COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

Enterprise Invoice Management 
& 
Enterprise Service Management Project 

 BSAS Assessment Manual
Client Intake Form
Standard Enrollment and Disenrollment Form 

December 2017

Introduction
Goals and Objectives
Client Confidentiality
Interview Assumptions
GAMBLING DISENROLLMENT ASSESSMENT
ESM ClientID
ProviderID
Disenrollment Date
Disenrollment Reason
Definitions:
1. First Name/ Last Name
2. Intake/Clinician Initials:
3.  Client Type
4. Disenrollment Plan
5. Referred to Self Help
6. Client referrals at disenrollment
7. Employment status at disenrollment. This is a National Outcome Measure, reporting is required by SAMHSA
8. Days worked past month?
9. Indicate the Social or Health Services provided to the client during treatment
10. Currently receiving services from a state agency:
11.  Living arrangement at Disenrollment: This item is a National Outcome Measure, reporting is required by SAMHSA
12. Have you  gambled in the past 30 days OR since enrollment?
13. Ranking of gambling
14 Have you used drugs or alcohol in the past 30 days OR since enrollment?
15.  Types of last regular alcohol and/or drug use
16.  Tobacco Questions:
T1. Tobacco Use?
T2.  Last Use
T3.  Number of cigarettes smoked per day?

Introduction

The Department of Public Health, Bureau of Substance Addiction Services collects client and service data via the EOHHS business application, Enterprise Invoice Management-Enterprise Service Management (EIM-ESM), which is accessed through the web-based EOHS Virtual Gateway. EIM-ESM is designed to provide timely and comprehensive reports on client characteristics at Intake, client status at Disenrollment, and client change between the beginning and end of the treatment episode.  The data system can be used to monitor treatment time and readmission rates for the same or different substance abuse problems.  An important dimension of the system is that client and fiscal information systems use the same database.  As a result, program managers may obtain detailed information on the type and amount of services provided and the cost of services to specific client groups.

Goals and Objectives
The primary goal of the EIM-ESM data collection by the Bureau of Substance Addiction Services is to enhance fiscal and program management.  To achieve that goal, the system has seven objectives:

•	Provide unduplicated client count
•	Provide count of  client enrollments
•	Monitor usage patterns
•	Provide timely reports on client characteristics
•	Verify billing and suspend payment, if necessary
•	Compute utilization rates
•	Produce budget status reports
•	Facilitate treatment and recidivisms studies

Client Confidentiality

Although client names and other identifying information, such as Social Security numbers (SSN) are collected by ESM, the Bureau adheres to the provision governing the confidentiality of alcohol and drug Addiction patient records (Code of Federal Regulations, Chapter 42, Part II).  In accordance with the law, the Bureau does not have access to the name and SSN data held by the EIM-ESM a part of the Client management information or billing information.  

The ESM-EIM security measures are robust.  EIM-ESM limits access to a client’s enrollment information and substance Addiction assessment information to the organization that is treating the client and holds the consent to enter the data into EIM-ESM.

Additionally, the data are protected by the Massachusetts Fair Information Practices Act. The data qualify as medical records and, therefore, cannot be requested as “public records”.

Interview Assumptions

The BSAS Intake and Assessments interviews are based on two important assumptions:

•	Neither the Intake nor Enrollment/Disenrollment Assessments are clinical interviews
•	Intake/Assessment items are question prompts, not specific questions.

The Bureau’s Intake/Assessments interviews are not designed as clinical interviews.  Although general descriptions of client status are obtained, the detail required for a comprehensive analysis of the client’s substance Addiction and related problems is not elicited.  Programs, therefore, are expected to conduct more detailed clinical interviews.  Collection of the Assessment data can be a part of the more comprehensive clinical interview.

Many of the interview items are designed as prompts.  A specific question format is not provided. Clinicians are free to ask the questions in their own style and format.  The only constraint is that all required questions must be asked and an answer provided even when it is “unknown’ or ‘refused’.

GAMBLING DISENROLLMENT ASSESSMENT

All questions marked with a  are required.  

ESM ClientID

The ClientID is automatically assigned when the client is entered into the ESM-EIM system.  This number should be recorded on the Enrollment form after the data is entered into EIM-ESM system.  This is helpful information to have in the client record when verifying the data in the system or when communicating with the Bureau regarding the specific client’s case and/or billing as the Bureau does not have access to the name.
ProviderID
This field is to be used by the provider in any way that is helpful to them in the management of client records.  This is not entered into the EIM-ESM system.

Disenrollment Date
Enter the day that the client was disenrolled/discharged from the program.  Enter the date using the mm/dd/yyyy format, for example: 06/01/2007.  

