Foundations of Addiction Treatment

By

Cynthia Moreno Tuohy, NCAC II, CCDC III, SAP

NAADAC Executive Director

Getting to Know Each Other

• Please give a brief self-introduction

describing:

• Your career background

• Specific experience relating to intake,

screening & assessment

Documentation

As a component of Case

Management

Introduction

This curriculum provides instruction on the components of documentation In this session we will learn:

• The purpose of clinical documentation

• Elements of good documentation

• Why documentation is important

• Various forms of progress notes forms.

• The dos and don’ts of documentation

• Use of standardized forms.

• Quality assurance

• Clinical file development

Participant Expectations

• Describe what you expect to achieve from this session

• Do you have specific issues in documentation, and if so, in what types of documentation or in what settings.

Learning Objectives

At the end of this session you will be able to:

• Provide an overview of why documentation is important.

• Describe various forms of documentation.

• Demonstrate how documentation supports treatment and validates what has been done.

• Improve documentation of services provided and recordation in the case files.

• Improve the quality of record keeping and insure that goals identified in the client’s “service plan” are tracked and recorded.

Purposes of Clinical Documentation

The twelve key purposes of clinical documentation are:

• To document professional work

• To serve as the basis for organization and continuity of care

• To record clinically meaningful information

• To record the client’s response, problems experienced in treatment, and the solutions to the problems.

• To serve as the basis for subsequent continuity of care by other practitioners.

• To provide risk management and malpractice protection

Purposes of Clinical Documentation

The twelve key purposes of clinical documentation are:

• To provide oversight of the counselor’s decision making process

• To provide documentation that will support the adequacy of the clinical assessment

• To comply with legal, regulatory and institutional requirements

• To facilitate utilization review through the recording of professional activities

• To facilitate quality improvement through

• To facilitate coordination of professional

Elements of Good Clinical

Documentation

Nine elements of good clinical documentation

Good clinical documentation:

• Serves the purposes of documentation (as outlined above) that are applicable to a given situation

• Uses relevant direct quotes from the client and other sources

• Distinguishes clearly between facts, observations, hard data and opinions

• Is internally consistent

• Is written in the present tense, as appropriate

Elements of Good Clinical

Documentation

Nine elements of good clinical documentation

Good clinical documentation:

• Provides relevant information in appropriate detail

• Is organized with appropriate headings and logical progression

• Is thoughtful, reflecting the application of professional knowledge, skills and judgment in the treatment and/or services provided

• Is appropriately concise

Goals of Writing

Accountability - service delivery,

service centered, impact on client

situation

Efficiency - focused and succinct

Privacy – protect client’s information

What to Include in Records

• Date of your interaction

• Basic information about client

• Counselor name,

• Other persons who talked or worked with

Counselor

What to Include in Records

• Purpose for contact/interview

• Reason for client contact

• More detailed information about the client’s problem and situation

1. Intake Form 2. Bio-psycho-social-spiritual History

Elements of Good Case Documentation

Use concrete, descriptive language

Record evidence of the senses: things seen, heard, smelled, tasted, and touched

Use words with clear meanings and avoid value-laden terms

Elements of Good Case Documentation

Fully identify persons, places, direct quotations, and sources of information

Record facts, not an evaluation of the facts

Clearly label your impressions and base them on observable information

What to Include in Records

• Date of your interaction

• Basic information about client

• Worker name, persons who talked with worker

• Purpose for contact/interview

• Reason for client contact

• More detailed information about the client’s problem and situation

Process Recording

• A specialized and highly detailed form of recording

• Everything that takes place in an interview is recorded, use of direct quotes; “he said”, “she said”

• Include column to record own impressions, gut feelings are relevant

• Can be used as an evaluative tool - assess what the counselor is feeling and doing

• Keeps agency informed of exact details of what type of treatment is given and the responses to the treatment

• Increases self-awareness and helps the counselor differentiate among facts, feelings and impressions

• Very time consuming and therefore, used primarily for students in internship

• Allows students to analyze in detail their interactions with clients

Sample Form

Date____10/10/2009________________Location ___Counseling Office

Client Name ___Joe Johns ____________

Client Identifier #____12345__________

Session Notes:

Client arrived at 1:50 p.m. for his 2:00 p.m. appointment. Client said, “Doc this has been a great day.” Counselor reminded client she is not a doctor. Client said, “I like calling you Doc.” Asked client about side effects of medication and he stated he has had none but has had trouble sleeping the past few nights. Advised client to discuss with unit physician.

