ASAM Fields. Intake and Admission ASAM:

Transcription

1 ASAM Procedure The first ASAM is completed at the time of the patient s initial appointment with the agency. For outpatient patients this would be completed in the Simple Screening module of IAWITS at the time of their assessment/intake. For Residential/Halfway House patients who are directly admitted to us from another facility, this would be completed in the Admission Outcome Measure. The Admission ASAM must be updated to show the existing status of the patient. This pertains to patients with a recent assessment/intake done with our agency within the past 30 days. The ASAM screen in the Initial Outcome Measure is pulled forward from the Simple Screening module. You need to eliminate any inappropriate and/or unnecessary items in the comments boxes and adjust the level of risk/care as needed. Once the patient is admitted to treatment the ASAM needs to be updated again within the time frame defined by licensure standards for the current level of care the patient is in. This is done throughout their entire treatment episode. IOP/Res/Day Tx EOP/Hwh = every 7 Days =every 30 Days

2 Continuing Care =every 90 Days If the initial Treatment Plan has yet to be developed within the established time frames above, you will need to update the ASAM by posting a Misc. Note. See F-14 of the manual for more information on how to enter this note. The subsequent ASAMs can be updated utilizing the Treatment Review module of IAWITS. Remember to get rid of unnecessary info that is pulled forward from the previous ASAM. At review, each dimension needs to be updated and/or changed. Unfortunately the first Treatment Plan Review ASAM will be blank, information does not pull forward from the Initial Outcome Measure. You will need to recreate this using the Admission ASAM (Initial OM) as guidance. ASAM Fields Information documented on the ASAM is the same for all levels of care and pay source. Some of this is written as questions in order to help you write the correct information into the comments box. Remember to leave out information on the ASAM that outside sources (like Insurance companies) do not need to know, i.e. sexual abuse, etc. If the ASAM needs this information, please don t be specific, but rather state that the patient has experienced trauma, etc. Intake and Admission ASAM: For more information on the levels of risk: _PPC-2R_Risk_Ratings_Grid_with_Mental_Health.pdf Dimension 1- Acute Intoxication and/or Withdrawal Potential: indicate last date of use and if there is potential for withdrawals (focus on the last 6-months, unless patient came from jail/prison, hospital, another residential program, etc. then give their past 6- months prior to incarceration/stay). Any signs of intoxication or withdrawal now? Has UA been obtained? UA results or BAL results? History of withdrawal, any meds for withdrawal? Medication Assisted Treatment: list the drugs. Do not put the substance abuse history here, that goes on the substance abuse screen comments box, except for a Direct Admit to treatment. Include nicotine withdrawals if reported and if referral was made to Quitline or their family doctor. (The nicotine information can also be documented in Dimension 2). Dimension 2- Biomedical Conditions and Complications: Note any physical health or major medical conditions and/or treatment the patient is receiving (i.e. - diabetes, asthma, recent heart attack, seizures, COPD, etc.) and if it could interfere with treatment. Indicate if the patient has a Primary Care Provider, state who the Primary Care Provider is (and the Clinic name) and/or who prescribes meds. If the patient is on meds due to health issues, list the med and the dosage. Note if release was signed to

3 Primary Care Provider (or if patient declined the release.) If patient does not have a Primary Care Provider, make a referral. Has the patient seen their Primary Care Provider in the past year? If not, make a referral. Any history of brain injury or head trauma? Is patient pregnant? What was the patients response to any referrals made here. Dimension 3- Emotional, Behavioral, or Cognitive conditions and complications: indicate if the patient has emotional, behavioral or cognitive conditions. Only list what pertains to the patient, i.e. - criminal behavior, relationship issues, learning disabilities, DV history, assaults, learning disability, lack of education, literacy skills. Indicate any Mental Health diagnosis, medications & doses and current provider (name and clinic) with next appointment if known. Note if a release was signed to provider. Indicate any significant past mental health diagnosis, and if the patient does or does not have suicidal or homicidal ideations, and note any past suicide attempts. Is a referral to MH necessary? (Did patient decline or accept?) Note the PHQ9 score. History of MH hospitalization (where, when and why?) Past diagnosis (things patient is not being treated for now)? Assessment/Direct Admission for patients age 17 and younger: list the legal charges and the probation status (if you know the PO s name, please list it.) (This is because when you are a minor, this is considered a behavioral concern, not a criminal lifestyle.) Dimension 4 Readiness to Change: indicate the stage of change we believe the patient to be in and what the internal and/or external motivation is. Why treatment now? Any past treatments: level of care, did they complete, longest period of sobriety and when this was. Indicate if voluntary, court ordered or committed. Stages of change: Precontemplation, Contemplation, Preparation, Action, Maintenance. For more information on stages, see this link: _Change/Stages_of_Change.pdfhttp:// les_and_essays/stages_of_change/stages_of_change.pdf Dimension 5 Relapse, Continued Use, or Continued Problem potential: Are they at risk for continued use? What are their risk factors (i.e. - early age of onset, rapid progression of use, daily IV use, no significant period of abstinence, extensive use history, multiple treatment attempts, pregnant and continues to use, use regardless of consequences, denial, etc.) Is the patient using or not using? What does the patient need to get from tx? List cravings or urges to use. What coping skills does the patient have or need? Any periods of sobriety or abstinence? Dimension 6 Recovery/Living Environment: With whom does the patient live? Does the patient have housing? If the patient is homeless, give specifics (i.e. - living in car, couch surfing, on streets or shelter, etc.) Does anyone in the house use substances? Does the patient have a Significant Other? Family support for recovery? Report if there is or is not a family history of substance abuse or mental health issues. Does the patient have any children? If so, where are they living? Have the children been removed from the home and when, and any DHS involvement with the kids. Does patient have contact

