COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

Enterprise Invoice Management 
& 
Enterprise Service Management Project 

 BSAS
Residential Treatment Enrollment Assessment Manual
For Residential Enrollment Assessment Form 

Version 16

December 2017 

Goals and Objectives
Client Confidentiality
Interview Assumptions
Residential Treatment Enrollment Assessment
	Enrollment Date
	ESM Client ID
Provider ID
First Name/Middle Initial/Last Name/Suffix
1. 	Client Code
2. 	Intake/Clinician Initials
3. 	Do you own or rent a house, apartment, or room?
4.  	Are you ‘Chronically Homeless’?
5. 	Enter the Zip Code of the Person’s Last Permanent Address:
6. 	Where did you stay last night?
7a.	Do you consider yourself to be transgender?
7b.	If you answered ‘Yes’ to Question 7a, you must answer Question 7b.
8.	With what sexuality do you identify?
9. 	Number of days between initial contact with the program and enrollment/bed availability
10.	Source of Referral
11. 	Frequency of attendance at self-help programs in 30 days prior to Admission.
12.	Client Type
13. 	Additional Client Type
14.	Do you have children?
14a. 	Number Children Under 6
14b.	Number of Children 6-18
14c. 	Children Over 18:
14d. 	Are any of your children of the Native American Indian race? (i.e., American Indian)
15.	Are you the primary caregiver for any children?
16. 	Employment at the time of Enrollment
17. 	Number of days worked last 30 days
18.  Where do you usually live?
19. 	Who do you live with?
20. 	Use of Mobility Aid
21. 	Vision Impairment
22. 	Hearing Impairment
23. 	Self Care/ADL Impairment
24. 	Developmental Disability
25. 	Prior Mental Health Treatment
26.	In last 12 months, take any medication that was prescribed to treat a mental or emotional condition?
28. 	Currently receiving services from state agency(ies)
29. 	Number of arrests in the last 30 days
30. 	History – Substance Mis-Use / Nicotine/Tobacco / Gambling
31a. 	Number of cigarettes currently smoked per day
31b. 	Interest in stopping nicotine/tobacco use
32a. 	Types of last regular gambling
32b.	Have you ever thought you might have a gambling problem or been told you might?
33.	Ranking of Substances
34.  	Last Needle Use
35a.	How many overdoses have you had in your lifetime?
35b.	How many overdoses have you had in the past year?
Residential Recovery Program - Enrollment 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
Section 7:	Diagnostic Criteria

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 Enrollment Assessment

All questions marked with   are required and must be completed. 

	Enrollment Date
Enter the day that the client was enrolled/admitted to the program (Services Rendered).  Enter the date using the MM/DD/YYYY format.  MM must be 01 through 12 and DD must be 01 through 31 (e.g. 06/01/2007).

Although 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.

	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 form after the data is entered into EIM-ESM system.  As the Bureau does not have access to client names, 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.

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.

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
The Client Code 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 none, 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 enrollment assessment interview.

3. 	Do you own or rent a house, apartment, or room?
Check only one box.  Select either ‘Yes’ or ‘No’

If the individual answers ‘Yes’ to Question 3, Skip Question 4 and go to Question 5.
If the individual answers ‘No’ to Question 3, they must answer Question 4.

4.  	Are you ‘Chronically Homeless’? 
Check only one box.  Select either ‘Yes’ or ‘No’

Read the HUD definition of a chronically homeless person before answering this question.

HUD definition of a chronically homeless person:
‘A person who is ‘chronically homeless’ is an unaccompanied homeless individual with a disabling condition who has either been continuously homeless for a year or more OR has had at least four (4) episodes of homelessness in the past three (3) years.  In order to be considered chronically homeless, a person must have been sleeping in a place not meant for human habitation (e.g. living on the streets) and/or in an emergency homeless shelter.’  A disabling condition is defined as ‘a diagnosable substance use disorder, serious mental illness, developmental disability, or chronic physical illness or disability, including the co-occurrence of two or more of these conditions.’  A disabling condition limits an individual’s ability to work or perform one or more activities of daily living.  An episode of homelessness is a separate, distinct, and sustained stay on the streets and/or in an emergency homeless shelter.  A chronically homeless person must be unaccompanied and disabled during each episode.’

5. 	Enter the Zip Code of the Person’s Last Permanent Address:
Do Not put zip code of Program.  

•	If the person is homeless now, this would have been captured on the Intake Form.
•	This question serves to show the migration of populations and if people are having to leave one area in order to obtain services.