Asked why is this a great day. Client stated that he likes the feeling of not being hung over and that he will get to talk with his children this evening. This will be the first time he has talked with his children ages 7, 9, and12 since entering the program. Client has written them several letters and explained why he is away. Client said “I am nervous about talking with them.” “I feel ashamed to tell them their father is a drunk.” Counselor listened and provided support for client. Said that she is sure his children love him and will be glad to hear his voice. Counselor asked, “What questions do you think your children will ask you?” Client stated he was not sure but thought they would ask when he would be home.

Session ended at 2:47 p.m. Next session is 10/14/2009 at 2:00 p.m.

Impressions/Comments:

This is client’s third time in an inpatient rehabilitation program. Comments from other staff question whether client is committed to sobriety at this time. Counselor’s impression is that client was saying what he thought she wanted to hear rather than what he is really feeling and thinking. Counselor thinks client is afraid of failing again.

Counselor Mary Helper Signature____________________________

Narrative Recording

• Narrative allows for much greater attention to client’s individuality

• Used in all fields of practice

• Organized by subject or chronologically

• Can include many important aspects of client or client situation

• Time consuming

• Information difficult to retrieve

• Quality depends on counselor’s ability to write or organize appropriately

Sample Narrative

Date ___________________ Client Identifier #_____________

Client__________________ Date of Birth________________

The purpose of my phone contact with Iama Person was to discuss the day care provider choices available to her while she is in our outpatient treatment program. The need for Iama to participate in parenting education classes was identified in the Treatment Plan. In order to participate in these classes, Iama will need help with childcare for her daughter.

Summary of contact: Iama has agreed to place her daughter Stacy in day care two days a week, which will then make it possible for Iama to attend parenting classes. Iama would like to visit the day care facilities before making a decision. I provided her with the contact names and phone numbers of the daycare resources available to her.

Outcome/Next Steps: Iama will call by next week to let me know which of the two day care facilities she chooses, and I will then refer Stacy to the daycare of her choice. I will continue to measure the effectiveness of services in addressing the issues of abuse and neglect which led to the Child Protection Division the decision that this is a family in need of Child Protective Services. Iama will continue with her individual and group counseling sessions and attend AA meetings on days she does not attend our program.

Counselor _______________Signature______________________

Case/Progress Notes

A proper case/progress note does not need to be particularly extensive;

• the date of the contact,

• description of the type of contact

• indication of who initiated the contact

• statement of where the contact took place

• indication of who was involved in the

• a description of the themes of the

• details of any new significant history obtained

Case/Progress Notes (cont.)

• details and description of relevant problems newly identified

• details and description of relevant significant new events

• statement of what was accomplished in the session

• statement of what wasn't accomplished in the session

• statements of any needs to be followed-up

• details of obstacles to progress and a plan to address

• description of a plan for further care

Sample Form

Date____________ Client Name______________________________

Client Identifier #________________________

• I went to transitional home for quarterly face-to-face contact with client. Client has been at the transitional home for three months and all reports are that he is doing well. I met with transition home counselor at the home prior to meeting with client. The transitional home counselor reported that the client had made much progress in his therapy group this quarter. She had reported at previous meeting that client had not wanted to share any of his issues with the group and just sat there until the time was up in group and then left with no remarks. During this quarter, he has begun to open up about his feelings regarding his birth father and his anger toward him. He has talked about his drug use. The transition home counselor began meeting with him individually two months ago and that one-on-one counseling has given him the encouragement to share with the group. The transition home counselor warned me that client would want to discuss his desire to return home as soon as possible.