Disenrollment Reason
Check only one box.  Select from the following choices:
•	Assessment Only
•	Completed 
•	Drop-out
•	Relapsed
•	Administrative/non-compliance
•	Incarcerated
•	Transferred to other substance Addiction program
•	Hospitalized, medical
•	Hospitalized, mental health
•	Inappropriate
•	Moved
•	Enrolled in Error
•	Deceased

Definitions:

Assessment Only

Client was Assessed but never treated.  Client was determined not to be appropriate for substance Addiction treatment after assessment due to absence of substance problem or need for a different treatment type; often the need for more intensive treatment.

Completed 

Acute Treatment Services:  Clients “complete” treatment when they are discharged as medically clear.  A completed discharge may be given after a few hours of observation or several days of treatment.  

Residential:  Clients “complete” treatment when either a) the client or the counselor agree that the treatment plan objectives have been attained or b) additional gains and remaining treatment objectives do not require the resources available in the residential program.

Ambulatory:  Client “complete” treatment if a) the client completes a treatment plan contracted length of treatment, or b) the client and the counselor agree that substantial gains have been made.  Completed treatment does not automatically imply that the client did well.  Clients who complete a contracted period and choose to remain in treatment should not be disenrolled.

Dropouts

Residential: Clients are dropouts if they a) leave without notifying the program; b) leave even though their counselor feels that sufficient gains were not made; or c) leave without meeting treatment objectives.

Ambulatory and Residential: Clients who complete an intake procedure but fail to return for treatment should be coded as dropout.

Ambulatory: Clients are dropouts if they a) leave treatment without a closing contact (the contact may be by telephone); b) are absent from treatment for 90 days; or c) leave before the treatment plan on contract is completed and the counselor feels that sufficient gains were not made.

DAE: Dropout is not a valid code for DAE programs. 

Acute Treatment Services: Clients who unilaterally decide to leave while continuing to exhibit one or more of the signs, symptoms, and/or conditions listed below are to be classified as dropout.  These criteria for “against medical advice” disenrollments are physiologically based and do not include aftercare treatment and rehabilitation concerns.

Relapsed

When the client’s current use of alcohol or drugs is the reason for discharge or disenrollment, “relapse” may be entered.  The client’s choice to use alcohol or drugs may be the underlying reason for dropping out, and the relapse may result in the program enforcing an administrative discharge.  However, these clients should be coded as relapse.

Administrative/non-compliance

For all Activities (program types), the noncompliance /administrative discharge/disenrollment category applies to clients discharged/disenrolled for an active violation of program policies and rules (other than for use of alcohol or drugs: see “relapse”.)

Incarcerated
Use ‘Incarcerated’ for a  client who is disenrolled because he/she enters a prison, jail, or correction facility.

Transferred to other substance Addiction program
Use for a client who is transferred to another substance Addiction treatment facility because of a move or for therapeutic reasons.  This is not used for a client who has completed treatment at one facility and is moving to another level or type of treatment.

Hospitalized, medical
Client is disenrolled from the substance Addiction treatment program due to admission to a medical facility.

Hospitalized, mental health
Client is disenrolled from the substance Addiction treatment program due to admission to a medical facility.

Inappropriate
After enrollment and attempt at treatment, a client is disenrolled as “inappropriate/referred” when a program cannot provide needed medical or psychological treatment and the client is sent to a more appropriate facility. This is different from ‘Assessment Only’ when the client is referred to a more appropriate setting immediately upon assessment.

Moved
Client has moved and cannot access the treatment program.

Enrolled in Error
Client was enrolled incorrectly or in error.

Deceased
Client has died.
1. First Name/ Last Name
This is not entered, again, into the system but is necessary for managing the client record.

2. Intake/Clinician Initials:
Enter he initials of the clinician who conducted the Assessment interview.

3.  Client Type    
Check one box.  Select either Primary or Collateral.

Selection must match the Client type selected on the Enrollment form.

Primary clients are those seeking treatment for their personal substance Addiction problem.

Collateral clients are seeking help because of a family member’s or a friend’s substance Addiction problem.  Collateral clients may also have significant personal problems involving drugs and/or alcohol.  If a collateral client decides to begin treatment for their own substance Addiction, they should be discharged as collateral client and re-enrolled as a primary client.
4. Disenrollment Plan  
Check one box.  Select either “Yes’ or ‘No’.
5. Referred to Self Help    
Check one box.  Select either “Yes’ or ‘No’.   This question should be answered as ‘Yes’ if the client is referred to self help at any point in the course of treatment.
6. Client referrals at disenrollment 
Referral # 1:  Select from the following codes.

