Form Instruments

INSTRUCTIONS

Please complete the following forms for all clients/patients entering services at your substance abuse facility or mental health organization during the designated reporting period. Clients/patients seen refers to the number of individuals who want to gain admission to treatment (or are referred to treatment) at the facility/organization/program, are financially eligible (through funds from State or local government support, insurance, or self pay), and do not have excluding conditions (e.g., precluded from facility by extensive health care needs or the individual needs care vastly beyond the level of care provided by the facility.)

The information is to be collected prospectively over the reporting period. Only those clients/patients who are seen and enter treatment during the reporting period) are to be counted.

Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this project is 0930-xxxx. Public reporting burden for this collection of information is estimated to average 4.5 hours per respondent per year, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 7-1044, Rockville, Maryland, 20857.

DEFINITIONS

Number of Clients/Patients/Consumers Seen. Unduplicated count of those signed in or formally registered for treatment. Clients/patients seen refers to the number of individuals who want to gain admission to treatment (or are referred to treatment) at the facility/organization/program, are financially eligible (through funds from State or local government support, insurance, or self pay), and do not have excluding conditions (e.g., precluded from facility by extensive health care needs or the individual needs care vastly beyond the level of care provided by the facility.)

Treatment: Substance abuse treatment is an organized array of services and interventions with a primary focus on caring for substance abuse disorders. For the Treatment Episode Data Set, the Center for Substance Abuse Treatment defines treatment to include the following general categories: hospital, short- and long-term residential and outpatient. Mental health treatment is an organized array of services and interventions with a primary focus on treating mental disorders, whether providing acute stabilization or ongoing treatment. These programs may exist in a variety of settings, such as traditional outpatient mental health centers (e.g., outpatient clinics and psychosocial rehabilitation programs) or more intensive inpatient treatment units.

Program: Currently, substance abuse treatment programs use the Service Delivery Unit (SDU) as their program definition for the National Survey of Substance Abuse Treatment Services. Mental health treatment programs use facility or organization in reporting for the Survey of Mental Health Organizations, General Hospital Mental Health Services, and Managed Behavioral Health Care Organization (SMHD).

Organization: An entity that provides mental health services in two or three service settings (inpatient, residential, or outpatient) and is not classified as a psychiatric or general hospital.

Co-occurring Disorders (COD): Refers to co-occurring substance use (abuse or dependence) and mental disorders. Clients said to have co-occurring disorders have one or more mental disorders as well as one or more disorders relating to the use of alcohol and/or other drugs.

Screening: The purpose of screening is to determine the likelihood that a person has a co-occurring substance use or mental disorder. The purpose is not to establish the presence or specific type of such a disorder, but to establish the need for an in-depth assessment. Screening is a formal process that typically is brief and occurs soon after the client presents for services. There are three essential elements that characterize screening: intent, formal process, and early implementation.

 Intent. Screening is intended to determine the possibility of a co-occurring disorder, not to establish definitively the presence, or absence, or specific type of such a disorder.

 Formal process. The information gathered during screening is substantially the same no matter who collects it. Although a standardized scale or test need not be used, the same information must be gathered in a consistently applied process and interpreted or used in essentially the same way for everyone screened.

 Early implementation. Screening is conducted early in a person’s treatment episode. For the purpose of this questionnaire, screening would routinely be conducted within the first four (4) visits or within the first month following admission to treatment.

DEFINITIONS (continued)

Assessment: An assessment consists of gathering information and engaging in a process with the client that enables the provider to establish the presence or absence of a co-occurring disorder; determine the client’s readiness for change; identify client strengths or problem areas that may affect the processes of treatment and recovery, and engage a person in the development of an appropriate treatment relationship. The purpose of the assessment is to establish (or rule out) the existence of a clinical disorder or service need and to work with the client to develop a treatment and service plan. Although a diagnosis is often an outcome of an assessment, a formal diagnosis is NOT required to meet the definition of assessment, as long as the assessment establishes (or rules out) the existence of some mental health or substance use disorder.

