COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

Enterprise Invoice Management 
& 
Enterprise Service Management Project 

 BSAS
 Residential Treatment Disenrollment Assessment Manual
For Residential Treatment Disenrollment Assessment Form 

Version 14

December 2017

Goals and Objectives
Client Confidentiality
Interview Assumptions
Residential Treatment Disenrollment Assessment
	ESM Client ID
Provider ID
	Disenrollment Date
	Disenrollment Reason
First Name/Middle Initial/Last Name/Suffix
1.	Client Code
2.	Intake/Clinician Initials
3.	Client’s Type
4.	Disenrollment / Discharge Plan
5a.	Referred to Self Help
5b.	Frequency of Attendance at Self-help Programs
6. 	Client Referrals at Disenrollment
7.	Employment Status at Disenrollment
8. 	Number of days worked in past 30 days or since enrollment if in treatment less than 30 days.
9.	Number of Arrests in past 30 days or since enrollment if in treatment less than 30 days.
10.	Social and/or health services provided to the client during  Treatment – While in your Program
11.	Currently receiving services from a state agency
12. 	Living arrangement at Disenrollment
H1.	Was the client homeless at Intake/Enrollment (whether or not chronic)?
H2.	Detailed Living Arrangement at Disenrollment:
H3.	Permanence of Living Arrangement at Disenrollment
13.   Any drug or alcohol use in last 30 days or since Enrollment if in treatment less than 30 days 
14a.	Primary Substance
14b. 	Frequency of Use
14c.	Route of Administration
15.	Any secondary drug during last 30 days or since Enrollment if in treatment less than 30 days?
15a.	Secondary Substance
15b. 	Frequency of Use
15c.	Route of Administration
16.	Any tertiary drug during the last 30 days or since enrollment if in treatment less than 30 days?
16a.	Tertiary Substance
16b. 	Frequency of Use
16c.	Route of Administration
17a.  Did the client use nicotine/tobacco since Enrollment?
17b.	Number of cigarettes currently smoked per day
17c. 	Interest in stopping nicotine/tobacco use
17d. 	While in this program, did the client attempt to stop using nicotine/tobacco?
Residential Recovery Program – Disenrollment Patient Placement Criteria
Section 1: Acute Intoxication and/or Withdrawal Potential
Section 2:  Biomedical Stabilization
Section 3: Behavioral Stabilization
Section 4: Treatment Acceptance/Resistance
Section 5: Relapse Potential
Section 6: Recovery Environment
Behaviors consistent with development of a safe post-discharge environment 

Introduction

The Department of Public Health (DPH), Bureau of Substance Addiction Services (BSAS) collects client and service data via the Executive Office of Health and Human Services (EOHHS) business application, Enterprise Invoice Management-Enterprise Service Management (EIM-ESM), which is accessed through the web-based EOHHS Virtual Gateway. 

Why Do We Collect this Data and Why is Accuracy Important?

At least half of the funding for substance addiction services is Federal.  BSAS reports to the Substance Abuse and Mental Health Services Administration (SAMHSA). 

•	It is a federal reporting requirement that we submit this data to SAMHSA
•	The data submitted to SAMHSA is referred to as the Treatment Episode Data Set (TEDS)
•	TEDS is the ONLY national client-level database on substance addiction treatment
	The data is used by federal policymakers, researchers, and many others
•	It provides data for trend analysis, understanding characteristics of persons admitted
	to substance addiction treatment and client outcomes
•	It includes information on all clients admitted to programs that receive public funds

•	Performance Management
•	Level of Care Management meeting process
•	Development of provider feedback reports
	Business Decision Support
	Analysis to determine client outcomes and to promote best practices

EIM-ESM is designed to provide timely and comprehensive reports on client characteristics at Intake and Enrollment, 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 addiction 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 eight objectives:

1.	Provide unduplicated client count
2.	Provide count of client enrollments
3.	Monitor usage patterns
4.	Provide timely reports on client characteristics
5.	Verify billing and suspend payment if necessary
6.	Compute utilization rates
7.	Produce budget status reports
8.	Facilitate treatment and recidivism studies

Client Confidentiality

The Bureau realizes that there is concern as to client confidentiality because client names and other identifying information such as Social Security numbers (SSN) are collected by EIM-ESM.  Not only does the Bureau adhere to the provision governing the confidentiality of alcohol and drug addiction patient records (Code of Federal Regulations, Chapter 42, Part II), but in addition the data is protected by HIPAA and by the Massachusetts Fair Information Practices Act. The data qualify as medical records and, therefore, cannot be requested as “public records”.

The EIM-ESM security measures are robust.  It is an award winning security system.  The way in which the information is stored is fragmented so is not relatable.  In addition, the Department of Public Health’s Legal Office determined that BSAS staff, including any research or analytic staff, should have no access to the EIM-ESM interface, unless required to meet their job responsibilities – Provider Support and Technical Assistance. The very few that do have access to the interface not only abide by the strictest of Confidentiality Agreements but are housed in locked offices to assure that no one might accidently view any part of the interface.
In addition, there is a Qualified Service Organization Agreement (a signed and dated document describing the agreed upon terms of a service relationship between the licensee and the qualified service organization, which meets the requirements of 42 CFR Part 2), between DPH and EOHHS which assures that access to client screens is not permitted by any EOHHS staff supporting the EIM-ESM application. 

Why is the collection of identifying information so important?
Without it the Bureau could not meet its goals:  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, and facilitate treatment and recidivism studies; without which accurate client outcomes would not be available to enhance treatment opportunities.

EIM-ESM also 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.

Only the enrolling agency can see that the client is enrolled in a BSAS Program.

Tips
•	Never email client names when contacting DPH for TA
•	Never use the client name when on a phone call with DPH for TA

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

1.	The Bureau’s Intake/Assessment 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.

2.	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”.

Residential Treatment Disenrollment Assessment

All questions marked with a are required and must be completed.  

	ESM Client ID
The Client ID is automatically assigned when the client is entered into the ESM-EIM system.  This number should be recorded on the Intake and Assessment forms 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.

Provider ID
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 date that the client was disenrolled/discharged from the program.  Enter the date using the MM/DD/YYYY format, for example: 06/01/2007.  

•	The Disenrollment Date is the last day the client received face-to-face service (session).
•	It is not the date the record was closed (unless of course it is closed on the same day.)

	Disenrollment Reason
Check only one box.  Select form the following choices:

•	Completed:  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.

•	Drop Out:  Clients are dropouts if they leave without notifying the program.

•	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:  Active violation of program policies or rules (other than for use of alcohol or drugs, see “relapse”).

•	Incarcerated:  A client who is discharged because he/she enters a prison, jail, or correctional facility.

•	Transferred to other substance addiction program:  Client is moved to another program of the same Level of Care.

•	Against Counselor’s Advice (ACA):  Client leaves even though his/her counselor feels that sufficient gains were not made; or leaves without meeting treatment objectives.

•	Hospitalized, Medical:  Client’s medical condition is such that he/she requires hospitalization.

•	Hospitalized, Mental Health:  Client’s mental health condition is such that he/she requires                  psychiatric hospitalization.

•	Inappropriate:  Client requires a more intensive Level of Care.

•	Deceased:  Client passed away while receiving treatment at your program.

•	 For Family Residential Programs Only DCF or Guardian Removed Child:  this is to be used when a baby is taken from its mother at birth and mom must leave program because of no remaining children with no transfer to another residential program.  (If mom is sent to another Residential Program, then the reason for discharge should be transferred.)

First Name/Middle Initial/Last Name/Suffix
While the client name is only entered into the Application at Intake, writing the full legal names on the Enrollment and Disenrollment Assessment forms is good record management.

