Substance Abuse Outpatient Care

Initial Appointment/Screening: Face to face client orientation is provided to all new clients to introduce them to program services, to ensure their understanding of the need of continuous care, and to empower them in accessing services. In accordance with Texas Administrative Code (TAC), clients will be informed of opportunities for family to be involved in the client’s treatment.

An appointment will be scheduled within a reasonable amount of time but not greater than 10 business days from a client’s request for substance use services.

The agency may provide written orientation materials to the client that supports the above information and is culturally sensitive and linguistically appropriate.

In urgent, non-life-threatening emergency circumstances, an appointment will be made as soon as possible but no later than within one (1) business day, subject to licensure requirements. If an agency cannot provide the needed services, the agency will offer to refer the client to another organization that can provide the services. The referral must be made within one (1) business day for urgent, non-life- threatening situation(s).

Each client must have a documented screening completed based on best practice standards of care with use of the Texas Department of Insurance criteria per TAC standards. The screening process shall collect information necessary to determine the type of services that are required to meet the client’s needs. [1]

Percentage of client charts with documentation of an appointment scheduled, after request (referral) for substance use outpatient services.

Percentage of client charts with documentation of completed screening as indicated.

Comprehensive Psychosocial Assessment: All clients referred to the program will receive a Comprehensive Psychosocial Assessment (in accordance with TAC Standards) by a licensed substance use counselor. Initial comprehensive psychosocial assessment protocols shall provide for screening individuals to determine level of need and appropriate development of treatment plan.

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

• Presenting problems resulting in need;
• Alcohol and other substance use;
• Psychiatric and chemical dependency treatment;
• Medical history and current health status, to include an assessment of Tuberculosis (TB), HIV, and other sexually transmitted infections (STI) risk behaviors as permitted by law;
• Relationships with family including domestic/intimate partner violence;
• History of trauma/related events;
• Stigma;
• Housing stability, expelled from home;
• Treatment adherences (e.g. HIV meds);
• Social and leisure activities;
• Education and vocational training;
• Employment history;
• Legal issues;
• Mental/emotional functioning; and
• Strengths and challenges. [1]

The assessment shall result in a diagnosed substance use issue, as allowed by the license and scope of practice of the counselor.

*Note: Clients are assessed for care coordination needs, and referrals are made to other case management programs as appropriate. If pressing needs emerge during the assessment requiring immediate attention that results in the assessment not finalized by the third session, this must be documented in the client’s primary record.

Specific 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.

A copy of the assessment(s) will be offered/provided to the client.

Percentage of client charts that have documentation of initial comprehensive assessments completed as indicated.

Percentage of client charts with documented use of assessment tools as indicated for substance use and sexual history.

Percentage of client charts with documented use of assessment tool as indicated for cognitive assessment.

Treatment Modalities: Providers must discuss treatment options with clients who use substances and should ask which treatment options they prefer.  

Providers should inquire about use of multiple substances and should consider the full spectrum of the client’s substance use when discussing treatment options with the client.

Providers must discuss alternative treatment modalities with the client that are focused on the substance(s) that the client is still using.

Providers must rely on the Patient Placement Criteria of the American Society of Addiction Medicine (ASAM) for guidance on selecting the best treatment alternatives for specific clients.

Medical treatment for substance use must adhere to current HIV Clinical Guidelines.

For medication-assisted therapies (e.g. methadone, suboxone) treatment, client charts will document contact with the client’s medical provider within 72 hours of initiation of methadone/suboxone to inform the medical provider of the new prescription or client refusal to authorize this communication.

Treatment for non-pharmacologic treatment modalities may include, but are not limited to, Twelve-Step Programs and Acupuncture. A person who provides acupuncture as a treatment modality must be licensed in the State of Texas and that practice is supervised by the Texas Medical Board.

All acupuncture services will be performed in accordance with the Acupuncture Act § 205.001(2)(A) and TAC Title 22, Chapter 9, §183.1. [2]

Percentage of client charts with documentation of discussion of treatment modalities with the client.

Percentage of client charts, for clients on medication-assisted therapies, with documentation of contact with client’s medical provider within 72 hours of treatment initiation or the client’s refusal to authorize the communication.

Percentage of clients with acupuncture services rendered with documented evidence of a physician’s order.

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

Individual, and family case records will include documentation of the following:

• Identification of the identified substance use disorder
• Goals and objectives
• Treatment modality (group or individual)
• Start date for substance use counseling
• Recommended number of sessions
• Date for reassessment
• Projected treatment end date
• Any recommendations for follow up

Treatment, as appropriate, will include counseling about (at minimum):

• Prevention and transmission risk behaviors, including root causes and underlying issues related to increased HIV transmission behaviors
• Treatment adherence
• Development of social support systems
• Community resources
• Maximizing social and adaptive functioning
• The role of spirituality and religion in a client’s life, disability, death and dying and exploration of future goals

The treatment plan will be signed by the substance use counselor rendering service.

In accordance with TAC on Substance Use, the treatment plan shall be reviewed at a minimum midway through the number of determined sessions agreed upon for frequency of modality and must reflect ongoing reassessment of client’s problems, needs and response to therapy.

Percentage of client charts that have documentation of treatment plans completed within 30 calendar days of the completed comprehensive assessment.

Percentage of client charts with documented evidence of treatment plans reviewed/modified at a minimum midway through the number of determined sessions agreed upon for frequency of modality in the client’s primary record.

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 session
• Interventions
• Assessment
• Duration of session
• Newly identified issues/goals
• Client’s responses to interventions and referrals
• HIV medication adherence
• Substance use treatment adherence
• Counselor authentication, in accordance with current TAC standards of care for substance use services.

Percentage of client charts with documented progress notes for each counseling session as indicated.

Percentage of client charts, as applicable, with documented referrals made based on need demonstrated in the assessment and/or progress notes.

Discharge Planning: Discharge planning will be done with each client 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 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.

Percentage of client charts with documentation, as applicable, of discharge planning with the client prior to case closure.

Services may be discontinued when the client has:

• Reached goals and objectives in their treatment plan
• Missed three (3) consecutive appointments in a six (6) month period.
• Continued non-adherence to treatment plan
• Chooses to terminate services
• Unacceptable client behavior
• Deceased

Completed discharge summary, in accordance with TAC Standards (§448.805) [3], as applicable.

Percentage of client charts with documentation of case closure (discharge) and reason for discharge, or discharge summary if applicable.

Proposed System Level Outcome Measure: Percentage of clients who demonstrate improved viral suppression after completing Substance Use Outpatient Treatment Plan objectives.