Substance Abuse Outpatient Care

Provision of Services: Support for Substance Abuse Treatment Services-Outpatient, is provided by or under the supervision of a physician or other qualified/licensed professionals. In Texas this includes a licensed chemical dependency counselor or one of the practitioners listed below who is licensed and in good standing in the State of Texas and has at least 1,000 hours of documented experience treating substance-related disorders:

• Licensed professional counselor (LPC)
• Licensed master social worker (LMSW)
• Licensed marriage and family therapist (LMFT)
• Licensed psychologist
• Licensed physician
• Licensed physician's assistant
• Certified addictions registered nurse (CARN)
• Advanced practice nurse practitioner recognized by the Board of Nurse Examiners as a clinical nurse specialist or nurse practitioner with a specialty in psych-mental health (APN-P/MH)

Services include and are limited to:

• Pre-treatment/recovery readiness programs
• Harm reduction
• Mental health counseling associated with substance use disorder
• Opiate-assisted therapy
• Neuropsychiatric pharmaceuticals
• Relapse prevention
• Acupuncture (requires a referral from the clients’ HIV medical provider, cannot be the primary treatment modality, and must be provided by a licensed acupuncture provider)

1. Percentage of clients with documentation that services are provided by or under the supervision of a physician or qualified licensed professional. (Pilot Measure)
    
2. Percentage of clients with documentation that all services provided are allowable under the Ryan White Part-B and State Services program. (Pilot Measure)

Comprehensive Psychosocial Assessment: All clients referred to the program will have a comprehensive psychosocial assessment completed by a licensed substance use counselor or other qualified licensed professionals. 

The comprehensive psychosocial assessment will be completed prior to the third counseling session and will include the following:

• Presenting problems
• Alcohol and other substance use
• Psychiatric and chemical dependency treatment
• Medical history and current health status
• Relationships with family including domestic/intimate partner violence
• History of trauma/related events
• Experience with HIV or substance use-related stigma
• Housing stability, expelled from home
• HIV treatment adherence
• Social and leisure activities
• Education and vocational training
• Employment status and history
• Legal issues
• Mental/emotional functioning
• Strengths and challenges

Approved assessment tools such as the Substance Abuse and Mental Illness Symptoms Screener (SAMISS) and Addiction Severity Index (ASI) may be used for substance use and sexual history, and the Mini Mental State Examination (MMSE) may be used for cognitive assessment. Other industry-recognized assessment tools may be used if approved by the substance abuse treatment services - outpatient provider agency.

3. Percentage of clients with documentation of initial comprehensive psychosocial assessments completed by the third counseling session.
    
4. Percent of clients with documentation of a comprehensive psychosocial assessment completed with a licensed professional using industry-recognized assessment tools.

Treatment Plan: A treatment plan shall be completed within 30 calendar days of completing a comprehensive psychosocial assessment specific to individual client needs. Treatment planning will be a collaborative process through which the provider and client develop desired treatment outcomes and identify the strategies and modalities for achieving them.

The treatment plan will include documentation of the following:

• Identification of the identified substance use disorder
• Goals and objectives and progress toward meeting them
• Treatment modality
• Start date for substance use counseling
• Recommended number of sessions
• Date for reassessment
• Projected treatment end date
• Any recommendations for follow up

The treatment plan must be signed by the licensed substance use counselor who is providing and or supervising the service.

5. Percentage of clients with documentation of a treatment plan completed within 30 calendar days of the completed comprehensive assessment.
    
6. Percentage of clients with documentation that treatment plans are reviewed/modified midway through the number of determined sessions agreed upon at a minimum.

Progress Notes: Services will be provided according to the individual's treatment plan and documented in the client's record. Progress notes are completed for every professional counseling session and include:

• Client name
• Session date
• Clinical observations
• Focus of the session
• Interventions
• Assessment
• Duration of session
• Newly identified issues/goals
• Client’s responses to interventions and referrals
• HIV medication adherence
• Substance use treatment adherence
• Documentation of missed visits with attempts to reschedule as applicable

7. Percentage of clients with documented progress notes for each counseling session that the client attended, or documentation of missed visits and attempts to reschedule as applicable.

Referrals: The agency will offer appropriate referrals to clients for support services as applicable to meet goals.

8. Percentage of clients with documentation of referrals offered as applicable.

Discharge Planning: Discharge planning will be completed when treatment goals are met and include:

• Circumstances of discharge
• Summary of needs at admission
• Summary of services provided
• Goals and objectives completed during counseling
• Referral after completing substance use treatment to a case manager and/or primary care provider, as appropriate
• Discharge plan
• Counselor authentication, in accordance with TAC Standards and the counselor licensure requirements.

In all cases, providers/case managers shall ensure that, to the greatest extent possible, clients who leave care are linked with appropriate services to meet their needs.

9. Percentage of clients with documentation of discharge planning in collaboration with the client prior to case closure as applicable.

Discharge: Services may be discontinued when the client has:

• Reached goals and objectives
• Ongoing non-adherence to the treatment plan
• Has missed three consecutive appointments in a six-month period
• Self-terminates services
• Unacceptable client behavior
• Deceased

Note: Staff should not inactivate clients in Take Charge Texas (TCT) at the time of discharge, unless the case is being closed due to a deceased client.

10. Percentage of clients with documentation of discharge summary as applicable.