Detox Programming Standards

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1 Detox Programming Standards

2 Acknowledgements The Ministry would like to acknowledge the Adult, and Child and Youth Provincial Standing Committees, the Regional Directors of Mental Health and Addictions, the Project Reference Group, and the Drug Treatment Funding Program Steering Committee for their contribution to document development. The Ministry would also like to acknowledge Tim Geissler for project facilitation and document development, and Health Canada for project funding under the Drug Treatment Funding Program. December 2012

3 Table of Contents Introduction... 3 Standard #1: Client Safety and Choice... 4 Standard #2: Screening/Assessment... 7 Standard #3: Medical Intervention... 8 Standard #4: Detox Programming... 9 Standard #5: Staff Qualifications Standard #6: Discharge Planning Appendix 1: National Treatment Strategy and Provincial Mental Health and Alcohol and Drug Misuse Framework Principles Appendix 2: Provincial Screening Tool and User Guide Appendix 3: Mental Health and Addictions Screening Tools Users Guide Appendix 4: Mental Health/Addictions Individualized Service Plan Appendix 5: Search Procedures Appendix 6: Medication Management Practice: Accreditation Canada References

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5 Introduction The Provincial Standards for Brief and Social Detox Services are informed by the guiding concepts that underpin the National Treatment Strategy tiered model of substance use services and the provincial Framework for Mental Health and Alcohol and Drug Misuse services (Appendix 1). Development of these standards was led by a working group of representatives from the Ministry of Health and health authorities who work in the field of alcohol and drug use treatment. Through a process of research, sharing of information, and discussions, the reference group created a set of draft standards. These were circulated to the steering committee and other stakeholders and their comments were used to refine the final version of the standards. The standards reflect the best available information from both clinical research and practice-based experience in regards to detox and withdrawal management standards that are most effective in helping people to change their alcohol and drug use and improve their overall health and wellbeing. The standards also emphasize the need for services to be individualized and holistic. In this way, the standards attempted to recognize and respect the diversity of people with alcohol and drug use issues. The Standards are somewhat broad in nature but also focus on details for service delivery. They offer a solid foundation and a structure for safe, effective and consistent service delivery across the province while also providing room flexibility for detox facilities in different regions to develop and deliver the kinds of services and supports that meet the needs of the specific clients and communities they serve. The standards are intended to support and inform health regions and health region-funded service providers. They align and do not override other quality criteria that service providers are expected to meet including applicable health legislation, regulations and accreditation requirements. Goals The main goals for client care engaged in detoxification services in Saskatchewan are to provide a safe place to withdraw from alcohol and drugs, promote respect and dignity for this process, and assist clients in accessing multiple health (biological, social, psychological, and spiritual) related services to promote ongoing recovery. Furthermore, while clients are accessing detox services they will be provided an opportunity to receive education on alcohol and drug misuse and health related issues along with the process of recovery (The intensity of this content will need to be appropriately matched with clients physical and mental status). Detoxification takes from hours to 2-3 weeks, depending on the predominant alcohol and drug used and the severity of dependence. It may be undertaken at home, on an outpatient basis, in a community inpatient detoxification unit, and in a hospital setting. The severity of dependence and the individual s medical condition determine the appropriate setting. The standards discussed in this document will focus on inpatient brief and social detoxification facilities in Saskatchewan. Detoxification can sometimes be undertaken without any medication to assist the process (non-medicated detoxification), but it is often necessary to prescribe sedative or substitute drugs. The standards set in this area by physicians and by the Addictions Medicine Advisory Committee in Saskatchewan to assist clients with their withdrawal can be found at: saskatoonhealthregion.ca/your_health/documents/ COMPLETE.pdf Principles of Brief and Social Detox 1) Detox programs provide an opportunity for engagement, planning and coordination of postwithdrawal care and further community services. It is an opportunity to establish a relationship with the client and match intervention with the clients goals and needs. 2) A comprehensive screening and assessment is the first step in managing the withdrawal process. It will define the risks that will confront the client by identifying drug use and health issues for the patient and it will also identify specific needs that may potentially interfere with successfully completing withdrawal. 3) An accurate consumption history will be recorded for each drug (whether prescribed or not) the quantity, frequency, duration and pattern of use; time and amount of last use; route of administration; recent pattern leading up to this 3