•

• I met with client alone to discuss his progress over the last quarter. He reported that he is feeling good about everything these days and just wants to go home. He wanted to know when that could happen. I told him it was not just my decision but that we would get together with his transition home counselor and other relevant treatment staff to discuss exactly what therapy and steps in recovery need to happen before that could occur. Client wanted to know a date and time when that meeting would happen. I advised him that I did not know. He became very angry and started acting out by raising his voice and making angry gestures. The transition home counselor came in and was able to calm him down without assistance. Client seems scary when he gets really mad. I decided to leave at that point and told the transition home counselor that I would call to set the appointment for an interdisciplinary team meeting.

Signature or initials of counselor Page #

Summary Recording

Summary recordings pull together multiple contacts in one narrative entry

• Involves primarily narrative format

• Much briefer and is used most often in the counseling professions

• Leaves out “I said”, “he said”

• The interview is summarized

• Main focus is client and not what helper says and does

• Irrelevant details are omitted and pertinent material is recorded in much briefer style

• Gives concise presentation of interview content

• Describes results or outcome, but not all detailed steps the counselor took to accomplish the results

• Preferred because it is briefer, and supports the supervisor and others staff from reading long recordings

• Lengthy progress notes does not always equate to good progress noting

Sample Summary Recording

SAMPLE SUMMARY RECORDING

• Date____10/10/2009 Client Identifier #_____123456______

• Client Name_____Marco Polo___ Date of Birth_____9/23/1968______

• Summary

• Client was referred to the program after being arrested for disorderly conduct. He attended his intake session and was cooperative evidenced through evasive and incomplete answers to questions related to his history of alcohol use. He denied any history of drug use. Mr. Smith agreed to attend psycho-social educational weekly group sessions for 8 weeks and weekly individual sessions for 4 weeks. Mr. Polo will be re-evaluated at the end of the 8 week program.

• Signature or initials of counselor____________________________________________

• Printed name of counselor__________________________________________________

• Page #_____

SOAP Note Recording

SOAP note recording is a strategy for summarizing the important points of each client visit.

• Subjective information –client’s perception

• Objective information –facts and observations you believe are relevant to record

• Assessments –your impression about how much progress has been or not been made

• Plans – should be concise and clear, what is your next step, what have you and client committed to do?

Example SOAP Note

• Date__10/10/2009_____________ Client Identifier #_______1234___________

• Client __Kato Ono Date of Birth____________________________

• Subjective:

• Kato (client) states they were in a hurry to get here – “can’t seem to manage my time! Kato stated that she thinks” “the medication is causing her to feel nervous” and she states she has been “feeling very shaky and disoriented at times”.

• Objective:

• Client was 15 minutes late for session. Her appearance was disheveled. Kato talked fast and was apologetic for her tardiness. Kato did not maintain eye contact. Client completed detoxification unit two weeks ago and began medications as prescribed by unit physician. Staff reports that client has been cooperative. Client has attended daily group meetings per her treatment plan.

• Session focused on methods to include her family in the treatment process.

• Assessment/Analysis:

• The session did not begin well due to client being late. Client was very anxious and had trouble focusing on session goal. Client may be adjusting to new medication.

• Plan:

• I (counselor) will consult with her physician regarding the medication levels and her anxiety, shaky feeling and disorientation. Client will discuss medication side affects with unit physician. Will meet in two days for next session to discuss results of the consultation and determine if she is ready to move onto incorporating her family in the treatment process.

• Signature or initials of counselor____________________________________________

• Printed name of counselor___________________________________________________

Activity - Writing a SOAP Note

• Divide into small groups of 3-4 persons. Choose a recorder and a reporter for the group.

• Identify a recent contact with a client

• Using the SOAP note format, describe your recent contact

DAP Note Recording

• DATA: A factual description of the session

• ASSESSMENT: An evaluation by the therapist of current status and progress toward meeting treatment goals

• PLAN: These are statements about what will happen next

Activity - Writing a DAP Note

• Divide into small groups of 3-4 persons.

• Choose a recorder and a reporter for the group.

• Using SOAP notes, adapt the information into the DAP note format.