Assessment is a formal process that may involve clinical interviews, administration of standardized instruments, and/or review of existing information. For instance, if reasonably current and credible assessment information is available at the time of program entry, the (full) process need not be repeated. There are two essential elements for the definition of assessment: establish or rule-out a co-occurring disorder (diagnosis) and results of assessment used in treatment plan.

• Establish (rule-out) Co-occurring Disorder. The assessment must establish justification for services and yield sufficient information to determine or rule-out the existence of co-occurring mental health and substance use disorders. [A specific diagnosis is NOT required.]

• Results used in treatment plan. The assessment results must routinely be included in the development of a treatment plan.

Direct Assessment: For the purpose of this questionnaire, ‘direct assessment’ refers to the process of conducting a formal assessment, as defined above, when no screening that meets the above definition has been conducted.

Referral: A process for facilitating client/consumer access to specialized treatments and services through linkage with, or directing clients/consumers to, agencies that can meet their needs. For COD, referrals are frequently made for detoxification, assessment, special treatment, and medications.

COORDINATION, CONSULTATION, COLLABORATION, INTEGRATION

The concepts below are associated with the Quadrant Model.

Minimal coordination, consultation, collaboration, and integration are not discreet points but bands along a continuum of contact and coordination among service providers. “Minimal coordination” is the lowest band along the continuum, and integration the highest band. Please note that these bands refer to behavior, not to organizational structure or location. “Minimal coordination” may characterize provision of services by two persons in the same agency working in the same building; “integration” may exist even if providers are in separate agencies in separate buildings.

Minimal coordination: “Minimal coordination” treatment exists if a service provider meets any of the following: (1) is aware of the condition or treatment but has no contact with other providers, or (2) has referred a person with a co-occurring condition to another provider with no or negligible follow up.

Consultation: Consultation is a relatively informal process for treating persons with co-occurring disorders, involving two or more service providers. Interaction between or among providers is informal, episodic, and limited. Consultation may involve transmission of medical/clinical information, or occasional exchange of information about the person’s status and progress. The threshold for “consultation” relative to “minimal coordination” is the occurrence of any interaction between providers after the initial referral, including active steps by the referring party to ensure that the referred person enters the recommended treatment service.

Collaboration: Collaboration is a more formal process of sharing responsibility for treating a person with co-occurring conditions, involving regular and planned communication, sharing of progress reports, or memoranda of agreement. In a collaborative relationship, different disorders are treated by different providers, the roles and responsibilities of the providers are clear, and the responsibilities of all providers include formal and planned communication with other providers. The threshold for “collaboration” relative to “consultation” is the existence of formal agreements and/or expectations for continuing contact between providers.

Integration: Integration requires the participation of substance abuse and mental health services providers in the development of a single treatment plan addressing both sets of conditions, and the continuing formal interaction and cooperation of these providers in the ongoing reassessment and treatment of the client. The threshold for “integration” relative to “collaboration” is the shared responsibility for the development and implementation of a treatment plan that addresses the co-occurring disorder. Integration might be provided by a single individual, if s/he is qualified to provide services that are intended to address both co-occurring conditions. Although integrated services may often be provided within a single program in a single location, this is not a requirement for an integrated system.

SCREENING, ASSESSMENT, AND TREATMENT

What type of services does this program/SDU/facility/organization provide? [Mark X to one only]

G Mental Health

G Substance Abuse

G Integrated Mental Health and Substance Abuse Co-occurring Program

NOTE: Please include only clients that enter your facility/organization during the reporting period.

A. _____ Number of clients/patients/consumers entering your program/facility/organization during the reporting period.

SCREENING

Screened for both mental and substance use disorders

B. _____ Total number of clients/patients/consumers screened for both mental and substance use disorders.

B1. _____ Number of these clients/patients/consumers who screened positive for both mental and substance use disorders (i.e. screened positive for co-occurring disorders).