This is the person’s last PERMANENT address.  They may be homeless in Boston but their last permanent address goes back a year or more to a family residence.

6. 	Where did you stay last night?
Check only one box.  If ‘Other’ is selected specify the place.  
The choices are:
•	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	Room, apartment, or house that you own or rent
•	9	Staying or living with a family member 
•	10	Staying or living with a friend
•	11 Room, apartment, or house to which you presently cannot return (future return may be uncertain)
•	12	Hotel or motel paid for without emergency shelter voucher
•	13	Foster care home or foster care group home
•	14	Place not meant for habitation
•	15	Other  specify______________________________________
•	88	Refused

7a.	Do you consider yourself to be transgender?
Check only one box.

The choices are:
•	Yes
•	No
•	Refused

7b.	If you answered ‘Yes’ to Question 7a, you must answer Question 7b.
Check only one box.  If ‘Other’ is selected, please specify: (e.g. Intersex)

The choices are:
•	Male to Female
•	Female to Male
•	Other, specify________________________________________

8.	With what sexuality do you identify?
Check only one box.  If ‘Other’ is selected, please specify:  (e.g. Queer)

The choices are:
•	Heterosexual 
•	Gay/Lesbian
•	Bisexual
•	Other, specify__________________________________________
•	Refused

9. 	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 from first request to first bed availability*.   If this information is unknown, enter 999.

•	The purpose of this question is to monitor waiting lists and capacity needs. 
•	Please Note:  this is the only instance when ‘Unknown’ is coded as 999, at all other times it will be 99. 

10.	Source of Referral 

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

Enter one code from the following choices.  You must enter 2 digits with leading zeroes for the entry to be valid. 
 
The choices are:
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	Information and Referral
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	Court – Section 35
61 - 62 Discontinued
63	Court - Other
64    Prerelease, Legal Aid, Police
65 Discontinued
66	Office of Community Corrections
	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)
	74-76 Discontinued
77    Massachusetts Rehabilitation Commission
78    Massachusetts Commission for the Blind
79    Massachusetts Commission for the Deaf and Hard of Hearing
80    Other State Agency
99     Unknown   
11. 	Frequency of attendance at self-help programs in 30 days prior to
    Enrollment.
Record the number of times a client reports having attended a self-help program (e.g. AA, NA etc…) in the 30 days prior to Enrollment

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

12.	Client Type
Select either Primary or Collateral

•	Primary Client(s) in Residential Treatment refers to the resident(s).
•	Collateral clients in Residential Treatment are those relations residing with the resident/client at the facility. 

13. 	Additional Client Type  
Check all that apply.  

The choices are:
•	 Student:  Clients enrolled in any type of formal/vocational education. 

•	Pregnant: Clients pregnant at the time of enrollment.

•	Postpartum: Postpartum is defined as the period between delivery and up to one year post delivery.

•	 Veteran/Any Military Service: Any person who has served in any branch of the U.S. Military.

•	Methadone:   Clients currently prescribed methadone by an Opioid Treatment Program to treat their opioid addiction.  This includes clients who are receiving their dosing outside the program in which they are currently enrolling.  

•	 Buprenorphine:  (e.g. Suboxone) Clients currently prescribed buprenorphine by a doctor to treat their opioid addiction.   This includes clients who are receiving their medication outside the program in which they are currently enrolling. 

•	 Injectable Naltrexone:  (e.g. Vivitrol) Clients currently prescribed injectable naltrexone by a doctor to treat their opioid addiction. This includes clients who are receiving their medication outside the program in which they are currently enrolling. 

•	Probation: Probation clients are under the supervision of the Office of the Commissioner of Probation.  The client’s substance addiction treatment may or may not be mandated as a condition of his/her probation.

•	Parole: Parole clients are under the supervision of the Massachusetts Parole Board.

•	Federal Probation:  Federal probation clients are under the supervision of the Federal government.

•	Federal Parole: Federal parole clients are under the supervision of the Federal government.

Medically Assisted Treatment (MAT) Additional Client Type:  

Only select methadone, buprenorphine, or injectable naltrexone if the client is entering your Program already engaged in MAT.

Those clients who become engaged in MAT while in your Program will be captured at Disenrollment.
Do not go back and change the enrollment assessment.
Outcome:  Your Program engaged the client in MAT to assist his/her Recovery.

14.	Do you have children?
Check only one box. 

The choices are:
•	Yes
•	No
•	Refused

If the client selects ‘No’ or ‘Refused’, skip to Question 15.
If the client selects ‘Yes’, answer Questions 14a-d.