DAP Note

SAMPLE DAP

• Date: __________________________

•

• Data:

• ____________________________________________________________________________

• ____________________________________________________________________________

• ____________________________________________________________________________

• ____________________________________________________________________________

• ____________________________________________________________________________

• ____________________________________________________________________________

• ____________________________________________________________________________

• ______________________________________________________________________

•

• Assessment:

• ____________________________________________________________________________

• ____________________________________________________________________________

• ____________________________________________________________________________

• ______________________________________________________________________

•

• Plan:

• ____________________________________________________________________________

• ____________________________________________________________________________

• ____________________________________________________________________________

• ______________________________________________________________________

•

• Signature or initials of Case Manager/Counselor: _____________________________________

•

• Printed Name of Case Manager/Counselor: _________________________________________

•

• Page #:________

Standardized Forms

Standardized Forms

• Easily collects and documents information

• Avoids missing information or discriminating in client care

• Assumes any format and gathers any type of information

• Minimize the need to do narrative notations by a check box method and other area fill-in-the-blank method

Pros & Cons of Forms

Pros & Cons of Forms

• Encourages gathering data quickly

• Means for evaluating data involving a large number of clients

• Easy documentation of services provided

• Standardizes record keeping, can use for computer analysis

• Clients can fill out forms for completion

• Encourages more efficient focus on certain information

• Making client information conform to predetermined notions

• Time consuming

MATERIAL THAT SHOULD NOT BE

DOCUMENTED

• Process recording

• Information about client’s political, religious or personal views

• Intimate and personal details

• Extreme details about a physical illness

• Gossipy information given to counselor about other clients

• Too much “process” in documentation

• Notes of self praise

• Problems and frustration in contacting to other professions

• Avoid unnecessary duplication

• Contain speculative and biased information

MATERIAL THAT SHOULD NOT BE

DOCUMENTED (cont.)

• Avoid too much “process” in documentation, what worker did. Results are more important than all the detailed steps in between

• Avoid writing in notes self praise for work with client

• Problems and frustration in contacting and relating to other professions do not belong in client record. Cannot be used as battleground

• Avoid unnecessary duplication

Important Guidelines for Records

• General statements with explanation

• Records current so others can pick up

• Give the source of information

• Use ink or print if maintained electronically

• Do not use “white out”

• Even if your agency doesn’t, you should maintain some notes

• Complete all sections of documents or write in “N/A”

• Do not make conclusions without supporting documentation

• Avoid authoritarian views of the client or the client-situation

• Records must be kept confidential

General Guidelines for Records (cont.)

• Document professionals’ views but also client’s perspective

• Provide clear information about problem areas and services provided

• Include follow-up information and who will do what and when

• Use ink, rather than pencil unless instructed otherwise. Records may also be printed if maintained electronically.

• Do not use “white out” or other substances for changing information that has been recorded. Draw a line through the information to be deleted and initial where the line is drawn. The new information can be added there or later in the document.

General Guidelines for Records (cont.)

• Good practice is a prerequisite to good recording

• Choose your words carefully

• Avoid inappropriate language (slang, pejorative language, overwriting, meaningless phrases)

• Avoid words such as always, average, perfect, or all

• Avoid sexist language

• Avoid labeling people with terms such as sleazy, strange, punks, slobs, or low class

• Avoid using abbreviations that are unknown or unclear

• Use paragraphs to divide content into different topics

• Record is structured so information can be retrieved easily

• Proofread your written products before they go out

Recording Information when with a

Client

• Advise the client you are note taking carefully

• Do not break rapport and look up for eye contact

• Client worry– advise them about the process

• share what is being written or discontinue note taking

• pay attention to what client is communicating

• Do not take notes when an individual is talking about feelings

• counselors subconsciously resort to note-taking when nervous or unsure of themselves

• Allow 5-10 minutes between interviews

Use of Tone

• Tone is important

• Tone is a writer’s attitude toward

the subject

• Feelings should not be included

Clinical Recordkeeping in Quality

Assurance

• Proper clinical documentation serves assures quality client care

• Professional self-reflection and self-appraisal is essential to a counselor’s professional development

• Clinical records support the clinical supervisor

• The counselor/case manager orientation form as a tool

Case Management

Introduction

This training is designed to assist counselors to provide effective case

management services in treating substance use disorders. This

training will present information regarding:

• Defining case management

• The role of the counselor/case manager

• Comprehensive case management assessments

• Using a strengths-based perspective

• Establishing referral networks

• Evaluating and documenting utilization of services.

