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

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1 I. DEFINITION OF SERVICE New Haven/Fairfield Counties Ryan White Part A Program Substance Abuse Service Standard SUBSTANCE ABUSE 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: 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 Prepared by Germane Solutions Page 1

2 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 1. Are provided only with a written referral from the client s primary care provider 2. Are offered by a provider with appropriate State license and certification if it exists Prepared by Germane Solutions Page 2

3 II. DESCRIPTION OF SERVICE Substance Abuse Treatment Services Outpatient 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 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 New Haven/Fairfield Counties Ryan White Part A Program Substance Abuse Service Standard SERVICES PERFORMANCE MEASURE/METHOD MONITORING STANDARD LIMITATIONS 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 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 or licensed practitioners wherever The acupuncture provider has appropriate State certification or licensure State license and certification exists 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 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 Limited to only those services as indicated Must be in an outpatient setting only Acupuncture can not be the dominant treatment modality Prepared by Germane Solutions Page 3

4 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 New Haven/Fairfield Counties Ryan White Part A Program Substance Abuse Service Standard SERVICES PERFORMANCE MEASURE/METHOD MONITORING STANDARD LIMITATIONS 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 The signature of the individual providing the service or the supervisor as applicable Prepared by Germane Solutions Page 4

5 Substance Abuse Treatment Inpatient SERVICE 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 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) PERFORMANCE MEASURE/METHOD 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 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 MONITORING STANDARD 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 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 Evidence of regular monitoring and assessment of client progress LIMITATION Prepared by Germane Solutions Page 5

6 III. NATIONAL FISCAL MONITORING STANDARDS (HRSA issued April 2013): SERVICE 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 2. No charges imposed on clients with incomes below 100% of the Federal Poverty Level (FPL) 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 PERFORMANCE MEASURE/METHOD 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 Review of provider policy for schedule of charges to ensure clients with incomes below 100% of the FPL are not charged for services 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. MONITORING STANDARDS 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 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. 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 Personnel are aware and consistently following the policy for schedule of charges and cap on charges. LIMITATIONS Prepared by Germane Solutions Page 6

7 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 selfreport 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 Urine or comparable drug screening test results showing decrease in drug use or maintenance of sobriety. Service Unit(s): Successful enrollment in a 24-hour treatment day Prepared by Germane Solutions Page 7

8 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 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 certifiedeligible staff 100% of all agencies have unlicensed/ certified staff supervised by licensed professional B. Continuous Quality Improvement (CQI) including Ongoing professional staff training in HIVspecific 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 professional 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 100% of agencies will have a CQI Plan updated annually Prepared by Germane Solutions Page 8

9 II. Outpatient Process D. Intake/Assessment: charts will contain a completed intake and assessment (per DMHAS regulation schedule). E. Treatment Plan compliant with DMHAS regulations * Engaged client = individual invested in treatment and attends 50% of appointments Outcome Measure Numerator Denominator Data Source Goal/Benchmark 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. E. Treatment is delivered with an individualized treatment plan, addresses adherence, indicate suggested treatment frequency by type; estimated end date documented; is coconstructed with client, and signed by client within 30 days of admission D. Number of new client charts with assessment completed within 14 days of first face-to-face visit E. Number of clients with a treatment plan completed within 30 days of admission Number of clients with clients with co-constructed, cosigned treatment plans Number of clients with treatment plans addressing adherence every 6 months D. Total number of new clients E. Total number of 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. Chart audit E. 100% of client charts have treatment plan completed and documented no later than 30 days of admission. 100 % or Treatment Plans are co-constructed with client, and signed by client 100% of Treatment Plans will address adherence to all client medications a minimum of every 6 months Prepared by Germane Solutions Page 9

10 II. Outpatient Process E. Treatment Plan compliant with DMHAS regulations Outcome Measure Numerator Denominator Data Source Goal/Benchmark 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. Number of client charts with methadone/ suboxone treatment document medical provider contacted within 72 hours of treatment initiation Number of clients on methadone/ suboxone 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. F. Access to & Maintenance in Medical Care: RW clients ongoing participation in primary HIV medical care 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. 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. Number of clients with treatment plans reassessed every 6 months F. Number of clients assessed/verified for medical care initially and every 3 months Total number of clients F. Total number of clients 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. Chart audit F. 100% of clients are assessed and verified for engagement in medical care. This is assessed initially, then reassessed and documented every 3 months. Prepared by Germane Solutions Page 10

