Outpatient Substance Abuse Discharge Process Client Name: CID# Discharge Staff: Discharge Date Please complete the following items when discharging a client from Substance Abuse. Discharge / Transfer Summary Discharge Survey (if client present) Discharge ASAM (Paper version) Feedback to Referral Source (if any) Completion Certificate (if client present) Generate ASAM in KIS Generate Discharge in KIS Letter to Client w/copy of Discharge Summary (if not present for Discharge Session) Review Treatment Plan & make sure Target Date/Date Achieved is filled in Discharge Status Codes to use in KIS: If client completed treatment successfully, use code 1 If client left voluntarily before completing 4 sessions, use code 16 If client left voluntarily after completing 4 sessions, but did not complete recommended treatment, use code 14 if unemployed or not seeking employment If client left voluntarily after completing 4 sessions, but did not complete recommended treatment, use code 15 if employed MEDICAID CLIENTS Was Treatment Plan done in first 30 days? Was Treatment Plan signed by a Qualified Reviewer? If NO, Complete a Limited Service Authorization/Verification of Need form TANF CLIENTS Is TANF Certification in chart? Does Treatment Plan reflect TANF Goals? Were TANF 30 Day Reassessments completed? Please review the chart to ensure all the above requirements have been completed.
SUTTON PLACE BEHAVIORAL HEALTH, INC. CLINICAL DISCHARGE/TRANSFER SUMMARY Status: Closed for Services (Check only if there will be no other services provided by the Agency.) Discharge from program Transfer to other program Transfer to other clinician *Complete Discharge Outcome Measures of C/FARS when chart is closed for all services Chart continues to be opened for: Substance Abuse Outpatient Mental Health Case Management Medication Management Other New Clinician/New Program: Summary Client was referred by: Copy of Summary was sent to: Reason for Referral/Presenting Problem: Strengths/Needs/Abilities/Preferences: Clinical Course of Treatment: Admission Date Discharge Date (Include number of sessions, referrals, UA results, levels of treatment, level of client involvement) Status at last contact: Medications at discharge: CID CLIENT S NAME (05-14-09)
Discharge/Transfer Summary (Continued) Page 2 % of Objectives Met for each Treatment Problem/Goal: 1: 2: 3: 4: 5: 6: Reason for Discharge: Recommendations/Referrals: Admitting ICD-9-CM Diagnosis/Diagnostic Impression Axis I 1. 2. 3. Axis II 1. 2. Axis III Medical Axis IV Stressors Axis V Admitting GAF/CGAS: Discharge ICD-9-CM Diagnosis/Diagnostic Impression Axis I 1. 2. 3. Axis II 1. 2. Axis III Medical Axis IV Stressors Axis V Discharge CAF/CGAS: Clinician Signature, Title, Date Client Signature, Date Other Signature, Title, Date Medical Director/Attending Psychiatrist, Date Supervision Signature, Date CID CLIENT S NAME (05-14-09)
Sutton Place Behavioral Health, Inc. DISCHARGE SATISFACTION SURVEY Ratings: SA=Strongly Agree A=Agree N=Not Applicable D=Disagree SD=Strongly Disagree Please circle your response. 1. I have learned something about my problems and myself while receiving services. 2. The treatment helped me with the problem I came here for. 3. I was allowed to express my true thoughts and feelings.. 4. The staff working with me treated me with respect. 5. I was able to apply the information I learned to my daily life. 6. I would recommend Sutton Place to others. Additional comments: Signature (Optional) Location: Yulee Hilliard Program: AMH ASA CCM ACM CMH CSA Date: Revised 01-13-04
Print Client Name: Client Identification Number: Date: Adult 65D-30 Outpatient ASAM Level I DIMENSIONS Circle all items in each dimension that apply to the client. YES NO DISCHARGE TRANSFER Place a check in the yes or no box that indicates validation of lack Enter Level ASAM Requirements Dimension 1: Acute Intoxication and/or Withdrawal Potential Dimension 2: Biomedical Conditions and Complications Dimension 3: Emotional, Behavioral or Cognitive Conditions and Complications Dimension 4: Readiness to Change Dimension 5: Relapse/ Continued Use Potential Dimension 6: Recovery Environment Recommendations/Notes: of validation for discharge or transfer from this level of care. Meets criteria in one of the six dimensions unless discharged for lack of diagnostic criteria. SEE BELOW FOR DISCHG CODES a. Client is free from intoxication or withdrawal symptoms/risks; or b. The client exhibits symptoms of severe intoxication and/or withdrawal, which can not be safely managed at this level of care. a. The client s biomedical conditions, if any, have diminished or stabilized to the extent they can be managed through outpatient appointments at the client s discretion, and the client does not meet any of the continued stay criteria in this or another dimension that indicates the need for further treatment in ASAM Level I; or b. The client has a biomedical condition that is interfering with addiction treatment and that requires treatment in another setting. a. The client s emotional, behavioral or cognitive conditions, if any, have diminished or stabilized to the extent they can be managed through outpatient appointments at the client s discretion, and the client does not meet any of the continued