DATE: June 27, 2016 SUD Provider Network Rosie Andueza, SUD Operations Program Manager Idaho Department of Health and Welfare

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1 DATE: June 27, 2016 TO: FROM: SUD Provider Network Rosie Andueza, SUD Operations Program Manager Idaho Department of Health and Welfare Liza Crook, SUD Program Supervisor Idaho Department of Juvenile Corrections SUBJECT: Follow-Up Survey The Idaho Department of Health and Welfare (IDHW) and the Idaho Department of Juvenile Corrections (IDJC) are implementing follow-up surveys for clients who receive substance use disorder treatment services funded by their agencies (with the exception of ATR funded clients). Clients discharged on or after July 1, 2016 will be included in the follow-up survey implementation. Providers will conduct a brief follow-up survey with clients at thirty days, six, and twelve months post-discharge for all IDJC and IDHW populations (with the exception ATR funded clients). The follow-up survey will be a reimbursable service and will be added to each partnering agency s rate matrix, including provisions for payment for a series of unsuccessful attempts at contacting the client. Due to the importance of this data and the information it will render, completion of the follow-up survey will be a requirement for serving these populations. This data will be invaluable in determining best-practices and future funding needs. All clients receiving treatment through IDHW or IDJC funding that have not been discharged prior to July 1, 2016 need to have an informed consent completed and retained in their clinical file. All new admissions to treatment need to have an informed consent completed and retained in their clinical file upon intake. The WITS Help Desk will WITS Administrators at least one week in advance of when it is time to conduct a thirty day, six or twelve month follow-up survey. This process of notification will be replaced in the coming months with WITS alerts. The surveys must be completed in WITS and providers will no longer receive authorizations for the Follow-up service. After July 1, 2016 providers will create a non-authorization Payor Plan in order to release Encounters to Billing for the PC /27/2016

2 Follow-up service; all claims will be adjudicated in WITS. Clients that successfully completed a thirty day follow-up survey during the pilot are to be contacted to complete the six and twelve month follow-up surveys, but the provider will not receive an authorization as they did during the pilot. Due to the importance of implementing the follow-up survey consistently throughout the provider network, attending a live training is mandatory for all providers of clinical treatment services. Recovery Support Service providers are not required to attend the training, but are welcome to do so. Each provider should have the staff they intend on designating to complete the follow-up surveys, or a supervisor able to relay the information to their staff, attend the training. Only one person per agency is required, not one person per facility for those providers that have multiple facilities. The informed consent form that is to be completed with all active IDHW (not ATR4) and IDJC funded clients is attached. Additionally, the follow-up survey worksheet that can be provided to clients is attached. These documents will be reviewed during the trainings. Training dates and registration links are as follows: Tuesday, July 12 th at 2:30 PM MST at Thursday, July 14 th at 10 AM MST at If your agency is unable to attend one of the two trainings listed above, there will be live weekly trainings conducted by the WITS Help Desk in the weeks immediately following the initial trainings that will meet the requirement that each agency attend a live training. If you have any questions you would like answered prior to the trainings please contact Dan Greenleaf at (208) or greenled@dhw.idaho.gov. Attached: Informed Consent Follow-up Survey Interview Worksheet PC /27/2016