Session Agenda

Topics covered in this session include:

• Defining case management

• The Role of the counselor (case manager)

• Case management assessment

• Making referrals

• Evaluating client progress

• Tracking clients and services

• Evaluating your agency and staff for case management services

Participant Expectations

• What do you expect to achieve from this

session?

• Do you have specific questions or

concerns related to case management ?

Learning Objectives

At the end of this session, you will be able to:

• Describe the function of case management

• Understand your role in case management

• Explain comprehensive case management assessment

• Identify local resources available to begin establishing a

referral network

• Evaluate and document use and value of services

Case Management: Definition

• A coordinated approach to the delivery of

health, substance use disorder, mental

health and social services.

• Linking clients with appropriate services to

address specific needs & achieve the

goals of the treatment plan

Main Functions of Case Management

• Better retention = better outcomes.

• A principal goal of case management is to keep clients engaged in treatment and moving toward recovery.

• Case management has seven main functions:

– Assessment

– Planning

– Linkage

– Monitoring

– Advocacy

– Consultation

– Collaboration

Role of a Case Manager

• A case manager/counselor will increase their knowledge of resources in their geographic area.

• A case manager/counselor develops “key-contacts”.

• A full array of services.

• As many services as possible with as much knowledge of their operations as possible

Knowledge, Skills & Attitudes

• Provide the client with a single point of contact for a full array of services

• Understand various models and theories of addiction and other problems related to substance use disorder

• Ability to describe philosophies, practices, policies and outcomes of generally accepted or scientifically supported models of treatment, recovery, relapse prevention and continuing care for SUD

• Ability to recognize the importance of family, social networks, community systems, and self-help groups in the treatment and recovery support processes

• Advocate for the client to receive the services they need to be successful on their treatment plan

Knowledge, Skills & Attitudes

Continued:

• Understand diverse cultures and incorporate relevant needs of culturally

diverse groups including those with disabilities, into practice

• Be thoughtful of community-based and client-oriented services.

• Catalog these resources in “user friendly” system, often by type of services

with the information noted above (health, family, school, legal, service clubs,

support groups, medical/dental, mental health).

• Assist the client with needs that may be thought to be “outside the realm” of

substance use disorder services.

• Work well and understand the value of an interdisciplinary approach to

service delivery.

A Variety of Services

• Drug use often damages many aspects of an clients life, including housing, employment, and relationships

• Many use multiple substances and may be suffering from related health disorders

• Higher incidence of mental health disorders

• Alienated their families and friends

• Involved in the criminal justice system

• Clients with substance use disorders who receive professional attention for additional problems will see improvements

Establishing a Referral Network

• Identify all potential service needs

• Identify reliable resources

• Decide what agencies are appropriate

• Approach each agency

• Each agency selected should be listed

• Evaluate the agency’s ability to help the client.

• Develop a system for periodic visits

Key Points for Referrals

• Establish and maintain relations with civic groups, agencies, other professionals, governmental entities and the community

• Ensure appropriate referrals, identify service gaps, expand community resources and help to address unmet needs

• Continuously assess and evaluate referral resources

• Differentiate between situations more appropriate for the client to self-refer

• Arrange referrals to other professionals, agencies, community programs or other appropriate resources to meet client needs

• Explain in clear and specific language the necessity for and process of referral to increase the likelihood of client understanding and follow-through.

• Exchange relevant information with the agency or professional to whom the referral is being made in a manner consistent with confidentiality regulations and professional standards of care.

• Evaluate the outcome of the referral.

Activity

• Divide into small and select one person to record the discussion and one person to report back to the group.

• List a variety of services needed to serve your clients in a comprehensive way.

• Catalog these resources in their general area by category (health, social services, support services (self-help groups), church, school, criminal justice, service clubs, housing, food, childcare, transportation).

• Elaborate on the information by reviewing the “Directories” provided.

• Have your list contain as much of the key contact and other information as possible (examples: service hours, location, contact numbers, service criteria).

• You are welcome to use the “Case Manager/Counselor Referral Services Grid in the Appendix or create your own schedule/chart.