stay criteria in this or another dimension that indicates the need for further treatment in ASAM Level I; or b. The client has an emotional, behavioral or cognitive condition that is interfering with treatment and that requires additional treatment in another setting. a. The client s awareness and acceptance of his/her addiction problem and commitment to recovery is sufficient to expect maintenance of a self-directed recovery plan, based on the following evidence: 1) the client recognizes the severity of the substance abuse problem; 2) the client has and understanding of the self-defeating relationship with substances; 3) the client is applying the skills necessary to maintain sobriety in a mutual self-help group and/or with post-treatment support care; and 4) the client does not meet any of the continued stay criteria in this or another dimension that indicates the need for further treatment in ASAM Level I; or b. The client consistently has failed to achieve essential treatment objectives despite revisions to the treatment plan, to an extent that no further progress is likely to occur. a. The client s therapeutic gains in addressing craving and relapse issues have been internalized and integrated so the client does not meet any of the ASAM Level I continued stay criteria in this or another dimension that indicates the need for further treatment in ASAM Level I; or b. The client is experiencing a worsening of drug-seeking behaviors or craving, requiring treatment in a more intensive level of care. a. The client s social system and significant others are supportive of recovery to an extent that the client can follow a self-directed treatment plan without substantial risk of relapse/continued use and the client does not meet any of the continued service criteria in this or another dimension that indicates the need for further treatment at ASAM Level I; or b. The client is functioning adequately in assessed life task areas of work, social functioning or primary relationships and does not meet any of the continued service criteria in this or another dimension that indicates the need for further treatment at ASAM Level I; or c. The client s social system remains non-supportive or has deteriorated. The client is having difficulty coping with this environment and is at substantial risk of relapse and requires placement in a more intensive level of care. Print Counselor Name: Counselor Signature/Credential: Date:
SUTTON PLACE BEHAVIORAL HEALTH CLIENT FEEDBACK FORM To: Address: Client Name: SS#: DOB: The above named client has been referred to our agency. The purpose of this form is to assist you in tracking this client's progress and advising you of action taken or services provided for the client. Please advise me by calling the number provided below if you would like monthly or quarterly reports on this client. Client did not contact agency. Client contacted this agency on Client completed screening and scheduled an appointment within 20 days for Client kept initial appointment on Client failed to keep initial appointment. Client entered program/treatment on and will continue until Client attended sessions before discontinuing program/treatment. Last contact was Client re-entered program on Individual plan has been formulated with this client. The plan addresses current mental health issues as the major treatment focus. The plan addresses alcohol and or other drug issues as the major focus. The client is progressing satisfactorily. The client is progressing poorly. The client has terminated treatment/services successfully. The client has terminated treatment/services unsuccessfully. The client completed the program but owes fees. The client was recommended or required to attend the Relapse Prevention Group. The client was recommended for the following services: COMMENTS: Treatment Provider: Sutton Place Behavioral Health 463142 State Road 200, Yulee, FL 32097 Phone: (904)225-8280 Fax: (904) 225-8232 Print Name of Representative Credential/Title Date Signature Rev.06/26/2008
Certificate of Completion This certificate is awarded to for successful completion of Outpatient Substance Abuse Treatment Sutton Place Behavioral Health Staff Date of Completion
Sutton Place Behavioral Health, Inc. Therapy/Counseling Progress Note Client: CID: Office/Site: Date: Location: Office: Other: Service Begin End Service Begin End Service Ind Counseling Psych Social Treatment Plan Group Family Counsel Tx Plan Review TBOS Crisis Phone Staffing Activities on Behalf Discharge Other Treatment Problem(s) Addressed: Subjective (Client arrives how? With whom? Therapist met with whom? Client/other reports?) S: Begin End Objective (Observations and Interventions) O: Observed affect: Appropriate Broad Constricted Blunted Flat Sad Fearful Angry Irritated Anxious Happy Other As evidenced by: Animated & congruent Otherwise Grooming/Hygiene: Appropriate Other Interaction with therapist: Interaction with others: Medication issues: Treatment Interventions: A: (Apparent response to treatment) Any evidence of suicidal/homicidal ideation? Any evidence of other problems? Client appears: Same Better Worse As evidenced by: P: (plan towards discharge) Diagnosis: (Revised 06-30-10) Service Provider Name, Credential(s) Page of Pages