6 presentation; and average daily consumption. For prescribed medications, also record prescribed dose and prescribing doctor. 4) If possible, formalize a treatment agreement with the client. The agreement may be verbal or written, and should not be used against the client in a punitive manner. 5) Frequent observations of the client are the mainstay of detox services in order to keep clients safe and help them stabilize from withdrawal. Client will be closely monitored on admission by both medical (vital signs) and non medical staff (behavioural observations). This will continue for the next 48 hours or until client has stabilized from withdrawal. 6) Hourly room checks will be done during the night to ensure client is breathing. Room and facility checks will be done regularly to ensure no drug paraphernalia or alcohol and drugs are one site. A search procedure guide is located in the Appendix 4. 7) Medication is used in withdrawal management stage to provide symptomatic relief, to treat complications and coexisting conditions, and to reduce the intensity of withdrawal. 8) Develop strategies to mange cravings and provide addiction/recovery education to help the client cope with the period after withdrawal. Education will be provided either in a group or individually to process strategies such as distraction and normalize cravings. Plans are established with clients to manage while in detox and in the community. NRT s will be available (based on resources) for managing nicotine cravings. 9) Strategies for discharge should encourage harm reduction and referral to the community for further support and ongoing recovery from community supports (e.g. addictions counsellor, 12 step meetings). Standard #1 Client Safety and Choice Objective: Ensure client are kept safe at all times and are provided support to make healthy choices. 1) Detox programs and its staff respect the individual rights of each person receiving service. It is the responsibility of each client in the program to treat staff and other clients with respect. 2) The program and its staff do everything possible to ensure the personal safety of each client receiving service. 3) The service has a complaints procedure in place that is clearly communicated to each client receiving service. The service deals with complaints promptly and sensitively. 4) The detox facility has policies and procedures in place that outline what will happen in case of emergencies. 5) The rationale of detox services is to provide a safe and appropriate level of support for withdrawal related to alcohol and drug use, which then allows the service providers and individual clients to work collaboratively on the best management withdrawal strategy. An understanding of the pharmacology and physiology of withdrawal allows the use of appropriate medications to modify the withdrawal process, making it more tolerable and safe. 6) Detox services may be an opportunity to initiate lasting abstinence, but the primary goal is patient safety, not necessarily long-term abstinence. 7) Detox services should not be withheld from people because of doubts about their commitment to long-term abstinence. If there are situations with clients of violence towards clients or staff, drug use in the facility, or medically related issues beyond the scope of expertise services may be declined. 8) Supportive care and client choice are crucial to success. Supportive care should include attention to the patient s environment, reassurance, attention to anxiety levels, addiction/recovery education and assistance with the development of coping skills. 4