1.	Client Code 
Repeat the Client Code as entered on the Enrollment Assessment.  It is a five character code composed of capital letters from the individual’s full name:
1.	First letter of the client’s first name
2.	Third letter of the client’s first name
3.	Middle initial (If non, enter 4)
4.	First letter of the client’s last name
5.	Third letter of the client’s last name

The Client Code was used to monitor multiple enrollments across years when EIM-ESM was not implemented and there was no unique Client ID assigned by a system.  This is also used by the Federal funding source, The Center for Substance Abuse Treatment, CSAT, to link records across years when monitoring substance addiction treatment utilization and trends.

If the individual’s first or last name does not have three letters, use a 4 in place of the third letter.  Be sure to base the Client Code on the individual’s full legal name.   Do not use shortened names, such as Bill for William or nicknames such as Buddy.  Also, try to obtain the middle initial.  Taking these steps will ensure the quality of data analysis where the Client Code is being used, in part, to uniquely identify clients.

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

3.	Client’s Type
Select either Primary or Collateral

•	A Primary Client is defined as:  a person who received treatment for their personal substance addiction problem(s). 
•	In Residential Programs, a Collateral Client is defined as:  a person who received help because of a family member’s substance addiction problem(s) (e.g., children of the primary client including infants). 

4.	Disenrollment / Discharge Plan  
Check one box.  Select either ‘Yes’ or ‘No’.
The choices are:
•	1  Yes
•	2  No

The client must be aware of his/her discharge plan. 

5a.	Referred to Self Help    
Check one box.  Select either ‘Yes’ or ‘No’.   
The choices are:
•	1  Yes
•	2  No

This question should be answered as ‘Yes’ if the client is referred to self help at any point in the course of treatment.

5b.	Frequency of Attendance at Self-help Programs
Record the number of times the client attended a self-help program (e.g.  AA, NA etc…) in the past 30 days or since enrollment if in treatment less than 30 days.

The choices are:
01- No attendance in the past month
02 - 1-3 times in past month (less than once per week)
03 - 4-7 times in past month (about once per week)
04 - 8-15 times in past month (2 or 3 times per week)
05 - 16-30 times in past month (4 or more times per week)
06 - Some attendance in past month, but frequency unknown
99 - Unknown

6. 	Client Referrals at Disenrollment 
You must pick at least one referral for the client (Referral #1).  Also indicate if you made additional referrals (Referral #s 2 & 3) to other types of programs/services.  

Select from the following codes:

Please pay close attention to the code numbers as series of numbers have been discontinued, some choices edited and  choices added.

The choices are:
00	 Referral Not Needed – Assessment Indicates that Client Does Not Require Entering Formal Treatment.
95      Referral Not Needed – Appropriate Mental Health Clinical Services Already in Place.
96      Referral Not Needed – Appropriate Substance Addiction Clinical Services Already in Place
97     Referral Not Made – Client Dropped Out
98	   Referral Attempted – Not Wanted by Client
01		Self, Family, Non-medical Professional
02	BMC Central Intake – Room 5
03	ATS – Detox
04	TSS – Transitional Support Services
05	CSS/CMID – Clinical Stabilization Services
06	Residential Treatment Substance Addiction Residential such as Halfway House, Therapeutic Community, Family Residential Program
07	Outpatient Substance Addiction Counseling
08	Opioid Treatment Includes Methadone Treatment, Office-based Suboxone Treatment
09	Drunk Driving Program Includes First Offender Driving Alcohol Education and Second Offender (2-week Residential DUIL) Programs
10	Acupuncture
11	Gambling Program
12 & 13 Discontinued
14   	Sober House Living situation, no treatment within House
15 Discontinued
16	    Recovery Support Centers
17	   Second Offender Aftercare  Outpatient (follows 2 week DUIL Residential Program)
18	   Family Intervention Program Programs designed to work with family members/concerned
others to engage substance abuser to enter treatment
19	   Other Substance Addiction Treatment
20	   Health Care Professional, Hospital
21	  Emergency Room
22	  HIV/AIDS Programs
23	  Needle Exchange Program
   24 – 25 Discontinued
	26	 Mental Health Professional
   27 – 29 Discontinued
30    School Personnel, School System, College
31	 Recovery High School
        32 – 39 Discontinued
40    Supervisor/Employee Counselor
              41 – 49 Discontinued
50    Shelter
51    Community or Religious Organization
        52 – 58 Discontinued
59	Drug Court
60 - 63 Discontinued
64    Prerelease, Legal Aid, Police
65 – 67 Discontinued
68    Office of the Commissioner of Probation
69    Massachusetts Parole Board
70    Department of Youth Services
71    Department of Children and Families (formerly Department of Social Services)
72    Department of Mental Health
73    Department of Developmental Services (formerly Department of Mental Retardation
74    Department of Public Health
75    Department of Transitional Assistance
76    Department of Early Education and Care
77    Massachusetts Rehabilitation Commission
78    Massachusetts Commission for the Blind
79    Massachusetts Commission for the Deaf and Hard of Hearing
80    Other State Agency