Suggested Services for Comprehensive

Case Management

• Crisis services

• Outpatient services

• Methadone/Buprenorphine maintenance treatment programs

• Inpatient services

• Residential services

• SUD program for adolescents

• School and community-based prevention programs

• Acupuncture as an adjunct to treatment

• 12-Step and other self-help groups

Suggested Services for Comprehensive

Case Management

• Medical/nursing services

– Health maintenance/prevention

– Treatment

• Nutritional services

– Health maintenance/prevention

– Treatment

– Food distribution programs

• Ophthalmic services

– Health maintenance/prevention

– Treatment

• Dental services

– Health maintenance/prevention

– Treatment

Suggested Services for Comprehensive

Case Management

• Daycare

• Nursery school

• Babysitting

• Neighborhood pools/parks

• Parenting classes/groups

• Voluntary foster care/child placement services

Suggested Services for Comprehensive

Case Management

• Crisis intervention

• Peer support

• Support groups

• Individual /couple/family counseling

• Psychotherapy

• Psychiatric care

Suggested Services for Comprehensive

Case Management

• Independent

• Supervised living

• Institutionalized living

Suggested Services for Comprehensive

Case Management

• Benefits/Entitlement Services

• Transportation

• Legal Services

• Spiritual Services

• Leisure Time Activities

• Educational/Vocational Services

• Employment Programs

Common Reasons for Conflict

• Unrealistic expectations about services and/or outcomes

• Unrealistic expectations of other agencies abilities or resources

• Disagreements over resources

• Conflicting loyalty between the agencies working together (historic)

• Conflicts with final decision-making authorities over the management of the case

• Differences in values, goals and definitions of the problem, solutions or roles

Common Reasons for Conflict

• Dissatisfaction with case handling

• Clients that triangulate one case manager against another

• Inappropriate demands of case managers (asking too much, too

fast)

• Resentment over spent time on documentation, in meetings, or

other non-direct client services

• Discrimination (stratification), power and reward differentials among

various case managers

• Differences in case manager credentials and status among agencies

• Unclear problem resolution (solution-focused rather than problem-

focused) attitudes and protocols

Strength-Based Approach

• Provides clients support for asserting direct control over their search for resources.

• Examines clients' own strengths and assets as the vehicle for resource acquisition.

• Helps clients take control and find their strengths and encourages use of informal helping networks.

• Promotes the primacy of the client-counselor/case manager relationship.

• Provides active outreach to clients.

• Helps clients access the resources they need to support recovery.

• Counters stigma about substance users as unworthy of needed services

• Supplements models that focus on pathology and disease -emphases clients strengths, assets and abilities.

• Leads to improved outcomes for clients in employability, retention in treatment and reduces drug/alcohol use.

Case Management Assessment

• Service procurement skills

• Prevocational and vocation-related skills

• Scan for indications of harm to self or others

• If the client is under the supervision of the criminal

justice system, supervision officers should be contacted

to determine whether or not there is a potential for

violent behavior

• Client's readiness to reintegrate into the community

Planning, Goal-Setting &

Implementation

• Each goal broken down into objectives or smaller steps/strategies that are

behaviorally specific, measurable, and tangible.

• Goals, objectives, and strategies are developed in partnership with the

client.

• Goals are framed in a positive context - as something to be achieved rather

than something to be avoided.

• Timeframes for completing the objectives and strategies are be identified.

• Successful completion of an objective should provide the client the

satisfaction of gaining a needed resource and demonstrating success.

• Failure to complete an objective should be emphasized as an opportunity to

reevaluate one's efforts.

The Case Manager…

The Counselor/Case Manager must:

(1) continue to motivate the client to remain engaged and

to progress in treatment

(2) organize the timing and application of services to

facilitate client success

(3) provide support during transitions

(4) intervene to avoid or respond to crises

(5) promote independence

(6) develop external support structures

Activity

• Review the handouts

• Select a scenario from your caseload who had multiple service providers.

• Discuss what services you provided and record those on the “Case Management/Service Plan”

• How were you able to coordinate, or not coordinate, services for the client?

• Refer to the “Multidisciplinary Team Notes” and complete those sections that were specific to the scenario you had in mind.

Effective Case Management

Planning

• Initiate collaboration with referral source.