7 9) The initial assessment is an important opportunity to begin building an effective therapeutic relationship with the client. An underlying counsellor s attitude and actions needs to reflect the following principles: a) Be non-judgemental, empathic and respectful. b) Listen and clearly identify and acknowledge the client s needs. c) Encourage the client to participate actively in treatment decisions from the outset. d) Communicate clearly, and allow time for the client to gain an understanding of what assistance is being provided and the reasoning behind it. 10) Withdrawal management is monitored clinically, medically and appropriate care is provided, which may range from medical professionals, counselling, education and support to the use of specific medications to alleviate symptoms of withdrawal. 11) Planning and coordinating post-withdrawal care is an integral part of detox and will be done in coordination with client and possibly family. 12) All clients will be monitored closely for suicidal ideation. Assessment and additional supports may be required for clients with concurrent mental health issues, past suicide attempts, and complicated withdrawal issues. Each facility should have a suicide intervention policy and procedures in place and staff trained appropriately to assess and intervene with this very vulnerable clientle. 13) The goal of suicide risk assessment is to determine the level of risk at a given time and to provide appropriate clinical care and management. Possible suicidal behaviour includes thinking about suicide, harming oneself or attempting suicide. Comprehensive assessment of the person is required in these situations. Staff should at least conduct these steps in the assessment of suicide risk: a) Engagement- discuss reasons for living and dying and explore positive coping strategies. b) Detection (of risk factors) have client name risks and what helps to manage these risks. Assess active suicidal plan and clients willingness to discuss how to keep safe. c) Preliminary suicide risk assessment Ask client questions relate to their ability to keep themselves safe and their willingness to discuss with counsellor if their status changes. d) Immediate management- a referral to emergency services may be required if client does not develop a basic alliance with staff and unwilling to discuss suicide ideation and safety plan 14) In February 2011, The Framework for Assessment and Management of People at Risk for Suicide manual was completed by a reference group of mental health and addiction professionals. This document is available and should be used as a guide for staff in assessing and developing intervention strategies with clients. This document provides both a framework and protocols for the assessment and management of people at risk of suicide. The content of the framework, as well as the protocols, are in response to the Suicide Alert issued by the Province of Saskatchewan in 2007 and the standards outlined in the 2009 Accreditation Canada Required Operating Practice (ROP). The framework is a blend of practice, both provincially and internationally. 15) Summary of Suicide Management Principles a) Anyone who talks about suicide should be taken seriously. People who die by suicide have often previously expressed suicidal thoughts or displayed warning signs. All people who report self-harm or suicidal intent should be treated as being in a state of potential emergency until convinced otherwise. b) When a health care provider remains uncertain after a clinical assessment, it is important to consult with a senior colleague or psychiatrist. c) Whenever possible, support people, including families and significant others, should be involved when working with a suicidal person. A collaborative partnership is equally relevant for the assessment component, crisis management and 5

8 subsequent treatment. At any time, support people can give information without compromising privacy. If a suicidal person declines involvement of others, their refusal may be circumvented to keep them safe. d) Any person at risk of suicide should be re-assessed regularly, particularly if their circumstances have changed. A suicidal person s mental state and suicide risk can fluctuate considerably over time. Changeability of risk status should be assessed and high changeability should be identified. More vigilant management is adopted, with respect to the safety of the person, in light of the identified risk of high changeability. e) Thorough and timely documentation should be structured and include: relevant suicide risk assessments; a comprehensive physical assessment if appropriate; support people s concerns; previous psychiatric history; previous treatment received including key clinical decisions; and discharge plan including who is providing follow up services. f) Training in suicide assessments improves staff performance, encourages appropriate referrals and advances the overall care provided. Provincial consensus recognizes Applied Suicide Intervention Skills Training (ASIST) as the foundational training for staff coming in contact with suicidal individuals. g) Access to appropriate and timely clinical supervision is important for all mental health clinicians. This should also include discussion regarding high-risk persons and the opportunity for debriefing on management interventions. h) Culturally appropriate services should be offered to the suicidal person whenever possible. i) Information for persons at risk of suicide, and their support people, should be provided. Material should contain information regarding: actions being taken to minimize suicide risk, contact information for 24-hour services and options for treatment and management. j) Intoxication with drugs or alcohol precludes a valid immediate assessment. If suicide risk is identified in an intoxicated person, he or she should be detained in an appropriate and safe setting until a full assessment is conducted. 16) Encouraging clients to participate in treatment choice enables their views to be considered and increases the awareness of both the client s and the counsellor s responsibilities. If possible, counsellors should formalize a treatment agreement with the client. This could either be completed in verbal or written manner. The acknowledgement of a verbal agreement should be recorded in the client file. Provide client information about of his or her responsibilities and those of the service provider. If possible, client should complete consents and service agreement forms before treatment begins. This may not always be possible when a client enters in an intoxicated state is an assumed informed consent exists when a client enters a detox facility. 6

