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

May 2009
Introduction
Goals and Objectives
Client Confidentiality
Interview Assumptions
GAMBLING ENROLLMENT ASSESSMENT
ESM ClientID
ProviderID
Enrollment Date
1. First Name/Last Name
2. Intake/Clinician Initials:
3. Number of days between initial contact with the program by the client or someone on behalf of the client and enrollment:
4.  Source of Referral
4a. Client Type
5. Do You Have Children?
6. Employment Status at enrollment
7. Number of Days Worked Past Month:
8.  Where Do You Usually Live?  This item is a National Outcome Measure, reporting is required by SAMHSA
9. Who do you live with?
10. Use of mobility aid
11. Vision Impairment:
12. Hearing Impairment
13. Self Care/ADL Impairment
14. Mental Retardation
15.  Prior Mental Health Treatment
16. During the past 12 months, did you take any prescription medication that was prescribed for you to treat a mental or emotional condition?
17. Number of prior admissions to each substance abuse treatment modality
18. Currently receiving services from a state agency:
19. Gambling History:
20. Ranking of gambling
23.  T1. Tobacco Use?
T2. Age of first use
T3.  Last Use
T4.  Number of cigarettes smoked per day?
24.  Have you ever used alcohol or drugs regularly (check all that apply)?
25. Ranking of Substances
26.  Last Needle Use?

Introduction

The Department of Public Health, Bureau of Substance Abuse 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 Abuse 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 abuse 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 abuse 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 abuse 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 ENROLLMENT ASSESSMENT

All questions marked with a  are required.  

System populated fields:
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 on the paper form only; it is not entered into the EIM-ESM system.
Enrollment Date
Enter the day that the client was enrolled to the program.  Enter the date using the mm/dd/yyyy format, for example: 06/01/2007.  Because the enrollment date will be automatically displayed when the Enrollment Assessment is opened for completion, this date does not have to be entered again.  However, its inclusion on the form validates data quality in the client record and in the system.
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 the initials of the clinician who conducted the Assessment interview.
3. Number of days between initial contact with the program by the client or someone on behalf of the client and enrollment:
Enter the number of days between the time that the client first contacted the program and the time that the client was enrolled for treatment.  If this information is unknown, enter 999.  If the client failed to comply with administrative procedures or to meet other obligations (i.e. no-shows), do not count those days.  

Use the following guideline for situations where the client is coming into a treatment program from another treatment setting. 
•	If a client has come into your program directly from an ATS program, providers should enter “0”.
•	If the referral/contact occurred before the client was ready for discharge/disenrollment from a previous program, do not count those days. 
•	If a client was ready to leave but was extended at the previous program while waiting for an opening, do count those days.
4.  Source of Referral
Enter one code from the following choices:
Must enter 2 digits with leading zeroes for the entry to be valid. 

01	Self, Family, Non-medical Professional	63	Court - Other	
02	BMC Central Intake	64	Prerelease, Legal Aid, Police	
03	ATS - Level A (Detox)	65	County House of Correction/Jail	
04	Transitional Support Services	66	Office of Community Corrections	
05	CSS – Clinical Stabilization Services	67	Dept. of Correction	
06	Residential Treatment	68	Dept. of Probation	
07	Outpatient SA Counseling	69	Massachusetts Parole Board	
08	Opioid Treatment	70	Dept. of Youth Services	
09	Drunk Driving Program	71	Dept. of Children and Families	
10	Acupuncture	72	Dept. of Mental Health	
11	Gambling	73	Dept. of Developmental Services	
12	Sect. 35 (WATC, MATC)			
13	Youth Program	74	Dept. of Public Health	
14	Sober House	75	Dept. of Transitional Assistance	
15	Information and Referral	76	Dept. of Early Education and Care	
17	Second Offender Aftercare	77	Mass. Rehab. Commission	
19	Other Substance Abuse Referral	78	Mass. Commission for the Blind	
20	Health Care Professional, Hospital	79	Mass. Comm. For Deaf & Hard of Hearing	
30	School Personnel, School System	81	Division of Medical Assistance (MassHealth)	
40	Supervisor/employee Counselor	80	Other State Agency	
50	Shelter	99	Unknown	
51	Community or Religious Organization			
60	Court - Section 35			
61	Court – DUI			
62	Court – Drugs			
4a. Client Type
Check one box.  Select either Primary or Collateral.