4 with children? Are there any family issues that may impact recovery? What legal charges (for adults, not minors)? When did they occur? Does the patient have a court appearance coming up? Name of PO? Any problems in school or work? Is the patient employed? Is transportation or day care an issue? Criminal using associates/peer groups. Is patient involved in a non-using community based program (i.e. church, NA, AA, gym, etc.) If in AA or NA, do they have a sponsor? Note the tentative discharge plan (i.e. transitional housing, going home to family, support system, etc.) Recommended Environment: Environment (level of care) the patient was recommended for. Actual Environment: Environment the patient is going to be admitted to (or if this is an admission this is the level they are admitted to.) This also needs to be the level of care the patient agrees to participate in. Clinical Override: Use this box to explain why the Recommended and the Actual Environments are different, if they are not use 0-N/A. If they are different this needs to be explained in the Bottom Comments box. 0-N/A 1-Lack of insurance benefits 2-Managed care refusal 3-Clinical judgment 4-Patient opinion 5-Level of care not available 6-Legal issues 7-Other Bottom Comments box: Intake (Assessment or Direct Admit): o Date of assessment or Direct Admit to Tx o Referral source, criminal case numbers and committal numbers, list the substance abuse screening tool utilized and the score. This should be written in such a way that an outside person would be able to understand what you mean. i. e. Patient s score on the Michigan Alcoholism Screening Test is suggestive of an alcohol problem. o If the patient came to us from another Tx Agency then you need to record that you have accepted a referral from XX (giving the name of the agency), that you received assessment and ASAM info with the recommended environment and if you agree to that recommendation. If you do not agree then you need to explain why.

5 o Race, Gender and age the patient describes themselves to be. o Children s names, gender, and age. o Info to support level of care recommendation. This is your validation for the recommending environment. o Explain why the recommended and actual environments are different (if applicable.) Example: explain that they are appropriate for IOP and that they are scheduled for IOP group on mm/dd/yyyy, but that patient will be EOP until that date. o Explain the disposition of the patient. e. what the patient is scheduled for next on mm/dd/yyyy, or patient declined services, or they are set up for an appointment with this counselor on this date, etc. Explain what the plan is for the patient. o If the patient scored positive on the Lie/Bet questions, then note the referral information. o Reference remission information if applicable (not very common.) Admission (not a direct Ad): o Admission Date o What has happened since the evaluation (i.e. - drug use, UA results, arrest, etc.) o Is patient still appropriate for the recommended level of care o Information to validate patient s level of care o Explain the disposition of the patient; what groups, individual and family sessions the patient will attend and how often, or if the patient declined services. Explain what is next for the patient (I.e. - patient is going to XX (name of group) group starting on mm/dd/yyyy and will attend 3-times weekly on Monday, Tuesday and Thursday. Patient will attend individual sessions with primary counselor once per week and will attend family sessions with Family Therapist/Jane Doe twice per month.) Review ASAM: This focuses on the last 7 or 30 days depending on level of care. For more information on the levels of risk: _PPC-2R_Risk_Ratings_Grid_with_Mental_Health.pdf Dimension 1- Acute Intoxication and/or Withdrawal Potential: indicate last date of use if this has changed from the previous review.what is the drug of choice? Are they still experiencing withdrawal symptoms (i.e. sweating, vomiting, nausea and fatigue), just indicate what the client is experiencing, don t put that the client denies symptoms. Any signs of intoxication or withdrawal now? Has UA been obtained and what are the results? Any Medication Assisted Treatment and are they being compliant? Was a referral and/or follow up for nicotine made to Quitline or their family doctor?