9 Standard #2 Screening/Assessment Objective: To ensure that individuals entering detox programs will best meet their bio-psycho-social-spiritual needs and preferences, and most effectively support them in managing withdrawal symptoms, recovery programming and referring to ongoing supports. 1) The critical issues are: a. ensuring client is admitted in a timely manner b. minimizing the risk of withdrawal complications c. managing withdrawal symptoms d. stabilizing medical and psychiatric conditions. 2) The client will take part in an initial screening to gather basic information including her or his age, gender, contact information and the reason why client may need service. The Provincial Mental Health and Screening Form (attached in Appendix along with user guide) will be used and some health regions have integrated this form with other screening requirements specific to their health region. The Provincial Mental Health and Addictions Screening Tool is used for new or returning clients. 3) It is important for the counsellor to explain to the client their rights with regard to consent to service and the limits of confidentiality that apply to disclosure of personal information. All standardized facility consents will be completed with counsellor and client. With the client s written consent, relevant aspects of the assessment are shared with any other alcohol and drug misuse service or program to which client may be referred. It is good practice to involve families/supportive others wherever possible because they will be providing ongoing support to the person after their involvement with alcohol and drug misuse services is ended. Participants must also be informed of the limitations to confidentiality, which include: If the individual is planning to harm her- or himself or others; If the service provider is subpoenaed by a judge to testify in court, or provide clinical notes; and If the individual is endangering a child or knows of someone who is. 4) Assessment is the first step in managing drug and alcohol withdrawal. The primary aims are to: a. predict the risks that will confront the client because of withdrawal b. identify the specific needs of the client to enhance the likelihood of completing withdrawal (ie, to match treatment to client needs) c. begin building a therapeutic relationship with the client 5) Components of a comprehensive assessment may consist of some or all of the following depending on physical wellbeing of client and resources upon admission: a. full drug consumption history b. identifying risks associated with polydrug use c. identifying past history of withdrawal and any associated complications d. medical and psychiatric history e. physical examination f. appropriate laboratory investigations g. formulating a management plan h. psychosocial assessment to identify expectations, supports, and barriers 6) Recording consumption history: an accurate consumption history should be recorded, for each drug (whether prescribed or not prescribed): a. quantity, frequency, duration of use, pattern of use b. time and amount of last use c. route of administration d. recent pattern leading up to this presentation e. average daily consumption. f. prescribed medications- record prescribed dose and physician. 7) When documenting a full consumption history is not practical: obtain whatever alcohol and drug use history is available from the client, family, friends, or other sources, especially details of the last episode of use. 7

10 a. identify any signs of drug consumption and effects during physical examination b. consider urine or blood testing in most clients c. take a further consumption history when the client is stable or when others are able to provide information. 8) Assessment Scales: Most facilities in Saskatchewan are using Clinical Institute Withdrawal of Alcohol Scale CIWA- AR to complete their initial assessment of alcohol withdrawal. The score on the forms is used to establish a treatment plan to manage withdrawal symptoms. A nursing assessment will occur in conjunction based on staffing resources. There are other assessment forms to assess cannabis, opiates, and nicotine in and are located in the appendix section of this document. All these scales demonstrate good reliability and are useful measures to begin medical and/or non medical withdrawal management. etg_demo/etg-ciwa-ar.pdf 9) Psychosocial assessment: it is also critical to identify and consider the client s social situation, support systems, capacity to undertake withdrawal and the likely success of detox. This assessment can assist in developing an agreed treatment plan with the client. Discussing these issues and seeking the participation of clients in developing treatment plans will improve their level of engagement and willingness to complete detox and engage in ongoing community recovery supports. 10) Parts of the assessment should include questions about expectations of withdrawal: a. past experiences of withdrawal or detox facilities b. current fears of withdrawal c. perceived ability to cope with withdrawal 11) Ask about supports for withdrawal treatment: a. Current living accommodations b. Supportive family and friends c. Client s links with local health professionals and support groups 12) Ask about potential barriers: a. relationship issues b. care of children c. drug use of cohabitants d. current legal issues e. financial problems f. housing concerns Standard #3 Medical Intervention Objective: To ensure clients immediate medical needs are met and a plan to manage withdrawal symptoms 1) There are a number of medical and non-medical interventions for clients accessing detox facilities. There are the immediate withdrawal management interventions that occur as well as treatment programming after clients stabilize. The medical interventions guidelines/standards for withdrawal management protocol were completed by the Addictions Medicine Advisory Committee in These Standards/ Guidelines have been established by this committee and can found in the Appendix attached to this document. They include assessment scales and medical withdrawal management strategies for alcohol, benzodiazepine, opiates, and cocaine. These standards are critical and will be implemented for those clients assessed as needing medical and pharmacological supports to alleviate their withdrawal symptoms. 2) A significant proportion of people accessing detox programs in Saskatchewan will require prescribed medications for a number of different reasons. Medications may also form part of an individual s overall medical treatment plan. Examples of concurrent conditions requiring medication include physical conditions such as: asthma, diabetes, arthritis, hepatitis or HIV/AIDS. Mental health conditions requiring medication may include: schizophrenia, and mood disorders, eating disorders, or other mental health issues 8