00	Referral Not Needed 	51	Community or Religious Organization	
97	Referral Not Made – Client Dropped Out	60	Court – Section 35	
98	Referral Attempted – Not Wanted by Client	61	Court – DUI	
01	Self, Family, Non-medical Professional	62	Court – Drugs	
02	BMC Central Intake – Room 5	63	Court – Other	
03	ATS – Level A (Detox)	64	Prerelease, Legal Aid, Police	
04	Transitional Support Services	65	County House of Correction/Jail	
05	Clinical Stabilization Services – CSS	66	Office of Community Corrections	
06	Residential Treatment	67	Dept. of Corrections	
07	Outpatient  SA Counseling	68	Dept. of Probation	
08	Opioid Treatment	69	Massachusetts Parole Board	
09	Drunk Driving Program	70	Dept. of Youth Services	
10	Acupuncture	71	Dept. of Children and Families	
11	Gambling Program	72	Dept. of Mental Health	
12	Sect. 35 (WATC, MATC)			
13	Youth Program	73	Dept. of Developmental Services	
14	Sober House	74	Dept. of Public Health	
15	Information and Referral	75	Dept. of Transitional Assistance	
17	Second Offender Aftercare	76	Dept. of Early Education and Care	
19	Other Substance Addiction Treatment	77	Mass. Rehab. Commission	
20	Primary Care Provider, Health Care Professional, Hospital, 	78	Mass. Commission for the Blind	
30	School Personnel, School System	79	Mass. Comm. For Deaf & Hard of Hearing	
40	Supervisor/employee Counselor	81	Division of Medical Assistance (MassHealth)	
50	Shelter	80	Other State Agency	

Additional Referral # 2:  Select from the same code set as above.  This second referral is not required but should be used if more than one type of referral was made.  For example, enter a second referral if client was referred to a Sober House (14) and Outpatient Counseling (07).  The second referral is not to be used when referral is made to more than one program of the same type (for example, when a referral is made to two Residential programs).

Additional Referral # 3:  Select from the same code set as above.  This third referral is not required but should be used if more than two types of referrals were made.  For example, enter a third referral if client was referred to a Sober House (14) and Outpatient Counseling (07) and Health Care Professional (20).  The third referral is not to be used when a referral is made to more than one program of the same type (for example, when a referral is made to three Residential programs).

7. Employment status at disenrollment. This is a National Outcome Measure, reporting is required by SAMHSA
Enter one of the following codes:
1	Working full-time	
2	Working part-time	
3	Unemployed – Looking	
4	Unemployed – Not Looking	
5	Not in labor force – Student	
6	Not in labor force – Retired	
7	Not in labor force – Disabled	
8	Not in labor force – Homemaker	
9	Not in labor force – Other	
10	Not in labor force – Incarcerated	
11	Volunteer	
12	Other	
13	Maternity/Family Leave	
99	Unknown	

8. Days worked past month?
If answered 3-10 in question # 8 then enter the number of days the client worked in the past 30 days here.
   
9. Indicate the Social or Health Services provided to the client during treatment
Many substance Addiction programs provide a range of social and medical services to the client during treatment.  Some of these service may be provided directly be the substance Addiction treatment program and some may be provided by other programs/agencies or independent professionals.

All listed social and health services must have one of the following entered:

0 = Not Provided
1 = Provided by your Agency
2 = Provided by another/different Agency 
3 = Provided by Both your Agency and Other Agency

The Social/health Services are:
•	Legal Aid/Services:  This includes services provided to assist the client with his/her legal needs.  This also includes programs’ contact with parole or Probation Officers, DSS meetings, and transportation to court.
•	Housing:  This includes services specifically provided to assist the client with housing needs, such as finding housing, obtaining subsidized housing, or assisting with a move.  It does not include the housing received while the client is in any residential treatment.
•	GED: Refers to the terms General Equivalency Diploma or General Educational Development.  These terms imply a High School Equivalency Certificate.
•	Vocational Training: Includes training in specialized job skills provided to the client such as computer training, word processing, or carpentry.
•	Literacy Services:  Includes services that teach the client how to read and/or write.
•	Job Placement/Referral: Includes services specifically provided to assist the client in getting a job, such as how to write a resume, what to do on a job interview, or how to conduct a job search.
•	Financial Counseling: Includes services to teach client money management skills.
•	Treatment for Emotional Problem:  Includes special counseling/treatment for specific emotional/mental health problems other than those that usually result from substance Addiction, for example, psychiatric consultation or specialized groups for PTSD.