•	Note there are three categories of Referral Not Needed
o	00 –Assessment indicates that client does not require entering formal treatment.
o	95 – Appropriate Mental Health clinical services already in place (i.e., clinician did not make the referral).
o	96 – Appropriate Substance Addiction clinical services already in place (i.e., clinician did not make the referral).

•	Also pay attention to the difference between Referral Not Made and Referral Attempted
o	97 – Referral Not Made – Client dropped out of treatment before a referrals was in place.
o	98 – Referral Attempted – Client refused clinician’s attempt to make a referral.

What determines your making a referral?
•	Action steps taken by you the Clinician on behalf of the client that resulted in an active referral (e.g., appointment is in place).
•	Simply providing the client with information of services available (e.g., handing a brochure to the client) does not qualify as a referral.

81     Division of Medical Assistance/MassHealth
99     Unknown

7.	Employment Status at Disenrollment
This item is a National Outcome Measure; reporting is required by SAMHSA.
Enter one of the following codes:
1	Full-time Employment – Working 35 hours or more each week, including active duty members of the uniformed services.
2	Part-time Employment – Working fewer than 35 hours each week.
3	Unemployed-Looking for Work – Looking for work during the past 30 days or on layoff from a job.
4	Unemployed-Not Looking for Work – Not looking for work during the past 30 days.
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

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’.  

8. 	Number of days worked in the past 30 days or since enrollment if in treatment less than 30 days.
Enter the number of days worked in the past 30 days or since Enrollment if in treatment less than 30 days.
If Unknown, use 99.

9.	Number of Arrests in the past 30 days or since enrollment if in treatment less than 30 days.
This is a National Outcome Measure, reporting is required by SAMHSA
Enter the number of arrests in the past 30 days or since Enrollment if in treatment less than 30 days.

A Section 35 is not an arrest.

Collateral Clients Stop Here

10.	Indicate the Social and/or health services provided to the client during		Treatment – While in your Program 
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/agency and some may be provided by other programs/agencies or independent professionals.

Why we ask the question and what we want to know:  

The purpose of this question is to collect an accurate report of all the services a client received during treatment, whether or not your program provided the service(s), taking a holistic approach to supporting recovery. 