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

Collateral 		clients are seeking help because of a family member’s or a friend’s substance abuse 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 abuse, they should be discharged as collateral client and re-enrolled as a primary client.

4b. Psycho-education Client?
A psycho-education client is a client who is not enrolled in treatment and has participated in a psycho-educational group about problem gambling

Check only one box. Select either ‘Yes’, ‘No’, ‘Refused’, or ‘Unknown’.
5. Do You Have Children?
Check only one box. Select either ‘Yes’, ‘No’, ‘Refused’, or ‘Unknown’.

If the client selects ‘No’, ‘Refused’, or ‘Unknown’, skip to Question 6..
If the client selects ‘Yes’, answer Question 5a-5c.

5a. Number Children Under 6:
Enter number of children less than 6 years of age.

5b. Number of Children 6-18:
Enter number of children between the ages of 6 and 18 years.

5c. Children Over 18:
Enter number of children over 18 years of age.

6. Employment Status at enrollment
This item is a National Outcome Measure, reporting is required by SAMHSA
Check only one. If the individual has not been in the labor force for many years, such as many homeless individuals, code as ‘Not in labor Force-Other’.  The “Unemployed” options are appropriate for individuals who have worked approximately within the past year.  The choices are:
•	 Full-time Employment
•	Part-time Employment
•	Maternity/Family Leave
•	Unemployed-Looking for Work
•	Unemployed-Not Looking for Work
•	Not in labor Force-Disabled
•	Not in labor Force-Homemaker
•	Not in labor Force-Student
•	Not in labor Force-Retired
•	Not in labor Force - Incarcerated
•	Not in labor Force-Other
•	Volunteer
•	Unknown
•	Other

7. Number of Days Worked Past Month:
Enter the number of days worked in 30 days prior to being admitted to the program.
8.  Where Do You Usually Live?  This item is a National Outcome Measure, reporting is required by SAMHSA 
The answer to this question should capture where the client usually lived over the past year, but if the client’s living situation has recently changed, that change should be indicated.  For example, if the client has been recently evicted or asked to leave a living situation due to their substance use, the streets or a shelter may be their only alternative if they do not enter treatment.

The clinician conducting the interview should probe to determine if the client was usually homeless over the past year or living in shelters or on the street, even when they have provided a contact name and address at enrollment. 
 
Check only one box.  The choices are:
•	House or apartment
•	Room/Boarding house
•	Institution
•	Group home
•	Shelter, Mission
•	On the Streets
•	Foster Care
•	Refused
•	Unknown

If the client has been in a residential treatment program, select ‘Group Home’.
If the client was incarcerated, select ‘Institution’.

9. Who do you live with?  
Check all that apply.  The choices are:
•	Alone
•	Child under 6
•	Child 6-18
•	Child over 18 (Check this box only if the Child Over 18 is the client’s own child)
•	Spouse/Equivalent
•	Parents
•	Other Relative
•	Roommate/Friend
•	Unknown
10. Use of mobility aid
Check all that apply.  The choices are:
•	None (Exclusive select)
•	Crutches
•	Walker
•	Manual wheelchair
•	Electric wheelchair

11. Vision Impairment:  
   Select one code from the following choices:
0	None: Normal Vision	
1	Slight: vision can be or is corrected with glasses/lenses	
2	Moderate: "Legally blind" but having some minimal vision	
3	Severe: No usable vision	

12. Hearing Impairment  
Select one code from the following choices:
0	None: Normal hearing requiring no correction	
1	Slight: Hearing is or can be adequately corrected with amplification (eg hearing aid)	
2	Moderate: Hard of hearing, even with amplification	
3	Severe: Profound deafness	

13. Self Care/ADL Impairment
Select one code from the following choices:
0	None: No problem accomplishing ADL skills such as bathing, dressing and other self care	
1	Slight: Uses adaptive device(s) and/or takes additional time to accomplish ADL but does not require a personal attendant	
2	Moderate: Needs personal attendant up to 20 hours a week for ADL	
3	Severe: Requires personal attendant for over 20 hours a week for ADL	

14. Mental Retardation              
Select one code from the following choices:

0	None	
1	Slight retardation	
2	Moderate retardation	
3	Severe retardation	

15.  Prior Mental Health Treatment
Select one code from the following choices.  If the client has received more than one level of treatment listed below, code the highest number.  

