DBT Supplemental Information to POSR Client Identifier Date // 9) On ADMISSION report (answer these questions on admission report only): Prior to entering DBT IOP, number of years client received any mental health services (1 = 1 year or less, 2 = 1+ up to 5 years, 3 = 5+ up to10 years, 4 = 10+ years) If applicable, date client began DBT before DBT was preauthorized / / 10) Mental Health Service Utilization On ADMISSION report: a) Enter A if client received service at Any time during the last six months b) Enter C if client is receiving the service Concurrently with DBT on admission c) Enter AC if client received service at any time in the past six months and client is receiving the service concurrently with DBT on admission On ONGOING or DISCHARGE report: a) Enter A if client received service at Any time during the last six months ACT ARMHS Mental Health Service A, C or AC Mental Health Service A, C or AC Crisis Response Services Day Treatment DBT Other Provider Emergency Services Hospital - Partial IRTS Medication Management Psychotherapy - Family Psychotherapy - Group Psychotherapy - Individual Other MH (specify): Substance Abuse 11) Previous 6 Month Period (complete both the number of days and the number of times) Medical admissions for self-harm injuries Emergency room visits for behavioral issues (self-harm/threats, seeking admission, overuse of drugs/alcohol) Number of suicide attempts during last 6 months (Enter total number of attempts) Number of non-suicidal self-injuries during last 6 months (Enter total number of self-injuries) 12) Education / Volunteer Work Average hours per week in school during last 30 days (0 = 0 hours, 1 = 1-7 hours, 2 = 8-20 hours, 3 = 21-40 hours, 4 = 40+ hours, 5 = school break) Average hours per week doing volunteer work during last 30 days (0 = 0 hours, 1 = 1-7 hours, 2 = 8-20 hours, 3 = 21-40 hours, 4 = 40+ hours) Days N/A Times 13) Borderline Symptom List (BSL-23) total score BSL - Supplement total score 14) Reason for DISCHARGE (complete on discharge / discontinuance report only) 1 = Transferred to hospital, partial hospitalization, ACT or residential treatment 2 = Transferred to standard outpatient or medications only 3 = Completed program 4 = Dropped out prior to completion 5 = Death - suicide 6 = Death non-suicide 7 = Moved / relocated 8 = Jail / prison 9 = Other
Program Outcomes Status Report DBT Supplemental Information Instructions Introduction The Minnesota Department of Human Services (DHS) requires that client outcomes be reported every six months for persons receiving DBT services from a certified provider. This information is used by DHS in the analysis of DBT services to assist in policy development and service administration. Only DHS certified providers need to report this data. Criteria for inclusion An outcome status report (POSR) and the DBT supplemental report is completed for clients who: 1. Were admitted to the DBT program during the 6 month period (includes readmissions) 2. Continue to receive DBT services 6 months after admission 3. Were discharged during the 6 month period (includes administrative discontinuances) Completing the Outcomes Data Both the POSR form and the DBT supplemental form are completed at the client s admission, six months from the client s admission and/or at the client s discharge. The type of report is recorded on the POSR form using the admission, ongoing and discharge indicators as follows: Admissions An admission report (Indicator 1) is completed when the client is admitted to a certified DBT program. The admission report looks at the client s status six months prior to admission. If the client had been receiving DBT services prior to your program s certification, you will be asked for that information on the DBT supplement. When completing the admission date, use the date that client is authorized to begin treatment in a certified DBT program. If the client was discharged and then readmitted in the same period, you will have a report for each admission and discharge. Ongoing Clients If the client has not been discharged within the six months after the client s admission, complete an ongoing report (Indicator 2). The ongoing report looks at the client s status six months prior to the date of the report. This report should coincide with the client s reauthorization for continuing DBT services. Page 1
Discharges Complete a discharge report (Indicator 3) at the time of the client s discharge from DBT services. This report looks at the client's status from the previous admission or ongoing report to the date of discharge. If the client was admitted in a previous period, and discharged during the current period, there should be only one report a discharge record (Indicator 3). Do not include an ongoing report (Indicator 2) when the client has been discharged. If the client was admitted and discharged, or discharged and readmitted, in the same 6 month period, there should be two records, an admission (Indicator 1) and a discharge (Indicator 3) report. Administrative Discontinuances This is for a client who was not seen during the 6 month period but was not formally discharged. Use Indicator 4 for the discontinuance and enter the discharge date that you consider the client to be discharged. On the POSR form, leave the rest of the items (1 to 6) blank. On the DBT supplement form, answer item 14, Reason for Discharge. Report submissions The POSR and DBT supplemental reports are submitted to DHS twice a year. For the January to June period, reports are due July 31; for July to December, reports are due on January 31. The report data is entered into an Excel spreadsheet or a text file. The completed spreadsheet or text file is submitted electronically using MN-ITS, the preferred method, or attached to a Secure e-mail. Because the reports contain private data they cannot by submitted by e-mail unless you receive a Secure e-mail sent to you by DHS. You can request the MN-ITS instructions or a secure e-mail by notifying the reporting help desk. Technical Support For assistance with completing the DBT POSR and supplement information, call the reporting help desk at (651) 431-2239, press 4 for DBT or e-mail the help desk at dhs.amhis@state.mn.us. Make sure to enter DBT in the subject line. For questions about DBT policy, contact the Adult Mental Health Division, at (651) 431-2225 or e-mail dbt.certification@state.mn.us. Page 2