• Obtain, review, and interpret all relevant screening, assessment, and initial treatment-planning information.

• Confirm the client's eligibility for admission and continued readiness for treatment and change.

• Complete necessary administrative procedures for admission to treatment.

• Establish realistic treatment and recovery expectations with the client and involved significant others including, but not limited to:

– Nature of services Program goals

– Confidentiality Releases Program procedures

– Schedule of treatment activities Rules regarding client conduct

– Costs of treatment Factors affecting duration of care

– Client rights and responsibilities

* Coordinate all treatment activities with services provided to the client by other resources

Linking, Monitoring and Advocacy

• Case finding and pretreatment - Counselors /Case Managers may be especially active in providing linking and advocacy during the pretreatment phase of the treatment continuum.

• Primary treatment - Counselor/Case Manager moves on to monitor the fit and relationship between the client and the resource. Advocacy on behalf of a client is direct and professional

• Disengagement - Disengagement in the case management setting, as with clinical termination, is not an event but a process.

Case Management Documentation and

Evaluation

• Establishing Benchmarks

• Measuring Practice

• Measuring System Outcomes

• Measuring Client Outcomes

Activity: Evaluating Case Management

Services

• Divide into small groups of 3-4 people. Select a Recorder and a Reporter

• Create their own evaluation instrument that can be used by their program

to:

• * evaluate the quality of various outside services; and

• * provide reference information about the different services (types if

service available in the program).

• Discuss what kinds of information could be included.

• You can use any of the examples in their handbook (in part or in full).

• Add computerized systems if this is an area of interest to you. Discuss the

barriers - expense, access, customization, and security of confidential data

Referral

Introduction

• This curriculum provides instruction to the referral process used in

substance use disorder services.

• Most successful when the services are comprehensive and inclusive

• Comprehensive services include: SUD treatment, mental health

services, family services, medical/dental services, childcare,

transportation, housing, food, employment, legal and other related

services.

• A treatment agency is able to refer to those services they do not

provide

Agenda

• The referral process

• When referral is appropriate

• How to make a referral

• Considerations in referral and/or termination of a client

Participant Introductions

• Do you have specific experience relating

to making treatment referrals?

Learning Objectives

• Understand the concept of making a referral;

• Understand the referral process;

• Understand the different components of a

referral;

• Be able to develop a referral; and

• Understand your role in the referral process.

Referral Process

• Referral is the process of sending a client, or

their family member either for consultation of

care, treatment, or other ancillary services:

1) from one clinician to another clinician

or specialist, or

2) from one setting or service to another,

The process of sending a client, either for

consultation of care, treatment or service

The process includes:

1)Establishing and maintaining relations with civic

groups, agencies, other professionals,

governmental entities, and the community-at-

large to ensure appropriate referral, identify

service gaps, expand community resources, and

help to address unmet needs

2)Continuously assessing and evaluating referral

resources to determine their appropriateness

The Process

3) Differentiating between situations in which it is most appropriate for the client to self-refer to a resource and instances requiring counselor referral

4) Arranging referrals to other professionals, agencies, community programs, or other appropriate resources to meet client needs;

5) Explaining in clear and specific language the necessity for and process of referral to increase the likelihood of client understanding and follow through

The Process

6)Exchanging relevant information with the

agency or professional to whom the

referral is being made in a manner

consistent with confidentiality regulations

and generally accepted professional

standards of care

7)Evaluate the outcome of the referral

When to Refer

Referral should be initiated if:

1)client needs service not available at

present facility/program

2)client is non-compliance

3)client preference is a different type of

treatment service than you are able to

provide

Referral Information

1)Client demographic information, including name, date of birth, mailing address, phone numbers, email address (if available) insurance plan, worker’s compensation information (if applicable)

2)Name of referring professional and contact information

3)Reason for referral and expectations

4)Psychiatric (mental health) diagnosis

Referral Information

5)Current level of functioning

6)Current medications and current medical

problems include results of screening for TB,

HIV, STD and hepatitis

7)Previous psychiatric/substance abuse history

8)Previous in-patient treatment history

Additional Referral Information

1)Outside consult reports

2)Hospital discharge summary and medications

3)Lab tests

4)Specialized tests

5)Legal information that is pertinent to the referral

source

Activity

• Please review the Case History below and

in accordance with the outlined referral

process and information, prepare the

“Example Referral Form”. Select a person

to record on the referral form and a person

to present your results at the end of the

activity.