11 3) The treatment of problematic alcohol and drug use may require medication for withdrawal, management and stabilization. There is abundant and conclusive evidence that therapies such as methadone maintenance can help individuals to participate in treatment, reduce their illegal alcohol and drug use, and improve their overall health. All facilities that provide service to individuals on medication(s) should support the individual to continue to take existing prescribed medications. Many of the facilities in Saskatchewan estimated that 10-20% of clients admitted are on methadone and this is integrated in the overall treatment plan for those clients. 4) At a minimum, written medication management policies and procedures at detox programs should include the following: a. procedures for dealing with medication errors and adverse medication reactions; b. procedures for controlling access to drugs; c. known medication allergy information is highlighted in the client s file; d. all medications are administered with the authority of a physician; e. policy establishing under what circumstances self-medication by the client is permitted along with a physician standing order sheet; and f. specific routines for the administration of drugs and dose schedules 5) Accreditation Canada has developed Medication Management standards and addresses the safe and effective use and management of medication to be used by facilities. The standards emphasize collaborative approach to prevent and reduce adverse drug events. Please see attached Appendix 4 for further details on these standards. All policies around medication management will reflect these standards of practice. 6) The main concept to integrate from this standard is reinforcing the role of affiliated Physicians as formally endorsing practice/protocols in each facility and for the Most Responsible Physician involved in Home, Other Community Residential, and Acute Inpatient, Emergency, and Medical Units. Standard #4 Detox Programming Objective: To ensure that all programming and supports offered are informed by the best available evidence about what works for clients accessing detox programs 1) The most important factor when it comes to programming is acknowledging, that not all clients, due the severity of their withdrawal symptoms or other medically related issues will be limited in their ability take part in active programming and education. 2) The programming offered facilitates access to a full range of evidence-informed supports, treatment and case management that are appropriate to the individual s needs and preferences. The client is provided options and is viewed as a collaborative process. Evidence includes both evidence-based practice (from research) and practice-based evidence (from counsellors, clients, and programs experiences and knowledge). Some examples of how a program may demonstrate that it is following evidence informed practice include: making research literature available to staff; holding regular training and education sessions; and, taking part in exchanges with other detox facilities in Saskatchewan. 3) The individual receiving service is given help and support to restore and address the bio/psycho/ social/spiritual issues they present with. The client is given help and tools to strengthen client s supports (including, as appropriate, relationships with family members, partners, and friends). This can be done in case management basis providing individual counselling and education or in a group setting. The detox facility needs to develop and maintain strong linkages and relationships with providers of other health and social services in the community. 9