14a. 	Number Children Under 6
Enter number of children less than 6 years of age.

14b.	Number of Children 6-18
Enter number of children between the ages of 6 and 18 years.

14c. 	Children Over 18:
Enter number of children over 18 years of age.

14d. 	Are any of your children of the Native American Indian race? (i.e., American Indian)
Answer ‘Yes’ if any of the children are of Native American/American Indian heritage.   Answer ‘No’ if none of the children of Native American/American Indian heritage.

15.	Are you the primary caregiver for any children?
Check only one box. 

The choices are:
•	Yes
•	No
•	Refused

Prompt

•	
If the client is involved with DCF and has an open service plan, the client should contact the DCF case manager. If the client doesn’t know how to reach the DCF social worker, call the area office (list of offices can be found at www.mass.gov/DCF ). 

•	For a list of Child Care Resource and Referral Agencies in Massachusetts go to:  
http://www.workworld.org/wwwebhelp/child_care_resource_and_referral_agencies_ccr_r_massachusetts.htm

If the client is the primary caregiver of children you must assess as to the children’s welfare and what arrangements have been made for their care in your full clinical assessment.

16. 	Employment at the time of Enrollment
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

•	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’.  

      99  Unknown
17. 	Number of days worked last 30 days
Enter the number of days worked in the 30 days prior to being admitted to the program.

18.  Where do you usually live? 
This item is a National Outcome Measure, reporting is required by SAMHSA.
Check only one box.

The choices are:
•	1   House or apartment
•	2   Room/boarding or sober house
•	3   Institution
•	4   Group home/treatment – treatment is provided within the house
•	5   Shelter/Mission
•	6   On the Streets
•	7   Foster Care
•	8   N/A - Infant	
•	88 Refused

*Where has the client spent/slept most of the time over the last 12 months?*

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

19. 	Who do you live with?  
Check all that apply.  

The choices are:
•	Alone
•	Child under 6 – whether or not your blood relation
•	Child 6-18 – whether or not your blood relation
•	Child over 18  - Only check this box if the Child Over 18 is the client’s own child
•	Spouse/Equivalent 
•	Parents
•	Other Relative
•	Roommate/Friend

Collaterals Stop Here

20. 	Use of Mobility Aid
Check all that apply.  

The choices are:
•	None 
•	Crutches
•	Walker
•	Manual wheelchair
•	Electric wheelchair

21. 	Vision Impairment  
Enter 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

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

23. 	Self-Care/ADL Impairment
Enter 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

24. 	Developmental Disability
Enter one code from the following choices:
0	None
1	Slight developmental disability
2	Moderate developmental disability
3	Severe developmental disability

25. 	Prior Mental Health Treatment
Check only one box.

The choices are:
•	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

If the client has received more than one level of treatment listed, code the highest number.

26.	During the last 12 months, did you take any prescription medication that was prescribed for you to treat a mental or emotional condition?
Check only one box.  

The choices are:
•	1  Yes
•	2  No
•	88 Refused
•	99 Unknown

27. 	Number of prior enrollments/admissions to each substance addiction treatment modality.
Do not count current enrollment in Question 27.

Detox:
Enter one code from the following choices:
0	No prior admissions
1	One prior admission
2	Two prior admissions
3	Three prior admissions
4	Four prior admissions
5	Five or more prior admissions
99	Unknown

Residential:
Enter one code from the following choices:
0	No prior admissions
1	One prior admission
2	Two prior admissions
3	Three prior admissions
4	Four prior admissions
5	Five or more prior admissions
99	Unknown

Outpatient:
Enter one code from the following choices:
0	No prior admissions
1	One prior admission
2	Two prior admissions
3	Three prior admissions
4	Four prior admissions
5	Five or more prior admissions
99	Unknown

Opioid:
Enter one code from the following choices:
0	No prior admissions
1	One prior admission
2	Two prior admissions
3	Three prior admissions
4	Four prior admissions
5	Five or more prior admissions
99  Unknown

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

Section 35 Commitments:
Select one code from the following choices:
0	No prior admissions
1	One prior admission
2	Two prior admissions
3	Three prior admissions
4	Four prior admissions
5	Five or more prior admissions
99  Unknown

Other:
Select one code from the following choices:
0	No prior admissions
1	One prior admission
2	Two prior admissions
3	Three prior admissions
4	Four prior admissions
5	Five or more prior admissions
99  Unknown

28. 	Currently receiving services from state agency(ies) 
These would be state agency services, other than substance addiction, currently being received by the client. 
Check all that apply.  