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 Agency 
3 = Provided by Both your Agency and Another 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, DCF meetings, and transportation to court.
•	Drug Screening: Includes testing for evidence of illicit substances used by the client (e.g. urine testing).  
•	Treatment for Medical Problem: Includes medical care for a physical problem.  It does not include treatment for tuberculosis or sexually transmitted disease as those services are listed separately (see below).
•	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.
•	Nicotine Replacement Therapy:  Includes services specifically provided to assist the client with the cessation of smoking.
•	Medication for Medical Problem:  Includes medication provided to the client to treat a medical condition during the course of treatment.
•	Medication for Emotional Problem: Includes medication provided to the client to treat an emotional/mental health condition during the course of treatment.
•	Housing:  Services provided to the client in order to secure permanent or transitional housing (i.e., tenancy preservation).  This does not pertain to residential treatment.
•	GED:  Client engaged in the acquirement of GED.
•	Vocational Training:  Client engaged in specific vocational course such as Certified Nursing Assistant Program.
•	Family Planning:  Services specifically provided to assist the client with her/her family planning needs (e.g. birth control education).
•	Child Care: Child care provided by the treatment program or arranged for by the program but provided by another agency.
•	Literacy Services:  Includes services that teach the client how to read and/or write.
•	English as Second Language: Includes services that teach individuals whose primary language is not English how to speak and/or read and write in English.
•	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.
•	Prenatal Care:  Medical services provided specifically for monitoring a client’s pregnancy.
•	Postpartum: Postpartum is defined as the period between delivery and up to one year post delivery.
•	 Medication for Withdrawal:  services specifically provided to assist the client with withdrawal from alcohol and/or drugs (not comfort medications such as Tylenol).  This would refer to not only inpatient (ATS/detox) protocols but also Medication-Assisted Treatment used as a detox protocol (versus maintenance) in either an outpatient or doctor office setting.
•	TB Testing:  This does not pertain to screening or assessment.  If the screening and assessment were positive, then the client likely would require a TB test (e.g. Mantoux test)
•	TB Treatment: Medication specifically for TB was administered to the client while in your program.
•	STD/STI*, HIV, Hep C Testing: This does not pertain to the screening and assessment for STD/HIV/Hep C.  But if any of the screening and/or assessments were positive, then the client would likely require a test to determine if he/she has and either or an STD, HIV, Hep C.
•	STD/STI*, Hep C Treatment: Medication specifically for either or a STD, HIV, Hep C was administered to the client while in your program. 
•	 Parenting Classes:  Classes specific for parents to learn about caring for their children.
•	 Medication-Assisted Treatment: The utilization of pharmacological interventions often in combination with non-pharmacological treatment services to decrease craving and relapse in order to assist persons with substance use disorders to attain and maintain abstinence from alcohol and illicit drug use. Pharmacological agents include, but are not limited to, opioid agonist medications such as methadone and buprenorphine and antagonist medications such as naltrexone. Examples of medically assisted therapy programs include Opioid Treatment Programs, office based opioid treatment programs, and programs licensed under 105 CMR 164.200 or 105 CMR 164.300.

Tip:  If MAT is used as a detox protocol, both MAT and Withdrawal Medications should be checked.

*STI – Sexually Transmitted Infection

11.	Currently receiving services from a state agency
Is the client currently receiving one or more of the state services listed below? 
Check all that apply.  

The choices are:
•	None	No State Services were received by the client.	
•	DCF:	Department of Children and Families/ formerly Department of Social Services
•	DYS:		Department of Youth Services
•	MPB:		Massachusetts Parole Board
•	OCP:		Office of the Commissioner of Probation (MA)
•	DMH:	Department of Mental Health  -  this does not pertain to all dual diagnosis clients.  	Clients eligible for DMH services are severely and persistently mentally ill.  A DMH 	client would be provided with case management services by DMH.
•	DDS:		Department of Developmental Services / former Department of Mental Retardation
•	DPH:		Department of Public Health -  other than substance addiction – we know that they 			are receiving substance addiction in that they are in your program (e.g. HIV/STD, 		WIC)
•	DTA:		Department of Transitional Assistance (e.g. Food Stamps, TANF)
•	DMA:		Department of Medical Assistance (e.g. MassHealth)
•	MRC:		Massachusetts Rehabilitation Commission
•	MCB: 		Massachusetts Commission for the Blind
•	MCDHH:  	Mass Commission for Deaf and Hard of Hearing
•	
Note here that OCP, MPB, and DMA have been reinserted.  
•	WHY:  A client might have come in without Medicaid so it would not have been checked, but while in treatment in your program the client’s Medicaid was approved.  They came in without insurance but left with insurance. – Good outcome.