12 4) Programming is initiated based on the needs of the client. Additional programming depends on the client s physical and cognitive functioning. Clients usually experience concentration and memory difficulties related to their withdrawal and are limited in their ability to retain information. It will be important to repeat programming concepts and strategies as concrete a possible during this phase. 5) The program addresses the need for rest, fluids, mild exercise, and nutrition. This period of service in the continuum of alcohol and drug misuse services includes managing acute physical withdrawal from the abused alcohol and drug and motivational counselling by a qualified addiction counsellor. Clients need to learn to manage their personal health problems and the potential health problems related to their alcohol/drug consumption and environment in which they used. The immediate focus is on self and any current crisis. 6) The client may benefit from sessions on the following topics: a. rest, mild exercise, fluids, nutrition, and stress management. b. managing post-acute withdrawal symptoms. c. introduction to symptoms and an examination of their drinking history. d. introduction to the process of recovery, recovery programs and 12 step groups. e. availability of recovery services and how they may be accessed. 7) Currently, research suggests that the following psychosocial therapies for alcohol and drug misuse issues are particularly effective: a. Motivational Enhancement Therapy; b. Motivational Interviewing; c. Trauma-informed practice; d. Cognitive Behavioural Therapy; e. 12 Step programs; f. Relapse Prevention; g. Pharmacotherapy 8) Providing a range of skills training through techniques such as cognitive restructuring, role play, active rehearsal, and repetitive practice are also considered to be best practice. Skills may include: a. problem-solving skills; b. communication skills; c. Stress management strategies; d. understanding the patterns and triggers to alcohol and drug use; e. coping skills (e.g., dealing with cravings); f. harm reduction (strategies such as Public Health presentations and testing for STD s and g. information about using clean needles) h. identifying and dealing with emotions and thoughts associated with alcohol and drug use 9) Programming examples for detox programs will include presentations in the areas of: a. public health (this may include on site testing for blood born pathogens/std s) b. harm reduction strategies education c. community resources/supports education d. Mental Illness Education e. First Nations and traditional healing teachings f. smoking cessation g. 12 step groups education h. recreation/leisure education i. Stages of Change 10) Much of the focus will likely be on the psychosocial stabilization of clients. Many tasks such as re-establishing consistent sleeping, eating and leisure patterns are essential for clients in assisting their overall return to a healthier lifestyle. Workshops related to sleep hygiene, nutrition, and healthy use of leisure time will aid clients in re-establishing a healthier lifestyle. 11) Programs should evaluate all written and visual materials provided to clients for comprehension as well as for cultural appropriateness. 10

13 Standard #5 Staff Qualifications Objective: To ensure that all programming and supports offered to clients possess the necessary skills for the role that they have been hired for at the detox facility. 1) All new staff should have the necessary skills and competencies for the roles to which they are appointed, and existing staff should have opportunities to upgrade their training and are supported in doing so. 2) Each member of staff, and volunteers, should stay within the scope of the role for which she or he is adequately qualified. Individuals receiving detox services are welcome to ask about an employee s qualifications. Each staff member needs to receive the necessary supervision to ensure she or he is meeting the standards for their assigned role at the facility. 3) Ongoing staff training and development could be delivered in a number of ways. Possible approaches include: health authority-led workshops; online learning and webinars; and staff meetings. 4) Staff should be trained to avoid discriminatory language and behaviors. The diversity of the counselors should reflect that of the community they are working in. Additionally, counselors must be specially trained for cultural appropriateness and sensitivity. They must be aware, for example, that cultural attitudes toward communication styles vary with regard to preferred space (physical distance), appropriate physical contact, eye contact, and terminology. Staff who are competent in languages such as Cree or Dene or know at least enough words spoken by the clientele help the program establish connections. Language competency entails not only the ability of a staff person to communicate with a client and the family but also familiarity with trends in street terminology. The CCSA core competencies for detox counselors: Competencies/Pages/default.aspx Standard #6 Discharge Planning Objective: To ensure that clients experience a seamless transition from the time they complete the detox program to the community and are supported in the community to continue building on ongoing recovery and well being. 1) The detox program will complete some form of discharge planning. Many health regions are using the Individual Service Plan document to work with clients in establishing goals and arranging follow up services (Appendix 3). 2) The detox program will actively support and encourage clients to work and establish relationships with service providers and self help groups in the community. 3) The detox program will actively work with the specific health region to identify what resources are available to clients and how to connect client with these resources. 4) The detox program will actively support the individual to make contact with other health and social service agencies and community organizations (e.g., primary care, housing, child care, employment services and support groups) as needed. 11