3 FOLLOW-UP SURVEY INFORMED CONSENT INTRODUCTION You are invited to participate in Follow-Up Survey process upon being discharged from Substance Use Disorder (SUD) Treatment. The decision to complete the survey and allow your answers to be provided to your referral source (IDHW, IDOC, IDJC, or ISC) is completely voluntary. The Follow-Up Survey is designed to get an idea of how your life is going following discharge from SUD Treatment, and what impact treatment may have had on your behaviors as well as quality of life. The survey is completely confidential, and used for data collection purposes only, regardless of your referral source to treatment, with the exception of mandatory reporting standards (Danger to self, others, or reports of harm to anyone who is vulnerable, etc.). The Follow-Up Survey will include basic questions related to substance use, housing, employment, income, physical health, mental health, involvement in additional treatment, informal recovery supports, and education. Participants will receive a phone call from the treatment provider that completed the discharge process asking a series of short answer questions, which should not take long to answer. The phone calls will be made at approximately 1 month, 6 months, and 1 year following discharge from treatment. You can stop participating at any time by informing the treatment provider of your desire to no longer participate. RISKS Due to the Follow-Up Survey taking place over the phone, there is a risk of anyone in your household or with access to the phone number(s) you provide asking you questions about why you are receiving the phone call. The phone calls will be made in a manner compliant with HIPAA to protect your information related to having participated in SUD Treatment. The person making the phone calls will be instructed to ask for you by name, not stating what agency they are with, or the nature of the call. If asked by whoever answers the phone they will be instructed to state, I am attempting to follow up with, can I please leave my name and number for to call me back? There is the risk of whoever answered the phone, calling the number back, which will go to the agency that made the phone call. If you are concerned about this, please do not provide any phone numbers that this risk applies to, answer No to Okay to Leave a Message, or opt out of the Follow-Up Survey. The phone calls will be made during normal business hours, Monday through Friday. BEST FORM OF CONTACT Best time/day to contact you: Phone Number: Ok to leave a message? Yes / No Text? Yes / No Phone Number: Ok to leave a message? Yes / No Text? Yes / No Address: Ok to mail paper survey to physical address? Yes / No BENEFITS TO TAKING PART IN THE STUDY With the increasing difficulty of securing funding for services, the Follow-Up Survey phone calls will provide needed information to present a picture of the lasting benefits of SUD Treatment to funders. This will provide the best opportunity for ongoing funding for future SUD Treatment. Additionally, by participating in the Follow-Up Survey, SUD Treatment will likely be able to be improved based upon the feedback that is provided to make it more effective. CONTACTS FOR QUESTIONS OR PROBLEMS If you have questions about the study, any concerns, unexpected problems, or think that something unusual or inappropriate is happening, please contact the Provider Agency s Clinical Director or Provider Relations at (800) Consent of Subject (or Legally Authorized Representative) Signature of Subject or Representative Date Upon signing, the participant will receive a copy of this form, and the original will be held in the participant s treatment record. If you do not consent to being contacted for the Follow-Up Survey, please clearly write Decline and your initials on the Signature line, as well as add the date. DHW/ PC /27/2016

4 FOLLOW UP INTERVIEW WORKSHEET Instructions: Please answer each question by checking only one box per question or writing in the number of times you have done what the question is asking about. If you check Other for any answer, please provide a brief description, with the specific answer that didn t fit into any of the other categories. IF YOU ARE PRESENTLY STRUGGLING WITH SUBSTANCE USE AND WOULD LIKE HELP IN FINDING RESOURCES TO ASSIST YOU, PLEASE CALL BPA HEALTH AT (800) TO TALK WITH SOMEONE THAT CAN HELP. Client Full Name Employment Status Living Arrangement Primary Source of Income First: Last: Disabled Employed Full Time Employed Part Time Homemaker In the Armed Forces Resident/Inmate Retired Seasonal Employee: In Season Seasonal Employee: Out of Season Student Unemployed Adult living with parents, relatives, or guardians Alone (without supervision) Halfway House Homeless Jail/Correctional Facility Safe and Sober Housing Disability None Public Assistance Retirement/Pension Wages/Salary Arrests in Prior 30 Days # of arrests: 1

5 Self Help Group in Past 30 Days No attendance in the past month 1-3 times in past month 4-7 times in past month 8-15 times in past month times in the past month Some attendance in the past month, but frequency unknown Education/Training Program in Past 30 Days Yes No Graduate from E/T Program in Past 30 Days Yes No Primary Substance Description Primary Intake Type Description Primary Frequency Description Alcohol Cocaine Marijuana Heroin Other opiates PCP Hallucinogens Amphetamines Other stimulants Tranquilizers Sedatives Inhalants Inhalation Injection Oral Smoking Daily 3-6 days in the past week 1-2 days in the past week 1-3 days in the past month No use in the past month 2

6 Secondary Substance Description Alcohol Cocaine Marijuana Heroin Other opiates PCP Hallucinogens Amphetamines Other stimulants Tranquilizers Sedatives Inhalants Other/Description: Secondary Intake Type Description Secondary Frequency Description Tertiary Substance Description Inhalation Injection Oral Smoking Daily 3-6 days in the past week 1-2 days in the past week 1-3 days in the past month No use in the past month Alcohol Cocaine Marijuana Heroin Other opiates PCP Hallucinogens Amphetamines Other stimulants Tranquilizers Sedatives Inhalants 3

7 Tertiary Intake Type Description Inhalation Injection Oral Smoking Tertiary Frequency Description Daily 3-6 days in the past week 1-2 days in the past week 1-3 days in the past month No use in the past month Received Substance Use Disorder Treatment Since Discharge Yes No Currently in Substance Use Disorder Treatment Yes No # of Days in Past 30 Missed Work/School Due to Drinking/Drug Use # of days: Significant Periods of Psychological Distress in Past 30 Days Yes No # of Emergency Room Visits Since Discharge # of visits: # of Hospitalizations for Medical Problems Since Discharge # of hospitalizations: Pregnant at Time of Follow Up? Yes No Date Completed Date: 4