Case History - Marco

• Marco is a 35 year old, married male who works as a computer technician for a local high tech company. His company does a lot of contract work for the Government. He has two young daughters, aged four and seven. He also takes care of his elderly father who is disabled. His father needs to be taken to regular medical appointments and needs assistance with other daily living issues as they arise. Marco’s wife of ten years is not supportive of Marco assisting his father. Marco is HIV positive and was recently diagnosed with depression. He has a 15 year history of opioid dependence, abusing both high doses of street opioids and pain killers. Marco has had several legal issues as a result of his use yet has never been charged with any crimes. Marco stopped using all drugs for a period of time after he first met his wife and only drank alcohol on occasions. Marco states he does not have a problem with alcohol. Marco has tried and failed in past outpatient treatment services several times. He has never had full substance use services. His wife is threatening to leave him and Marco is very concerned. Marco also realizes he cannot afford to lose his job. Marco has come to your outpatient substance use disorder treatment facility. You have assessed him and now are thinking of his full situation.

Discuss & Report Out

• Discuss and prepare the referral form for those services you would refer Marco and explain why you chose those services. Have someone in your small group record the responses and someone else fill in the referral form .

• Each small group is to report their findings starting with the referral form and then their explanations for the referrals.

Continuing Activity

• Continue in your same small group and trade referral forms.

• Each small group is to review the new the referral form given to them.

• As a small group, add any other items you believe would be helpful on the referral form and explain why. Remember to choose a recorder and reporter for this activity.

Report Out

• Each small group is to report their findings

and their explanation for any changes and

additions to the referral form.

Policy and Procedures for Referrals

• It is helpful for a treatment agency to have

a policy and procedure for coordination

with other agencies or ancillary services.

Other Considerations in Making A

Referral

• It is important when making a referral to confirm that the client has all the paperwork

transferred from your agency to the referral agency (all paperwork appropriate to that

specific type of service). It is also important for the referring agency to confirm if the

client has been accepted or the service delivered. As a service provider, you may

want to develop a tracking system to ensure that you have completed the referral

process.

• We recognize that at times a referral source that you may be referring to may not be

responding in the most careful, thoughtful or professional manner. The referring

counselor must always be professional and respectful of other agencies and his/her

peers and be thoughtful that each person involved in the client care are part of a

multidisciplinary team to service the client’s best interests and needs. Regardless of

the circumstances, the counselor’s code of ethics should not be breached.

Inappropriate Situations for a Counselor to

Continue to Provide Services to a Client.

• The counselor determines that the client is no longer benefiting from the current treatment relationship

• The counselor is not skilled at addressing the specific needs of the client

• The counselor will be unavailable for an extended period of time and there is not a skilled person to take their place

• The client can no longer afford the care

• The client refuses to comply

• The policies of the treatment agency no longer permit the client to continue in care

• The client requests referral to another agency.

• The client relocates.

Referring and Terminating the

Therapeutic Relationship

• Openly discuss with the client your intention to refer and if there is also a termination from your care, discuss this and your reasons

• Give the client the opportunity to make changes if the termination is due to their behavior in order to continue the relationship with you

• Give written or verbal notice to the client that the relationship will be ended or reduced

• Offer the client several more sessions for closure purposes

• Give the client up to three referrals for alternative treatment providers that are skilled at serving their needs

Referring and Terminating the

Therapeutic Relationship

• Provide the client with information to contact in the event of an emergency

• Write a summary in the client file around the referral and/or termination issues. Note that this information cannot be shared with the referral agency without a “Release of Information”

• Allow the client enough time to find substitute services if you are terminating from your care

• Transfer any client records needed to the referring agency promptly and appropriately for the service that they will provide to your client. (Example: You would not transfer a treatment plan to a child care center)

Wrap Up

• Questions…...

• Comments…..

• Thank you for your participation!

• Cynthia Moreno Tuohy - cynthia@naadac.org