14 5) In order to help ensure continuity of care, clients who access detox services should be given an appointment time and potentially meet with a community counsellor upon discharge. Individuals who enter detox without having a alcohol and drug misuse counsellor should be given support by the program to schedule an appointment with such a counsellor before they leave detox. 6) Where possible, client in detox treatment should be provided education about community resources available able to attend. At a minimum, individuals should be given up-to-date and accurate telephone numbers, contact names, addresses, and websites for available services in the community. These should be part of a discharge package that may also include harm reduction information. Wherever possible, clients who need basic needs such as housing and food should be provided community contacts such as the Salvation Army. 7) Access to stable and affordable housing is a concern for many individuals receiving detox services. The detox program should connect clients who are homeless with services that can assist them in finding housing early on in the program. 8) When a client receiving service is a parent of a young child or children, the detox program should help her or him link to parenting services and supports as required. 9) A variety of these community supports may also need to be linked with physicians and medication management such as methadone or other psychotropic medication to help manage concurrent issues. 10) Post-withdrawal interventions should be used, such as motivational enhancement, relapse prevention, cognitive behavioural therapies, other psychosocial interventions and self-help groups. 12

15 Appendix 1 National Treatment Strategy and Provincial Mental Health and Alcohol and Drug Misuse Framework Principles National Treatment Strategy No wrong door. A person may access the continuum of services and supports by way of any of the five tiers and, upon entry, should be linked to other needed services and supports, either in the same tier or in a different tier. Co-ordination of this linkage is the responsibility of the system, not the individual. To ensure that this principle can be applied in practice, all sectors should routinely screen people for alcohol and drug use problems and provide ready access to comprehensive assessment services if needed. Availability and accessibility. Services and supports in all tiers should be both available and accessible within a reasonable distance and travel time of each person s home community, or should be facilitated by different means (e.g., telehealth, online or mobile services). Matching. A person should be matched to services and supports whose intensity is appropriate to her or his needs and strengths. Matching implies a need not only for standardized screening and assessment tools, but also for processes that respect each person s informed choice of what type of care may work best for her or him (based on cultural relevance, language group or other considerations). Choice and eligibility. If more than one service or support meets a person s needs, the person should be able to choose among those services and supports for which she or he is eligible. A person should be able to access services and supports within a given tier and across different tiers, as needed over time, though the focus might be in a particular tier at a given time. Flexibility. A person should be referred from a lower tier to a higher tier (stepped up) or from a higher tier to a lower tier (stepped down) as appropriate to her or his needs. Responsiveness. People and their needs change over time and with changing circumstances. As a person travels along pathways and through the lifespan, she or he should be given the help needed (e.g., information, referral, assessment, treatment) to ultimately shift the focus to services and supports in lower tiers. Collaboration. A person s journey through the pathways should be facilitated by collaboration between providers of distinct kinds of services and supports. Collaboration should occur both at the clinical level (e.g., through shared service protocols between different providers) and at the administrative and organizational levels (e.g., through partnerships and inter-agency agreements), and should always include the person seeking help. Co-ordination. To facilitate service delivery as well as system planning, monitoring and evaluation, health information systems should allow easy sharing of information between systems. Excerpted from National Treatment Strategy Working Group, 2008 Provincial Mental Health and Alcohol and Drug Misuse Framework Services are Person and Family Centred Services are Coordinated and Collaborative Services are Integrated Services are Supported by Continuous Quality Improvement and Services are Engaged with Communities 13