B2. _____ Number who screened positive for a mental disorder but not for a substance use disorder.

B3. _____ Number who screened positive for a substance use disorder but not for mental disorder.

B4. _____ Number who screened negative for both mental and substance use disorders.

[Note: The sum of items B1 – B4 should equal the number reported in item B.]

Screened only for a substance use disorder; no screen for a mental disorder

C. _____ Number of clients/patients/consumers screened only for a substance abuse disorder.

C1. _____ Number with positive screen for a substance use disorder.

C2. _____ Number with negative screen for a substance use disorder.

[Note: The sum of items C1 – C2 should equal the number reported in item C.]

Screened only for a mental disorder; no screen for a substance use disorder

D. _____ Number of clients/patients/consumers screened only for a mental disorder.

D1. _____ Number with positive screen for a mental disorder.

D2. _____ Number with negative screen for a mental disorder.

[Note: The sum of items D1 – D2 should equal the number reported in item D.]

Not screened for either type of disorder

E. _____ Number of clients/patients/consumers not screened for either substance use or mental disorders.

E1. _____ Number of clients/patients/consumers reported in item E who were directly assessed for both mental and substance use disorders.

E2. _____ Number of clients/patients/consumers reported in item E who were directly assessed for a mental disorder but not for a substance use disorder.

E3. _____ Number of clients/patients/consumers reported in item E who were directly assessed for a substance use disorder but not for a mental disorder.

E4. _____ Number of clients/patients/consumers reported in item E who were not directly assessed for either substance use or mental disorders.

[Note: The sum of items E1 – E4 should equal the number reported in item E.]

[Note: The sum of items B - E should equal the number reported in item A.]

ASSESSMENT

F. _____ Total number of clients/patients/consumers assessed for both mental and substance use disorders. [NOTE: Include all persons assessed for both disorders, whether or not they were screened.]

F1. _____ Total number of clients/patients/consumers reported in item F who were determined to have both a mental disorder and substance use disorder (i.e., to have co-occurring disorders).

F2. _____ Total number of clients/patients/consumers reported in item F who were determined to have only a mental disorder, but no substance use disorder.

F3. _____ Total number of clients/patients/consumers reported in item F who were determined to have only a substance use disorder, but no mental disorder.

F4. _____ Total number of clients/patients/consumers reported in item F who were determined to have neither a mental nor a substance use disorder.

[Note: The sum of items F1 – F4 should equal the number reported in item F.]

G. _____ Total number of clients/patients/consumers assessed for a mental disorder but not for a substance abuse disorder. [NOTE: Include all persons assessed only for a mental disorder, whether or not they were screened.]

G1. _____ Number of persons reported in item G who were determined to have a mental disorder.

G2._____ Number of persons reported in item G who were determined not to have a mental disorder

[Note: The sum of items G1 – G2 should equal the number reported in item G.]

H. _____ Total number of clients/patients/consumers assessed for a substance use disorder but not for a mental disorder. [NOTE: Include all persons assessed only for a substance use disorder, whether or not they were screened.]

H1. _____ Number of persons reported in item H who were determined to have a substance use disorder.

H2._____ Number of persons reported in item G who were determined not to have a substance use disorder

[Note: The sum of items H1 – H2 should equal the number reported in item H.]

I. _____ Number of clients/patients/consumers not assessed for either a mental or a substance use disorder.

[Note: The sum of items F – I should equal the number reported in item A.]

HAVE CO-OCCURRING DISORDER

J. _____ Number of clients/patients/consumers determined to have co-occurring disorder through a formal process of assessment. [Should equal number in item F1.]

K. _____ Number of clients/patients/consumers determined to have co-occurring disorder through processes not meeting the threshold definition of assessment.

L. _____ Total number of clients/patients/consumers determined to have a co-occurring disorder. [Should equal sum of items J and K.]