Completing the DBT Supplemental Report The DBT supplement contains questions specific to newly admitted clients, questions that will be completed for all clients (new admissions, ongoing and discharged), and a question specific to the client s discharge. For each admitted client, complete items 9 13 on the DBT Supplement at the time of admission. The admission report looks at the client s status six months prior to admission. Answer these questions to the best of your ability based on the information known. Six months after the client s admission (and every 6 months thereafter if the client continues DBT services), complete an ongoing report. On the DBT Supplement, complete items 10 13. The ongoing report looks at the client s status during the last six months. For clients discharged within the six month reporting period, complete a discharge report. On the DBT Supplement, complete items 10-14. This report looks at the client's status six months prior to the date of discharge. The information may overlap with the previous report. For clients who are administrative discontinuances (see above), complete item 14 on the DBT Supplement. Explanation of Data Elements 9) On ADMISSION report: The two questions under item 9 are answered only on the admission report when the client is admitted to a certified DBT program and preauthorized to begin services. Number of years client received any mental health services This question is answered by client self-report or history documented in client records. Enter the codes for the number of calendar years that client received any mental health service, including those received before age 18. The codes are: 1 1 year or less 3 More than 5 years up to 10 years 2 More than 1 year up to 5 years 4 More than 10 years Date client began DBT before program was certified If applicable, complete at admission. This information is relevant for clients that entered a DBT program prior to the program s certification by the State of MN. This date will precede the Admission Date for the current episode of care being reported. Page 3
10) Mental Health Service Utilization Only mental health services should be reported in this section. Use the codes listed depending on if it s an admission report or an ongoing or discharge report. For other specify the mental health service the client received. On ADMISSION report: a) Enter A if client received service at Any time during in last six months b) Enter C if client is receiving these service Concurrently with DBT on admission c) Enter AC if client received service at any time in the past six months and client is receiving the service concurrently with DBT on admission On ONGOING or DISCHARGE report: a) Enter A if client received service at Any time during the last six months Mental Health Service A, C or AC Mental Health Service A, C or AC ACT IRTS ARMHS Medication Management Crisis Response Service Psychotherapy - Family Day Treatment Psychotherapy - Group DBT Other provider Psychotherapy - individual Emergency Services Other MH (specify): Hospital - Partial Substance Abuse 11) Previous 6 Month Period Medical admissions for self-harm injuries Days This is the number of days in the last 6 months the client was an inpatient in a hospital unit for medical care related to self-inflicted injury and/or suicide attempt. Medical admissions for self-harm injuries Times This is the number of episodes in the last 6 months the client was an inpatient in a hospital unit for medical care related to self-inflicted injury and/or suicide attempt. Emergency room visits related to behavioral issues- Times This is number of episodes in the last 6 months that the client presented at an urgent care clinic or hospital emergency room for any of the following reasons: threats of self-inflicted injury or suicide, actual self-inflicted injury or suicide attempt, seeking hospital admission, overdose or misuse of substances or alcohol. Number of suicide attempts during last 6 months This is total number of episodes of self-inflicted injury with suicidal intent Number of non-suicidal self-injuries during last 6 months This is total number of episodes of non-suicidal self-inflicted injuries (i.e., behaviors such as cutting, drug use or other self-injury with no suicidal intent) Page 4
12) Education / Volunteer Work Average hours per week in school This is average number of hours per week client participates in educational activities during the last 30 days. The codes are: 0-0 hours 3-21 to 40 hours 1 1 to 7 hours 4 - More than 40 hours 2-8 to 20 hours 5 - On a school break Average hours per week doing volunteer work This is the average number of hours per week client participates in volunteer work activity during the last 30 days. The codes are: 0-0 hours 3-21 to 40 hours 1 1 to 7 hours 4 - More than 40 hours 2-8 to 20 hours 13) Borderline Symptom List (BSL-23) The BSL-23 is administered at the time of admission to the certified DBT program, at six months, and at discharge from program. This list is a 23 item client self-report of symptoms. Total score is the sum of the each column. BSL - Supplement: Items for Assessing for Behavior The BSL - Supplement: Items for Assessing for Behavior is administered at the time of admission to the certified DBT program, at six months, and at discharge from program. The supplement, 11 items, is also self-reported by the client. The total score is the sum of each column. 14) Reason for discharge The reason for discharge is the clinician s description for discontinuation of DBT IOP. Answer this question only at the time of Discharge or Discontinuance from a certified DBT program. The codes are: 1 - Transferred to hospital, partial hospitalization, ACT or residential treatment 2 - Transferred to standard outpatient or medications only 3 - Completed program 4 - Dropped out prior to completion 5 - Death - suicide 6 - Death non-suicide 7 - Moved/relocated 8 - Jail/prison 9 - Other Page 5