activities vary based on level of service and accreditation *Center for Substance Abuse Treatment (CSAT) provides consensus-based and evidenced-based treatment guidelines *National Registry of Evidence-based Programs and Practices (NREPP) maintains a database of evidence-based interventions |
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Utilization Management
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*Treat at least intensive level that meets treatment objectives *ASAM provides criteria for each of its4 levels (I, II, III, IV) *Addiction Severity Index (ASI) - interview results in a “score” that can be used in outcomes research studies |
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Risk Management and Legal Issues
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*Confidentiality and Release of Information -Clients want to avoid stigma -Clients may fear law enforcement investigation |
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Risk Management and Legal Issues
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*42 CFR Part 2, Confidentiality of Alcohol and Drug Abuse Patient Records -Circumstances permitting disclosure -Authorization must contain specific items -Qualified Service Organization Agreement |
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Risk Management and Legal Issues
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Court-Ordered Treatment for DUI and other crimes when court feels that perpetrator’s substance abuse wasa factor
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Risk Management and Legal Issues
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In some states, involuntary commitments can be ordered if individual is deemed to be a danger to self or others
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Role of Health Information Manager
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*Need for timely and reliable information *“Proof” for payers of quality and cost *Traditional record management, risk management, utilization management quality improvement, release of information, client rights coordination *Electronic client record systems *Confidentiality advocate |
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Trends
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*Specialized programs *Government funding and requirements *Need for data *Managed Care *Integrated Delivery Systems *Health Information Exchange |
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T/F The regulations in 42 C.F.R. Part 2 are more confidential than the privacy provisions of the HIPAA. |
True
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What are the 2 laws enacted in the 1970's to guarantee a strict level of confidentiality for those seeking alcohol and drug abuse treatment?
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The Comprehensive Alcohol Abuse and Alcohol Prevention, Treatment and Rehabilitation Act of 1970 and The Drug Abuse and Treatment Act of 1972 |
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What are the exceptions to the general prohibition in 42 C.F.R. part 2 for disclosure?
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*Written consent of the patient *For internal communications on a need to know basis *When there is no patient identifying information *In a bona fide medical emergency *With a court order (with special procedures) *When a crime is committed at the treatment program or against program personnel *For research and audits *In child and vulnerable adult abuse reporting, under to provisions of the applicable state law *Under the provisions of a qualified service organization agreement (QSOA) |
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T/F Quality Assessment and Improvement and Performance Improvement are the same thing. |
True
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What is the general rule for Utilization Management?
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Clients should be served at the least intensive level that will meet their treatment objectives, such as outpatient therapy and should move on to a more intensive level, such as residential treatment, only when it is justified by their specific treatment needs.
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What is DASIS?
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Drug and Alcohol Services Information System
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What is the purpose of DASIS?
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to provide one data system that provides national and state level data on substance abuse clients and on the facilities that receive federal grants or contracts to provide substance abuse treatment. |
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What are the 3 components of DASIS?
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Treatment Episode Data Set (TEDS) National Survey of Substance Abuse Treatment Services (N-SSATS) Inventory of Substance Abuse Treatment Services (I-SATS) |
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What is NREPP? What does it stand for?
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NREPP is the National Registry of Evidence-based Programs & Practices. NREPP is a searchable online registry of more than 350 substance abuse and mental health interventions. NREPP was developed to help the public learn more about evidence-based interventions that are available for implementation. NREPP does not endorse or approve interventions. |
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NREPP is ran by SAMHSA. What is SAMHSA?
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Substance Abuse and Mental Health Services Administration. SAMSHA is a federal agency within the U.S. Department of Health that helps aims to limit the consequences of substance abuse and mental health issues on American communities.
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What are the criteria that address treating adolescents for substance abuse?
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*knowledge of the clinicians about adolescent behavior and development, in addition to chemical dependency treatment *Low staff to patient ratio *Separation of the adolescent unit from an adult unit *availability of academic and vocational activities |
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What is the primary purpose for documentation?
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to support client treatment |
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T/F Records are NOT increasingly important for documenting evidence based practices and outcome measures. |
False
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Other purposes for client records:
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*To improve communication among care providers *To serve as legal records of care provided *To support reimbursement clains *To monitor the quality of care *To provide data for research and education |
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What is a way to demonstrate that a client's treatment is successful?
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proper documentation
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What are some of the components of the legal/administrative documentation?
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*Admission information *Commitment papers *Fee agreement and financial assessment *Insurance authorization *Special program enrollment forms *Program or agency rules *Consents to treatment *Contents to release of information *Client rights information |
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What are some of the components of the Clinical Documentation?
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*Clinical assessments *Medical assessment, if necessary *Individualized treatment plan *Clinical service notes or progress nontes *Discharge summary/aftercare plan *Follow up information *List of medications |
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What are the two key documents in the substance abuse record?
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Clinical assessment & Individualized treatment plan |
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What is usually in the clinical assessment?
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*identifying information *presenting problem *health, medical, and/or developmental history *family and social history *history of psychoactive substance use *history of psychological factors impacting the client's condition |
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What is usually in the clinical assessment? (continued)
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*educational/vocational history *client abilities, strengths, needs, and preferences *preliminary diagnoses *admission to program information, including specific reasons when admission is denied *initial problem list *clinical assessment summary |
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Why is an ITP updated?
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to reflect changes in the client's condition and revised treatment goals.
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