The choices are:
•	None		No services from any state agency

•	DCF 		Department of Children and Families/ formerly Department of Social Services

•	DYS		Department of Youth Services

•	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; they 	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 e.g. HIV/STD, WIC

•	DTA 		Department of Transitional Assistance / cash assistance & food stamps

•	MRC		Massachusetts Rehabilitation Commission

•	MCB 		Massachusetts Commission for the Blind

•	MCDHH 	Mass Commission for Deaf and Hard of Hearing

•	
You will note that a number of the State Agencies have been deleted from this list.  This is because BSAS has associated a number of client types with services (i.e., if a client is marked as being on probation, BSAS analysts will automatically associate services from the Office of the Commissioner of Probation (OCP), if a client is checked as being on state parole, BSAS analysts will automatically associate services from the Massachusetts Parole Board (MPB).  
•	Also if a client has Medicaid at Intake, BSAS analysts will automatically associate services from DMA.  
How to code:  
•	Coding example 1: The client’s record indicates that s/he has MassHealth. S/he is receiving state services from an agency other than DMA/Masshealth that is not on the list (such as Elder Affairs, or Veterans Services). Mark this as “Other”.  
•	This is true for Parole and Probation as well.  The client is already flagged as Parole or Probation under “Additional Client Type”. So mark “Other” only when s/he is receiving services from an agency other than MPB or OCP that is not on the list.
*Reminder:  Only clients currently incarcerated receive services from the Department of Corrections.  Once a person is released they no longer receive those services.

Other 		Other State Agency

29. 	Number of arrests in the last 30 days 
This is a National Outcome Measure, reporting is required by SAMHSA.
Enter number of times the client was arrested in the last 30 days. 

Section 35 is not an arrest, it is a civil commitment

30. 	History – Substance Mis-Use / Nicotine/Tobacco / Gambling 
This item is a National Outcome Measure, reporting is required by SAMHSA.
This series is intended to elicit information about the client’s substance use, tobacco use, and gambling (RE:  gambling, please refer to regular gambling activity in place of ‘use’).  Information about the age of first use, the last time a client used a substance/tobacco/gambled, the frequency of last regular use, and the usual route of administration (NA for gambling) needs to be competed for all substances/substance categories, tobacco and gambling listed as A-Y on the history matrix.  
The choices include:
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.   (e.g. pain management)   	e.g. Oxycodone/Oxycontin
Hydrocodone/Vicodin
Methadone	
G	Non-prescribed Opiates
Non-medical use of pharmaceutical opiates which were not prescribed for the client (i.e., diversion)  	e.g. Oxycodone/Oxycontin
Hydrocodone/Vicodin
Methadone	
H	PCP	
I	Other Hallucinogens	e.g. LSD, Mescaline, Psilocybin – Street names  include Magic Mushrooms	
J	Methamphetamine	e.g. Desoxyn  - Street names include Base, Crystal, Ice, Crystal Meth		
K	Other Amphetamines	e.g. Biphetamine, Adderall, Dexedrine – Street names  include Uppers	
L	Other Stimulants	e.g. Ritalin	
M	Benzodiazepines	e.g. Valium, Xanax, Serax, Ativan, Klonopin, Librium and Tranxene –  Street names include Libs, Benzos, Vees	
N	Other Tranquillizers	e.g. Thorazine, Haldol, Clozaril, Risperdol	
O	Barbiturates	e.g. Amytal, Nembutal, Seconal, Phenobarbital	
P	Other Sedatives/Hypnotics	
Q	Inhalants	
R	Over the Counter	
S	Club Drugs	e.g. MDMA/Ecstasy, Rohypnol, GHB, Special K – Ketamine	
U	Other	
X	Nicotine/Tobacco	
Y	Gambling                                                                                             See Q 32a for types of gambling	

Tip  
•	For pharmaceutical drugs that were prescribed for the client, only mark misuse (more than the recommended dosage) or non-medical use.  (Example - If a person were prescribed benzodiazepines for a mental health disorder and only took as prescribed, you would not list that on the history table.)  

•	Note:  For the safety of the client, you must have all drugs currently being taken listed in their client record.

Below are the general instructions for completing the history questions:
Have you ever used?
Enter ‘Y’ for Yes and ‘N’ for No.  If the answer is No, skip to the next substance.