6 Dimension 2- Biomedical Conditions and Complications: Note any changes to what was written. Note any appointments the patient has been to. Note any changes to medication. If the patient is using the ER instead of a PCP, educate the patient on how to use a walk-in clinic (i.e. Urgent Care.) Note any new injuries since last review. Note any physical health or major medical conditions and/or treatment the patient is receiving (i.e. - diabetes, asthma, recent heart attack, seizures, COPD, etc.) and if it could interfere with treatment. Indicate if the patient has a Primary Care Provider, state who the Primary Care Provider is (and the Clinic name) and/or who prescribes meds. If the patient is on meds due to health issues, list the med and the dosage. Note if release was signed to Primary Care Provider (or if patient declined the release.) If patient does not have a Primary Care Provider, make a referral. Has the patient seen their Primary Care Provider in the past year? If not, make a referral. Any history of brain injury or head trauma? Is patient pregnant? What was the patients response to any referrals made here. Dimension 3- Emotional, Behavioral, or Cognitive conditions and complications: Comment on continued Mental Health treatment. Indicate any appointments attended or missed and compliance with referrals and recommendations. Paint a picture of current stability or lack of and the patients active MH symptoms/behaviors (i.e. client is crying all the time, isolation, aggression, outbursts, suicidal thoughts/planning, self-harming.) List the current meds and dosage, even if it doesn t change it needs to be listed at each review. Appointments attended with the dates. If 17 and under and have court or changes to legal status, note changes here. Dimension 4 Readiness to Change: indicate the stage of change we believe the patient to be in and what the internal and/or external motivation is. Note any change to the voluntary or involuntary status. Is the patient gaining any insight to their addiction or recovery needs? Participation in group and individual sessions. Stages of change: Precontemplation, Contemplation, Preparation, Action, Maintenance. Dimension 5 Relapse, Continued Use, or Continued Problem potential: Are they at risk for continued use? What are their risk factors (i.e. - early age of onset, rapid progression of use, daily IV use, no significant period of abstinence, extensive use history, multiple treatment attempts, pregnant and continues to use, use regardless of consequences, denial, etc.) Is the patient using or not using? What does the patient need to get from tx? List cravings or urges to use. What coping skills does the patient have or need? Dimension 6 Recovery/Living Environment: Note any changes to: With whom does the patient live? Does the patient have housing? If the patient is homeless, give specifics (i.e. - living in car, couch surfing, on streets or shelter, etc.) Does anyone in the house use substances? Does the patient have a Significant Other? Family support for recovery? Report if there is or is not a family history of substance abuse or mental health issues. Does the patient have any children? If so, where are they living? Have the children been removed from the home and when, and any DHS involvement with the kids. Does patient have contact with children? Are there any family issues that may

7 impact recovery? What legal charges (for adults, not minors)? When did they occur? Does the patient have a court appearance coming up? Name of PO? Any problems in school or work? Is the patient employed? Is transportation or day care an issue? Criminal using associates/peer groups. Is patient involved in a non-using community based program (i.e. church, NA, AA, gym, etc.) If in AA or NA, do they have a sponsor? Note the tentative discharge plan (i.e. transitional housing, going home to family, support system, etc.) Recommended Environment: Environment (level of care) the patient was recommended for. Actual Environment: Environment the patient is going to be admitted to (or if this is an admission this is the level they are admitted to.) This also needs to be the level of care the patient agrees to participate in. Clinical Override: Use this box to explain why the Recommended and the Actual Environments are different, if they are not use 0-N/A. If they are different this needs to be explained in the Bottom Comments box. 0-N/A 1-Lack of insurance benefits 2-Managed care refusal 3-Clinical judgment 4-Patient opinion 5-Level of care not available 6-Legal issues 7-Other Bottom Comments box: Each time the ASAM is updated this box should have unnecessary info deleted and the new info added. Tx Review: o Date of review o Information validating patient s current level or recommended level of care for patients transferring to a new level (i.e.-progress, lack of progress, usage, UA results, arrest, etc.) o Explain the disposition of the patient; what groups, individual and family sessions the patient will attend and how often, or if the patient declined services.

8 o Tx plan goals/assignments that the patient is working on. (I.e patient is working on having better boundaries, coping skills, etc.) Note specific progress.