0	No prior mental health treatment history	
1	Has received counseling for mental health problem	
2	Has one hospitalization for mental health problem	
3	Has more than one hospitalization for mental health problem	
16. During the past 12 months, did you take any prescription medication that
was prescribed for you to treat a mental or emotional condition?
Check only one box. Select either ‘Yes’, ‘No’, ‘Refused’, or ‘Unknown’.

17. Number of prior admissions to each substance abuse treatment modality
Do not count current enrollment in Question 17.
Detox:
Select one code from the following choices
0	No prior admissions	
1	1 prior admission	
2	2 prior admission	
3	3 prior admission	
4	4 prior admission	
5	5 or more prior admission 	
99	Unknown	
Residential:
Select one code from the following choices:
0	No prior admissions	
1	1 prior admission	
2	2 prior admission	
3	3 prior admission	
4	4 prior admission	
5	5 or more prior admission 	
99	Unknown	
Outpatient:
Select one code from the following choices:
0	No prior admissions	
1	1 prior admission	
2	2 prior admission	
3	3 prior admission	
4	4 prior admission	
5	5 or more prior admission 	
99	Unknown	
Opioid:
Select one code from the following choices:
0	No prior admissions	
1	1 prior admission	
2	2 prior admission	
3	3 prior admission	
4	4 prior admission	
5	5 or more prior admission 	
99	Unknown	

Drunk Driver:
Select one code from the following choices:
0	No prior admissions	
1	1 prior admission	
2	2 prior admission	
3	3 prior admission	
4	4 prior admission	
5	5 or more prior admission 	
99	Unknown	
Other:
Select one code from the following choices:
0	No prior admissions	
1	1 prior admission	
2	2 prior admission	
3	3 prior admission	
4	4 prior admission	
5	5 or more prior admission 	
99	Unknown	

18. 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

19. Gambling History:
This series of question is intended to elicit information about the client’s gambling habits.  Information about the age of first bet, the last time a client bet, and the frequency of last bet needs to be competed for all gambling categories listed as A-L on the gambling matrix.  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 gambling history questions:

Ever Gambled?
Enter ‘Y’ for yes and “N” for ‘No’.  If the answer is No, skip to the next gambling type.
Age of First Bet?
How old was the client the first time he/she gambled?
Last 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	In the last week	
6	Today	
88	Refused	
99	Unknown	
Frequency of Last Bet? 
If the client has stopped betting, how frequently did he/she bet previously?
 
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	
20. 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.

21. Has gambling caused you to have legal problems?
Check only one box. Select either ‘Yes’or ‘No’.

22. What is the number of times in your lifetime that your gambling has led to you being arrested?
Enter the number of times that the client’s gambling has to his/her arrest.
23.  T1. Tobacco Use? 
Check only one box. Select either ‘Yes’, ‘No’, ‘Refused’, or ‘Unknown’.

If the client selects ‘’No’, Refused’, or ‘Unknown’, skip to Question 24.
If the client selects ‘Yes’, answer Question T2-T4
  T2. Age of first use
How old was the client the first time he/she used tobacco?  
T3.  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	
T4.  Number of cigarettes smoked per day? 
Indicate number of cigarettes, not number of packs: 1 pack = 20 cigarettes.

24.  Have you ever used alcohol or drugs regularly (check all that apply)? 

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

25. Ranking of Substances 
Rank substances by entering corresponding letter for substances listed above in Question 24.
A primary substance must be marked.  If there is no Secondary or Tertiary Substance of choice, leave the field blank. If a Primary Secondary or Tertiary substance is listed the previous questions must be completed

If the client is unable to evaluate their preference /Addiction to particular substances, 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 use
•	Degree of present or past physical, mental, social dysfunction caused by the substance
•	Degree of present or past physical or psychological dependence on the substance, regardless of the frequency of use of a specific drug.

26.  Last Needle Use? 
Select from the following codes:

0	Never	
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