BPA Health - SUD Agency EBP & Co-Occurring Confirming Please answer the questions as listed below. You will be able to save and resume your work at anytime by choosing the "save" button on the bottom right hand of the page. Please note you will need to fill out this form sequentially, page by page, and will be unable to skip forward to another page without finishing the page you are on. Introduction Introduction & Instructions Hello! Thank you for your continued commitment to our SUD clients! The purpose of this form is to document your co-occurring capabilities and written descriptions of Evidence-Based Practices (EBP) on a site-by-site basis in advance of the new SUD contract going into effect 10/01/2018. All treatment providers and sites in the BPA Health network must be co-occurring capable. Be prepared to demonstrate these capabilities in a co-occurring assessment form. This form replaces the DDCAT and is intended to simplify the process. Additionally, we are required to reaffirm our providers' written descriptions of Evidence-Based Practices (EBP) by site. You may copy and pate information from your existing written descriptions to complete the appropriate fields. Make sure to complete for any new EBPs as well. You are not required to complete this form all at once. You will be allowed to save your progress by clicking the "Save" button on the bottom right hand of each page. An email will be sent to you with a link that will allow you to continue with the form at a later time. If you have questions or need help with this form, please contact Provider Relations at providerrelations@bpahealth.com. Are you ready to proceed? Yes No Page 1 of 10
Agency Information General Agency Information Agency Name Region Region Map Unsure? Click the Region Map to the right to determine. Name of Person Completing Form Email of Person Completing Form First Last The person who is the main contact for BPA Health. Agency point of contact, if different than above: Email of agency point of contact, if different than above: Page 2 of 10
Location Details Specific Locations Please enter each service/treatment location individually. Is this the sole agency location for all treatment service? Yes No Please enter each service location individually. Scroll down the form and choose the "+Add Address" at the bottom left of this form as needed to add additional locations. Please enter information below: Location/Address 1 Please list a unique name for this location; you will need to use this unique name in the following section: (Example: Use the City Name, or the Street and City to identify) Address Address Line 1 Address Line 2 City State Zip Code Phone Extension Fax Location Point of Contact Location Point of Contact Email Co-Occurring Capability Assessment for this Location Will there be Licensed Masters Degree capable of diagnosing mental health disorders and experience treating individuals with co-occurring disorders at this location? Yes No 1. Which practitioners will be designated as cross-trained staff? Page 3 of 10
List each practitioner below Practitioner Name 1 Name License Type Title First MI Last 2. Other than the GAIN how will you screen and diagnose clients with co-occurring disorders at this location? Include description of screening and diagnosis plan below. Tools can be found at: https://store.samhsa.gov/shin/content/sma15-4930/sma15-4930.pdf 3. What are your procedures for assessing clients stage of change for co-occurring treatment at this location? 4. How will you assist client access to necessary comprehensive services at this location? 5. What are your procedures for providing co-occurring treatment planning at this location? Page 4 of 10
6. How will you communicate and collaborate with other treatment team members, including medication prescribers, from this location? 7. What types of Evidenced Based group treatment will you provide for clients with cooccurring disorders at this location? 8. How will family interventions be offered for families or other supporters of clients in your program at this location? 9. How will cross-trained staff assist clients in building natural social support in the community at this location? 10. Policy and Procedure showing emergency services available by telephone 24 hours a day, 7 days a week. 11. Policy and Procedure for arrangement with specific medical and psychiatric services, to be made available on-site or through consultation or referral. Including a time frame appropriate to the severity and urgency of the consultation requested. Page 5 of 10
12. Policy and Procedure describing a process of documenting active reassessment of the client s mental status and follow through with mental health treatment as well as psychotropic medication. Page 6 of 10
EBP's, Release & Signature Written Description of Evidence Based Programs and Practices (EBP) Please note that BPA Health is requiring you to fill out each question as listed below, for each EBP you are using at the locations you indicate below. We suggest you copy and paste from any internal documents you may have on file. EBP Descriptions, by location Please include a written description for EACH EBP you will be using in your groups, and at which location(s). EBP 1 EBP Category Anger Management for Substance Abuse and Mental Health Clients: A Cognitive Behavioral Therapy Manual (SAMHSA) Cognitive Based Interventions for Substance Abuse (CBI-SA) Co-Occurring Disorders Program (Hazelden) Dialectical Behavioral Therapy Helping Women Recover Living in Balance Matrix Model Motivational Interviewing Moral Recognation Therapy (MRT) Relapse Prevention Therapy (RPT) Seeking Safety The Change Companies: Interactive Journaling Thinking for a Change Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) Trauma Recovery Empowerment Model for Men (TREM) Choose One Location(s) where this EBP is used (separate locations with a comma) Use unique name(s) from the previous page. Program Description Page 7 of 10
Briefly explain the EBP including counseling methodology used such as CBT or Person Centered. Program Goals Briefly explain how the EBP will assist client in substance use recovery. Interventions Utilized Examples include: clients have own workbooks to complete homework; group role plays additional family sessions; drug and alcohol testing, etc. Implementation Requirements Include training/certification requirements for facilitators as described by author or developed. Why have you chosen this EBP? Page 8 of 10
Do you intend to make any adaptations to the EBP? Yes No Where is this listed as an EBP? NREPP Hazelden Gold Star NCIC Other Peer Reviewed Journal Peer Reviewed Journal 1 Peer Reviewed Journal 2 This EBP is appropriate for the following populations: (check all that apply) Opiate Use Disorders Criminal Justice Network PWWC Adolescents Co-occurring Who is this EBP is NOT appropriate for? (e.g. adolescents, a specific gender) What is the process for determining discharge from this particular EBP? (e.g. successfully demonstrates skills from all modules) I attest the information I have provided is current, that all group facilitators are appropriately trained, and when required, certified to facilitate group. I will send in updated descriptions when changes are made. Signature Date Attested to EBPs Name of Signer Page 9 of 10
Page 10 of 10