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17 Appendix 2 Provincial Screening Tool and User Guide Provincial Mental Health & Addictions Screening Tool (For New Clients or Returning Clients) DATE OF REFERRAL: DATE OF INTAKE: HSN #: Site: Method of Contact: In Person Mail/Fax Phone Referral Source: Alerts: Allergies Other Health Risks Safety Risk Pregnant Due Date Note(s): Last Name First Name Middle: Other Name(s): Preferred Name: Language: English Other Unknown Gender: Male Female Age/Date of Birth (dd/mm/yyyy): Health Region: (Region where client resides) Province: Address: City: Postal Code: Home Phone: Work Phone: Cell Phone: Occupation/ Employment/ School: Marital Status: Custody Order/ Legal Guardianship: General Practitioner/ Specialist: Previous/ Current MH/AD Services: File Status: Active # Closed # No Previous Contact Access to other MH/AD resources: EFAP/EAP Health Benefits Student Resources Private Practice Other 15

18 Living Arrangements: Alone Board and Room Children Community Care Home Correctional Facility Family of Origin Foster Home Group Home Homeless Housing Coalition Long Term Care Facility MHAS Approved Home Other Relatives Roommate/Friend SHNB Special Care Home Spouse/Children Spouse/Partner Supportive Housing Treatment Centre Unknown Client Note: Family/Collateral Information Last Name First Name Age Address: Address: Address: Relationship To Client Phone: Phone: Phone: Referral Source Can be Contacted Emergency Contact Lives With Next Of Kin Custodian/ Guardian Presenting Problems (must circle primary) Acculturation Difficulty Aggressive Behaviors Alcohol Anger Management Anxiety Attachment Issues Attention Difficulties Behavioural Concerns Chronic Pain Cognitive Difficulty Communication Difficulties Conduct Concerns Delusional Depression Developmental Concerns 16 Drugs Eating Difficulties Emotional Abuse or Neglect by Other Gambling Grief/ Loss Hallucinations Homicidal Thoughts Hyperactivity Impulsivity Learning Difficulties Mania/ Hypomania Methadone Mood Swings Obsessions/Compulsions Oppositional Behaviour Roommate/Friend Other: Panic Parenting Concerns Physical Abuse or Neglect by Other Psychosis Relationship Difficulties Self Care Deficit Self-Esteem/Confidence Self-Harm Sexual Abuse by Other Sexual and Gender Identity Difficulties Sexual Intrusive and/or Offending Behavior Sleep Problems Social Skills Somatic Problem Speech/Language Difficulties Stressful Events Alcohol and Drug Use/ Abuse Alcohol and Drug/ Gambling Affected Suicidal Ideation/ Behaviour Temperament Issues Toileting Issues Trauma Violence Against Significant Others

19 Family Mental health History: Description of Problems/ Symptoms: Suicide Screening (Ideation/Planning/Behaviour/History) Yes No If yes, summarize suicide safety plan: Current Medications Coping (What is the individual doing to cope at this time?) Resources/Supports (check applicable) Adequate housing Church affiliation Community groups Education Elders Employment Family Financial Stability Friends Health/Social Service Internet Access Medical Practitioners NNADAP Social/Recreational Transportation Other: Client Motivation/Stage of Change (not for use with children/adolescents at time of intake) Pre-contemplation Contemplation Preparation Action Maintenance Relapse Screening Summary (Describe issues/problems to be addressed in treatment e.g. history, impact on functioning, contributing risk factors or any other issues that may relate to provision of services) Please attach any information that does not fit here. 17

20 Risk Assessment Management Priority Rating: Symptoms Coping Supports Triage Level: 1 - Very severe 2 - Severe 3 - Moderate 4 - Mild Action Plan/ Collateral Information Declined Services Referred Elsewhere: Pending Service Completed Invited to re-contact Client to Contact/ Call-back Unable to contact client: No contact letter sent (yyyy-mm-dd): Sent Information/ Forms (yyyy-mm-dd): Information Sent: Assignment Information (Please attach any additional Information that does not fit here) Program Assigned To: Clinician Assigned To: Appointment Time / Date Of Request (yyyy-mm-dd): Appointment Confirmed with: On Telephone Letter Sent (yyyy-mm-dd): Other: 18

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