DDCMHT – V. Continuity of Care

V.A – INTEGRATED DISCHARGE PLANNING

Definition: Programs that offer treatment to individuals with a co-occurring substance use disorder develop discharge plans that include an equivalent focus on needed follow-up services for both mental health and substance use disorders.

Source: Discharge plans, memoranda of understanding.

Item Response Coding: Coding of this item requires an understanding of the key elements considered in the documented discharge plan of individuals with co- occurring substance use disorders.

 

V.B – TREATMENT CONTINUITY CAPACITY

Definition: When programs address the continuum of treatment needs for individuals with co-occurring disorders, there should be a formal mechanism for providing ongoing needed substance use follow-up. Best practice indicates that substance use concerns are followed-up and monitored in a manner that is integrated with traditional mental health follow-up. The program emphasizes continuity of care within the program’s scope of practice, but if a linkage with another level of care is necessary it sets forth the expectation that treatment continues indefinitely with a goal of illness management.

Source: Interview with clinicians, medical records, and policy and procedure manual.

Item Response Coding: Coding of this item requires an understanding of the continuity of care available for the continued treatment and monitoring of substance use disorders in conjunction with mental health disorders. Outpatient programs, or programs in an agency with an outpatient component, will have a greater capacity to provide ongoing follow-up services, even if linkage with another level of care is necessary. Inpatient or residential programs that stand alone or serve a large geographic area may not have this option.

 

V.C – INTEGRATED ONGOING RECOVERY FOCUS

Definition: Programs that offer services to individuals with co-occurring disorders support the use of a recovery philosophy (vs. symptom remission only) for both substance use and mental health disorders.

Source: Interviews with clinicians and patients, document review (mission statement, brochure, policy and procedure manual), and review of treatment plans.

Item Response Coding: Coding of this item requires an understanding the program’s philosophy and how the concept of recovery (vs. remission) is used in the treatment and planning of both substance use and mental health disorders.

 

V.D – COMMUNITY-BASED PEER SUPPORT GROUPS

Definition: Programs that offer services to individuals with co-occurring disorders anticipate difficulties  that the individuals with co-occurring disorders might experience when linking or continuing with peer recovery support groups in the community. Thus these programs provide the needed assistance to support this transition beyond active treatment.

Source: Interviews with clinicians and patients, review of progress notes, and discharge procedures.

Item Response Coding: Coding of this item requires an understanding of peer recovery support groups within the program’s continuum of services and the systems for facilitating the connection with groups in the community. Note: Some programs have difficulty with specialized interventions to facilitate the use of peer support groups while the individual is in treatment. These programs will likely have difficulty meeting this goal when the individual is discharged.

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V.E – ONGOING PHARMACOLOGICAL SUPPORT

Definition: Programs that serve individuals with co-occurring disorders have the capacity to assist them with medication planning, prescription and medication access and monitoring, and prescribing sufficient supplies of medications for substance use disorders at discharge.

Source: Interview with clinicians and prescriber, discharge procedures, and review of discharge plans.

Item Response Coding: Coding of this item requires an understanding of the program’s prescribing guidelines for individuals with co-occurring disorders at discharge. Note: Programs that have difficulty providing pharmacotherapy for substance use disorders while the individual is in treatment will likely have difficulty providing this service at discharge.

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