Other: 	Some other State Agency
12. 	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.  

The choices are:
•	House or apartment
•	Room/boarding/sober house
•	Institution (i.e., nursing home, criminal justice)
•	Group home/treatment (e.g. recovery home)
•	Shelter/mission
•	On the streets
•	Foster Care
•	Refused
•	Unknown
H1.	Was this client homeless at Intake/Enrollment (whether or not chronic)?
Check one box.  Select either ‘Yes’ or ‘No’.

If the answer to H1 is “Yes’ then it is required to complete H2 and H3.  If the answer is ‘No’, skip to Question 13.

H2.	Detailed Living Arrangement at Disenrollment:
1.	Emergency shelter
2.	Transitional housing for homeless persons
3.	Permanent housing for formerly homeless
4.	Psychiatric hospital or other psychiatric facility
5.	Substance addiction treatment facility or detox
6.	Hospital (non-psychiatric)
7.	Jail, prison or juvenile detention facility
8.	Don’t know
9.	Refused
10.	Rental room/house/apartment
11.	Apartment or house that you own
12.	Living with family
13.	Living with friends
14.	Hotel or motel paid for without emergency shelter voucher
15.	Foster care home or foster care group home
16.	Place not meant for habitation
17.	Other

H3.	Permanence of Living Arrangement at Disenrollment
•	Permanent
•	Transitional
•	Refused
•	Unknown

13. 	Has there been any drug or alcohol use in the last 30 days or since Enrollment if in treatment less than 30 days? 
This item is a National Outcome Measure, reporting is required by SAMHSA
Check one box.  Select either ‘Yes’ or ‘No’.

If the answer to Question 13 is ‘Yes’, fill out Questions 14a, 14b and 14c.  If the answer to Question 13 is ‘No’ skip to Question 17.

•	If there has not been any drug use since enrollment in your program, DO NOT list a primary, secondary, or tertiary drug
•	If the client left treatment unexpectedly, base answer on last face-to-face session.

14a.	Primary Substance
What substance did the client use primarily within the last 30 days or since Enrollment if in treatment less than 30 days?	 Select from the following codes:

The choices are:
A	Alcohol
B	Cocaine
C	Crack
D	Marijuana / Hashish
E	Heroin
F	Prescribed Opiates – Misuse/non-medical use of pharmaceutical opiates which were 
            prescribed for the client
G	Non-prescribed opiates – Non-medical use of pharmaceutical opiates which were not 
	prescribed for the client
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

14b. 	Frequency of Use
Report the frequency of primary substance use in the last 30 days or since Enrollment if in treatment less than 30 days.  Select from the following codes:
 
The choices are:
1	No use during last 30 days or since enrollment	
2	1-3 times during the last 30 days or since enrollment 	
3	1-2 times per week during the past 30 days or since enrollment	
4	3-6 times per week during the past 30 days or since enrollment 	
5	Daily during the past 30 days or since enrollment	
99	Unknown	

14c.	Route of Administration
Report the route of administration used for the primary drug. Select from the following codes:

1	Oral (swallow and/or chewing)	
2	Smoking	
3	Inhalation	
4	Injection	
5	Other	

15.	Did the client use a secondary drug during the last 30 days or since Enrollment if in treatment less than 30 days?
Select either ‘Yes’ or ‘No’.  If Yes, answer Questions 15a, 15b and 15c.  If ‘No’, skip to Question 17.

15a.	Secondary Substance
What secondary substance did the client use within the last 30 days or since Enrollment if in treatment less than 30 days?  Utilize the codes from Question 14a.

15b. 	Frequency of Use
Report the frequency of secondary substance use within the last 30 days or since Enrollment if in treatment less than 30 days.    Utilize the codes from Question 14b.