TREATMENT

M. _____ Number of persons reported in item L who received treatment within your facility.

M1. _____ Number of persons reported in item M who were treated for both disorders within your facility.

M2. _____ Number of persons reported in item M who were treated for their mental disorder(s) at your facility and treated elsewhere for their substance use disorder(s).

M3. _____ Number of persons reported in item M who were treated for their substance use disorder(s) at your facility and treated elsewhere for their mental disorder(s).

M4. _____ Number of persons reported in item M who were treated for their mental disorder(s) at your facility and who, to your knowledge, were not treated elsewhere for their substance use disorder(s).

M5. _____ Number of persons reported in item M who were treated for their substance use disorder(s) at your facility and who, to your knowledge, were not treated elsewhere for their mental disorder(s).

N. ____ Sum of M1, M2, and M3. (Number of persons treated for co-occurring disorders.)

N1. _____ Number of persons reported in item N treated for co-occurring disorders with minimal coordination

N2. _____ Number of persons reported in item N treated for co-occurring disorders with through consultation.

N3. _____ Number of persons reported in item N treated for co-occurring disorders through collaboration.

N4. _____ Number of persons reported in item N treated for co-occurring disorders through integration.

[Note: The sum of items N1 – N4 should equal the number reported in item N.]

Policies On Screening, Assessment, Referral And Treatment

INSTRUCTIONS

In answering the following questions, use the accompanying definitions. Note that some definitions have minimum essential elements, in which case all elements must apply to your program for a “yes” answer. The questions focus on a program’s policy or intent, and recognize that any policy is unlikely to be implemented with all clients. If none of the options precisely matches your program’s practice, pick the one best answer that most closely describes your program.

For the purposes of this questionnaire, the terms “screening” and “assessment” apply specifically to the acquisition and use of information intended to determine the presence or absence of co-occurring substance abuse and mental disorders. The processes of screening and assessment are viewed as points along a continuum of information about persons receiving services for substance abuse or mental disorders or both. Screening and assessment are points along the continuum. Some programs may engage in information processes that do not fully meet the minimum definition of “screening,” and others may exceed the minimum requirements for “assessment.”

1

. SCREENING AND ASSESSMENT

A. Does your program/facility/organization have a written policy/procedure requiring all clients to be screened for the possible existence of a co-occurring disorder?

G Yes (answer item A1 and skip item B)

G No (skip item A1 and answer item B)

A1. Does your program/facility/organization have a written policy/procedure requiring assessment of all clients whose screening suggests the existence of a co-occurring disorder?

G Yes (skip item B and answer item C)

G No (skip item B and answer item C)

B. Does your program/facility/organization have a written policy/procedure requiring all clients to be assessed for the presence of a co-occurring disorder?

G Yes

G No

C. (Answer this question regardless of the answers to questions A, A1, and B)

Which statement best describes the typical way assessments are conducted by your program?

[Check “b” or “c” only if all minimum elements of the definition of assessment apply to your program, otherwise answer “a.”]

G a. We do not conduct assessments

G b. Assessments are conducted by a member of our program staff (include persons contracted to assess clients/patients)

G c. We refer out for assessments

2

. TREATMENT AND REFERRAL

A. Does your program/facility/organization have a written policy/procedure governing disposition of persons who have a co-occurring disorder?

G Yes

G No (skip to item C)

B. Which option best describes how your program typically operates?

G a. We do not typically serve persons known to have co-occurring disorders

G b. We treat mental disorders only

G c. We treat substance abuse disorders only

G d. We treat both mental disorders and substance abuse disorders within our program

G e. We treat mental disorders within our program and refer the person for substance abuse treatment

G f. We treat substance abuse disorders within our program and refer the person for mental disorder treatment

C. What type of services are persons with co-occurring conditions most likely to receive from your program/facility/organization?

G a. No contact

G b. Minimal Coordination

G c. Consultation

G d. Collaboration

G e. Integration

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