11 II. Outpatient Process G. Risk Reduction Counseling: to prevent secondary transmission of HIV H. Referral to Support Services I. Discharge of Client for Services Outcome Measure Numerator Denominator Data Source Goal/Benchmark G. All clients will receive risk reduction counseling a minimum of twice yearly H. Substance Abuse providers routinely coordinate all necessary services along the Continuum of Care. I. Upon termination of active substance abuse services, a client case is closed and contains a closure summary documenting the case disposition. G. 100% of clients receive risk reduction counseling at a minimum of twice a year H. Number of clients with referrals to support services I. Number of client charts with closure summary G. Total number of clients H Total number clients with documented need for referral I. Total number of closed charts G. Chart audit G. 100% of clients receive risk reduction counseling at a minimum of twice a year 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. Chart audit I. 100 % of closed cases include documentation stating the reason for closure and a closure summary with a supervisor s signature indicating approval. Prepared by Germane Solutions Page 11

12 III. Outpatient Outcome J. Decreased use of drugs and alcohol frequency or maintenance of decreased drug use K. Efficacy of Services: clients are satisfied with their treatment Outcome Measure Numerator Denominator Data Source Goal/Benchmark 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 K. Standardized Ryan White Part A Client satisfaction surveys are conducted annually. J. Number of clients show decreased drug use frequency or maintenance of decreased drug use in a 6 month time K. Number of clients offered a survey J. Number of clients K. Total number of clients J. Chart audit or other site data system K. Chart audit or 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. 100% of clients are offered a standardized Ryan White client satisfaction survey annually Prepared by Germane Solutions Page 12

13 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. N. Treatment Plan N. Charts will have a treatment plan initiated within 72 hours of admission. M. Number of new client charts with assessment completed within 3 days of admission N. # of charts with treatment plan initiated within 72 hours M. Total number of new clients N. Total number of clients M. Chart audit M. 100% charts will have an individual intake and biopsychosocial assessment documented with 3 days of admission N. Chart audit 100% of charts will have an initiated treatment plan within 72 hours of admission. Prepared by Germane Solutions Page 13

14 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 V. DATA REPORTING 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. 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. The Chart Audit Tool for Substance Abuse Recovery Readiness is attached on the next page Prepared by Germane Solutions Page 14

15 STRUCTURE ( WHO ) Substance Abuse Tool STAFF Verification Licensure Substance Abuse staff currently licensed, certified, or license- eligible Verification Supervision of all unlicensed/certified staff is supervised by a licensed Substance Abuse professional 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 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 CQI Plan updated annually ensures ongoing improvement of services. Plan exists, has EMA- wide components and is updated on a yearly basis 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 ) INFRASTRUCTURE INITIAL ASSESSMENT Documentation of Presenting Issue Chart 7 shows that some system for Presenting Issue is recorded - - AXIS, DSM, etc. 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) Methadone/ Buprenorphine Clients Only Document contact with medical provider within 9 72 hours to inform the provider of new Rx or client refusal to authorize contact HIV Risk Reduction Counseling HIV Risk 10 reduction counseling a minimum of twice yearly Suggested Treatment Frequency/Duration Estimated # of sessions by type (individual, 11 group); estimated end date (documented) or rationale for continuation with note of frequency of intervention/plan Treatment Plan Treatment Plan Addresses 12 adherance; Signed by client within 30 days of intake Goals Set Documentation, signature and date, where appropriate, that treatment goals are set 13 with client and therapist/clinician. Date documented for review/reassessment OUTCOME ("What Impact") Prepared by Germane Solutions

16 CARE STATUS CARE STATUS Goals Met Documentation that goals are met, dated. Further treatment plan outlined. 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 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) Referral of Follow- Up (if indicated) Coordination necessary services in Continuum 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 mandate Prepared by Germane Solutions

17 Prepared by Germane Solutions New Haven/Fairfield Counties Ryan White Part A Program Substance Abuse Service Standard

18 Prepared by Germane Solutions New Haven/Fairfield Counties Ryan White Part A Program Substance Abuse Service Standard

19 Prepared by Germane Solutions New Haven/Fairfield Counties Ryan White Part A Program Substance Abuse Service Standard

20 Prepared by Germane Solutions New Haven/Fairfield Counties Ryan White Part A Program Substance Abuse Service Standard