15c.	Route of Administration
Report the route of administration used for the secondary drug. Utilize the codes from Question 14c.

16.	Did the client use a tertiary drug during the last 30 days or since enrollment if in treatment less than 30 days?
Select either ‘Yes’ or ‘No’.  If Yes, answer Questions 16a, 16b, and 16c.  If ‘No’, skip to Question 17.

16a.	Tertiary Substance
What tertiary substance did the client use within the last 30 days or since Enrollment if in treatment less than 30 days?  Utilize the codes from Question 14a.

16b. 	Frequency of Use
Report the frequency of tertiary substance use within the last 30 days or since Enrollment if in treatment less than 30 days.    Utilize the codes from Question 14b.

16c.	Route of Administration
Report the route of administration used for the tertiary drug. Utilize the codes from Question 14c.

17a.  Did the client use nicotine/tobacco since Enrollment?    
Check only one box.   If the answer to Question 17a is ‘Yes’, answer Questions 17b, 17c and 17d.   

The choices are:
•	Yes
•	No
•	Refused
•	Unknown

17b.	Number of cigarettes currently smoked per day
Indicate the number of cigarettes, not number of packs.  
If client uses another type of nicotine/tobacco product, mark Zero (0) and go to Question 17c.

1 pack = 20 cigarettes

17c. 	Interest in stopping nicotine/tobacco use
Check only one box.

The choices are:
•	01   No
•	02   Yes, within 6 months
•	03   Yes, within 30 days
•	04    Does not apply (already stopped)	
•	88  Refused
•	99  Unknown

17d. 	While in this program, did the client attempt to stop using nicotine/tobacco?
Check only one box.

The choices are:
•	01   Yes
•	02    No	
•	88  Refused
•	99  Unknown

Residential Recovery Program – Disenrollment Patient Placement Criteria

This series of questions is intended to elicit information that indicates the client’s outcomes at disenrollment from a substance addiction treatment setting. Starred (*) items indicate behavior changes on the part of the resident at the point of discharge.  For all questions, the answer choices are:
‘No’, ‘Yes’, or ‘N/A-Unknown’.

Section 1: Acute Intoxication and/or Withdrawal Potential
Sobriety status is the outcome measure identified under this dimension. A ‘no’ response on any of these indicates that the resident is acutely intoxicated or at risk of a physical withdrawal at the point of discharge and indicates the need for a more intensive level of care.  The client is not at risk of physical withdrawal as evidenced by an answer of ‘yes’ to AT LEAST ONE of the following:

1a.	Clean Urine Screens
1b.	Stable Vital Signs
1c.	Staff Observation
1d.	Self report of no recent drug/alcohol addiction:

Section 2:  Biomedical Stabilization
 Positive steps taken to improve health status is the outcome measure identified under this dimension. Any ‘no’ response on the first 2 items indicates the need for a more intensive level of care. Starred (*) items indicate steps taken by the resident to address personal healthcare up to and including the point of discharge.

2a.	The resident’s biomedical condition is sufficiently stable as evidenced by the ability to participate in the essential components of a residential substance addiction program, AND
2b.		The resident is demonstrating responsibility in matters of personal health care and is complying with the prescribed course(s) of treatment

Behaviors consistent with biomedical stabilization may include the following outcome measures:
   	
	*2-1.  	Resident has a primary care clinician
     	*2-2. 	Resident has addressed necessary medical/health concern
     	*2-3. 	Resident has begun the practice of health promotion activities
*2-4. 	Resident has participated in health education groups, such as HIV education, smoking   cessation, nutrition, stress management, prenatal/postpartum.