10. Currently receiving services from a state agency: 
Receiving services pertains to services received directly by the client themselves. 
Check all that apply.  The choices are:

None
DCF	Department of Children and Families
DYS	Department of Youth Services
DOC	Department of Corrections
MPB	Massachusetts Parole Board
OCP	Office of the Commissioner of Probation
DMH	Department of Mental Health
DDS	Department of Developmental Services
DPH	Department of Public Health
DTA	Department of Transitional Assistance
DMA	MassHealth 
EEC	Dept. of Early Education and Care
MRC	Massachusetts Rehabilitation Commission
MCB	Massachusetts Commission for the Blind
MCDHH	Mass Commission for Deaf and Hard of Hearing
	      Other	Other State Agency

11.  Living arrangement at Disenrollment: This item is a National Outcome Measure, reporting is required by SAMHSA
Check only one box.  Select the answer that best describes the living situation for the client at disenrollment.  For example, if the client is going to a residential program at disenrollment, select ‘Group Home’.  The choices are:

•	House or apartment
•	Room/boarding house
•	Institution
•	Group home
•	Shelter/mission
•	On the streets
•	Foster Care
•	Refused
•	Unknown

12. Have you  gambled in the past 30 days OR since enrollment?
Don’t repeat history taken at enrollment. The gambling types include. 
A	Lottery – Scratch tickets
B	Casino Games
C	Dog/Horse Tracks, Jai Alai
D	Lottery – Keno
E	Card Games
F	Stock market
G	Lottery / Numbers Games
H	Sports Betting
I	Internet Gambling
J	Slot Machines
K	Bingo
L	Other
Below are the general instructions for completing the substance Addiction history questions:
Betting  Status?
Check ‘Y’ for yes and “N” for ‘No’ for each substance.

Lest Bet?
When was the last time the client bet? Select from the following codes:

1	12 or more months ago	
2	3-11 months ago	
3	1-2 months ago	
4	Past 30 days	
5	last week	
6	Today	
88	Refused	
99	Unknown	

Frequency of Last Bet?
Report the frequency of alcohol/drug use since enrollment.

Select from the following codes:

1	Less than once a month	
2	1-3 times a month	
3	1-2 times a week	
4	3-6 times a week	
5	Daily	

13. Ranking of gambling 
Rank types of gambling by entering corresponding letter for gambling type listed above in Question 18.
A primary gambling type must be marked.  If there is no Secondary or Tertiary gambling of choice, leave the field blank. If a Primary Secondary or Tertiary type of gambling is listed the previous questions must be completed

If the client is unable to evaluate their preference /addiction to particular type of gambling, the perceived severity may be determined by the clinician.  If the client is unable to evaluate, the clinician should use the following in making a determination:

•	Pattern and frequency of betting
•	Degree of present or past physical, mental, social dysfunction caused by the betting
•	Degree of present or past psychological dependence on gambling, regardless of the frequency of betting.

14 Have you used drugs or alcohol in the past 30 days OR since enrollment?
Check one box.  Select either ‘Yes’ or ‘No’. If ‘No’ is selected, skip to question 15.
15.  Types of last regular alcohol and/or drug use
This series of questions is intended to elicit information on any substance use by the client since enrollment or in the past 30 days for long term treatment programs.  If the client was not using drugs or alcohol at the time of enrollment and did not relapse, then select ‘None’. 

The substances include:
1	          None
A	Alcohol
B	Cocaine
C	Crack
D	Marijuana / Hashish
E	Heroin
F	Non-Prescription Methadone
G	Other Opiates / Synthetics
H	PCP
I	Other Hallucinogens
J	Methamphetamine
K	Other Amphetamines
L	Other Stimulants
M	Benzodiazepines
N	Other Tranquilizers
O	Barbiturates
P	Other Sedatives / Hypnotics
Q	Inhalants
R	Over the Counter
S	Club Drugs
U	Other
V	Oxycodone
W	Non-prescription Suboxone

16.  Tobacco Questions:
T1. Tobacco Use?       
Check only one box. Select either ‘Yes’, ’No’, Refused or ‘Unknown’.

If the answer to question T1 is ‘Yes’ the complete Questions T2-T3
  
T2.  Last Use
Select from the following codes
1	12 or more months ago	
2	3-11 months ago	
3	1-2 months ago	
4	Past 30 days	
5	Used in Last week	
6	Today	
88	Refused	
99	Unknown	

T3.  Number of cigarettes smoked per day? 
Indicate number of cigarettes, not number of packs: 1 pack = 20 cigarettes.