DDCMHT – III. Clinical Process: Assessment

III.A – INTEGRATED SCREENING

Definition: Programs that provide services to individuals with co-occurring disorders routinely and systematically screen for both substance use and mental health symptoms. The following text box provides a standard definition of “screening” that originates from SAMHSACo-Occurring Measure (2007).

Screening: The purpose of screening is to determine the likelihood that a person has a co-occurring substance use or mental disorder. The purpose is not to establish the presence or specific type of such a disorder, but to establish the need for an in-depth assessment. Screening is a formal process that typically is brief and occurs soon after the patient presents for services. There are three essential elements that characterize screening: intent, formal process, and early implementation.

  • Intent: Screening is intended to determine the possibility of a co-occurring disorder, not to establish definitively the presence, or absence, or specific type of such a disorder.
  • Formal process: The information gathered during screening is substantially the same no matter who collects it. Although a standardized scale or test need not be used, the same information must be gathered in a consistently applied process and interpreted or used in essentially the same way for everyone screened.
  • Early implementation: Screening is conducted early in a person’s treatment episode. For the purpose of this questionnaire, screening would routinely be conducted within the first four visits or within the first month following admission to treatment.

Source: Interviews with program leadership and staff, observations of medical record (or electronic medical record system) or intake screening form packets.

Item Response Coding: Coding of this item requires the evaluation of screening methods routinely used in the program.

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III.B – INTEGRATED ASSESSMENT

Definition: Programs that provide services to persons with co-occurring disorders should routinely and systematically assess for substance use disorders  as indicated by a positive screen. The following text box provides a standard definition of “assessment” that originates from SAMHSAs Co-Occurring Measure (2007).

  • Assessment: An assessment consists of gathering information and engaging in a process with the patient that enables the provider to establish the presence or absence of a co-occurring disorder; determine the patient’s readiness for change; identify patient strengths or problem areas that may affect the processes of treatment and recovery; and engage a person in the development of an appropriate treatment relationship. The purpose of the assessment is to establish (or rule out) the existence of a clinical disorder or service need and to work with the patient to develop a treatment and service plan. Although a diagnosis is often an outcome of an assessment, a formal diagnosis is not required to meet the definition of assessment, as long as the assessment establishes (or rules out) the existence of some mental health or substance use disorder. Assessment is a formal process that may involve clinical interviews, administration of standardized instruments, and/or review of existing information. For instance, if reasonably current and credible assessment information is available at the time of program entry, the (full) process need not be repeated. There are two essential elements for the definition of assessment: establish or rule-out a co-occurring disorder (diagnosis) and use results of the assessment in the treatment plan.
  • Establish (rule-out) co-occurring disorder: The assessment must establish justification for services and yield sufficient information to determine or rule-out the existence of co-occurring mental health and substance use disorders. (A specific diagnosis is not required.)
  • Use results in the treatment plan: The assessment results must routinely be included in the development of a treatment plan.

Source: Interview with program leadership and staff, policy and procedure manual, and medical record.

Item Response Coding: Coding of this item requires the evaluation of the assessment methodology routinely used in the program or facility.

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III.C – DOCUMENTED INTEGRATED DIAGNOSES

Definition: Programs serving persons with co-occurring disorders have the capacity to routinely and systematically diagnose both mental health and substance use disorders.

Source: Medical record (or electronic medical record), interviews with staff.

Item Response Coding: Coding of this item requires the review of diagnostic practices within the program.

 

III.D – DOCUMENTED INTEGRATED HISTORY

Definition: Biopsychosocial and other clinical assessment and evaluative processes routinely assess and describe past history and the chronological or sequential relationship between substance use and mental health disorders or problems.

Source: Medical record.

Item Response Coding: Coding of this item requires the review of documentation, specifically the protocols or standards in the collection of the individual’s substance use and mental health history.

 

III.E – ACCEPTANCE OF S.A. SYMPTOM ACUITY

Definition: Programs offering services to individuals with co-occurring disorders use substance use disorder symptom acuity or instability within the current presentation to assist with the determination of the individual’s needs and appropriateness, and whether the program is capable of effectively addressing these needs.

Source: Interview with program leadership and staff, policy and procedure manual, and initial contact and/ or referral form.

Item Response Coding: Coding of this item requires an understanding of clinical protocol for individuals who present with different levels of substance use symptom acuity (e.g., intoxication, withdrawal, dangerousness, risk to self, agitation, self-regulatory capacity). The level of care capacities within the program must be taken into account when rating this item.

 

III.F – ACCEPTANCE OF S.A. SEVERITY / PERSISTENCE

Definition: Programs offering services to individuals with co-occurring disorders use the severity and persistence of disability related to the substance use disorder as:

  • An indicator to assist with the determination of the individual’s needs, and
  • An indicator whether the program is capable of effectively addressing these needs.

Source: Interviews with program leadership  and staff, policy and procedure documentation, and mission statement.

Item Response Coding: Coding of this item requires an understanding of clinical protocol for individuals who present with different levels of severity and persistence of substance use disorder.

 

III.G – STAGING

Definition: For individuals with substance use and mental health disorders, the assessment of readiness for change is essential to the planning of appropriate services. Although the stages of change model has been more traditionally associated with treatment for substance use disorders, assessment of motivational stages across the individual’s identified areas of need (including both substance use and mental health) is  a more comprehensive approach. Doing so helps to more strategically and efficiently match the individual to appropriate levels of service intensities.

Source: Interview with program staff, medical records (electronic medical record).

Item Response Coding: Coding of this item requires an understanding of the assessment procedures used in the determination of the stages of change or a similar model to systematically determine treatment readiness or motivation.

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