Section 3: Behavioral Stabilization
This section measures the resident’s engagement in behaviors that are consistent with recovery goals. Any ‘no’ response to the following 4 items indicates the need for a more intensive level of care that will address behavior issues. Starred (*) items indicate behavior change up to and including the point of disenrollment. The resident’s behavioral condition and the achievement of recovery goals are evidenced by the following:

3a.	Resident has complied with the rules of the program, AND
3b.	Resident has progressed in achieving goals established in the treatment/service plan, AND
3c. 	Resident has changed behaviors in response to corrective action measures, AND
3d. 	Resident has demonstrated recovery based social functioning with community, staff, and 
	peers.
Behaviors consistent with behavioral stabilization may include the following outcome measures: 

*3-1. 	Abstained from illicit and non-prescribed drugs/alcohol
*3-2. 	Abstained  from illegal behavior (not including drug use)
*3-3. 	Addressed pending legal issues
*3-4. 	Addressed bad debts and/or financial obligations
*3-5. 	Changed other behavior in compliance with treatment/service plan

Section 4: Treatment Acceptance/Resistance
Any ‘no’ response in this section indicates that the resident does not accept treatment and provides documentation that the resident is no longer appropriate for placement in a Residential Recovery Program.

4a.	The resident has participated in a recovery home environment that promotes recovery through peer interaction, counseling, and educational forums, AND
4b. 	The resident has made the behavioral changes necessary for recovery as indicated in the treatment/service plan, AND
4c. 	The resident has followed the rules and policies of the program.
4d. 		Other
.
Section 5: Relapse Potential
This section measures the resident’s adoption of behaviors likely to reduce relapse potential.  Any ‘’yes’ response to the following 2 items indicates that relapse potential has been reduced in the Residential Recovery Home setting and the need for a structured residential program to address relapse potential has been eliminated. Starred (*) items indicate behaviors that change on the part of the resident at the point of discharge. The resident’s relapse potential is reduced as evidenced by:

5a.	Identification of relapse triggers, AND
5b.	The development of alternative coping skills necessary to maintain recovery.

Behaviors consistent with a reduction in relapse potential may include one or more of the following:
*5-1. 	Membership in 12-step or other self-help
*5-2. 	Relaxation and/or meditation
*5-3. 	Exercise
*5-4. 	Religious/spiritual/faith community activity
*5-5. 	Therapy
*5-6. 	Relapse prevention group
*5-7. 	Other

Section 6: Recovery Environment
Employment status, recovery supports, housing, and a safe post-discharge environment are the outcome measures identified under this dimension. Starred (*) items indicate the impact of the residential program on the development of a positive recovery environment.

	6a.	The resident has increased recovery potential by participating in planning for the development of a post-discharge occupation or activities in which recovery is supported.
6b. 	The resident has increased recovery potential by participating in the development of plans for a support network in the treatment programs and the community.

Behaviors consistent with the development of a support network may include one or more of the following:
 
	*6b-1. 	Involvement in the 12-step community
   *6b-2. 	Involvement in other self help
   *6b-3. 	Involvement in Smart Recovery
   *6b-4. 	Involvement in women for sobriety
   *6b-5. 	Support of family
   *6b-6. 	Moving into a 3/4 residential graduate program
   *6b-7. 	Moving into sober/supportive housing
   *6b-8. 	Attending, or scheduled to attend outpatient counseling, methadone, or acupuncture treatment.
   *6b-9.	Involvement with alumni group
   *6b-10. 	Involvement with religious/spiritual/faith activities
   *6b-11.	Involvement in an environment that supports recovery
6c. 	The resident has increased recovery potential by participating in the development of plans for a safe post-discharge environment.

Behaviors consistent with development of a safe post-discharge environment may include ONE of the following:
Check only one box.

The choices are:
•	Living with family and/or independent housing
•	Arrangements completed for cooperative housing
•	Moving into 3/4 residential graduate program
•	Moving into sober/supportive housing
•	Arrangements completed for shelter
•	Acceptance to live-in school
•	Arrangements completed for another treatment environment
•	Resident walked away from program
•	Medical hospital transfer
•	Psychiatric hospital transfer
•	Incarcerated
•	Died
•	Other
•	Unknown