•	Please check either ‘Y’ or ‘N’ under the use status column.
•	Do not leave it blank as it becomes a data quality issue. (Was it really a ‘no’ or was the question not asked?)
•	Data entry person needs to answer ‘Yes’ or ‘No’ before moving on – Unknown is not a choice.
•	It is acceptable to draw a downward arrow through the appropriate column.  

Age of First Use
How old was the client the first time he/she got intoxicated?  How old was the client the first time he/she used a particular drug?

Note that for alcohol the question is ‘age of first intoxication’ not ‘first use’.

Last Use
When was the last time the client used this substance? 

Enter one of the following codes:
1	12 or more months ago
2	3-11 months ago
3	1-2 months ago
4	Last 30 days
5	Used in last week

Frequency of Last Use 
If the client has stopped using this substance, code how frequently he/she used the substance previously. This question was worded this way in recognition that many clients detox either through treatment or on their own before entering particular programs and also that some clients have a complicated history of substance use. 

Enter one of 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
99  Unknown

Usual Route of Admission
Enter one of the following codes:
1	Oral
2	Smoking
3	Inhalation
4	Injection
5	Other

31a. 	Number of cigarettes currently smoked per day
Indicate the number of cigarettes, not number of packs.  
If client uses another type of tobacco produce, mark Zero, (0) and go to Question 31b.
If client does not have a history of nicotine/tobacco use, skip Question 31a&b and go to Question 32a.

1 pack = 20 cigarettes

31b. 	Interest in stopping nicotine/tobacco use
Check only one box.

The choices are:
•	1   No
•	2   Yes, within 6 months
•	3   Yes, within 30 days
•	88  Refused
•	99  Unknown

32a. 	Types of last regular gambling
Check all that apply.  For those clients with a gambling history noted in Question 30, check all types of last gambling done on a regular basis.  If no gambling history, skip Question 32 and go to Question 33.  

The choices are:
	Lottery -Scratch Tickets
	Lottery – Keno 
	Lottery/Numbers Games 
	Slot Machines
	Casino Games
	Card Games
	Sports Betting
	Bingo
	Dog/Horse Tracks, Jai Alai
	Stock Market
	Internet Gambling
32b.	Have you ever thought you might have a gambling problem or been told you might?
Check only one box
The choices are:
•	1  Yes
•	2  No
•	88 Refused

33.	Ranking of Substances 
Rank substances by entering corresponding letter for substances listed above in Question 30.
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.

Nicotine/Tobacco and Gambling CANNOT be marked as a primary, secondary and/or a tertiary drug.  This applies for substances A through W only.

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.

34.  	Last Needle Use
Check only one box.  

The choices are:
•	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

35a.	How many overdoses have you had in your lifetime?
Enter the number of overdoses the client reported having in their lifetime.        

35b.	How many overdoses have you had in the past year?
Enter the number of overdoses the client reported having in the year prior to admission.        

Residential Recovery Program - Enrollment Patient Placement Criteria

This series of questions is intended to elicit information that indicates the appropriate placement of the client in a residential substance addiction treatment setting.  Each section includes objective indicators, and some sections include client outcomes measures.  Starred (*) items indicate behavior changes on the part of the client at the point of discharge.
The choices are:
	Yes
	No
	N/A or Unknown

Section 1:	Acute Intoxication and/or Withdrawal Potential
Sobriety status is the outcome measure identified under this dimension. Any ‘No’ response indicates that the client is acutely intoxicated or at risk of a physical withdrawal and indicates the need of 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. 	Verification of detoxification
1d. 	Staff Observation
1e. 	Self-report of no recent drug/alcohol addiction

Section 2:	Biomedical Stabilization
A ‘Yes’ in this section indicates that the client is medically stable enough to participate in what the program considers to be its most “essential components.” 

2a. 	The client's biomedical conditions, if any, are sufficiently stable as evidenced by the ability to participate in the essential components of a residential substance addiction program.
2b.	The  is demonstrating responsibility in matters of personal health care and is complying with the course(s) of treatment.

Behaviors consistent with biomedical stabilization may include the following outcome measures:

*2-1. 	Client has a primary care clinician

Section 3:	Behavioral Stabilization
A ‘Yes’ response in this section indicates the need for the client to be in a Residential Recovery Program.
	
3a.	The client's behavioral conditions, if present, are sufficiently stable to prevent behaviors which put themselves or others at risk.
3b. 	The client is sufficiently oriented so that s/he comprehends and understands the materials presented during the intake/screening process, AND can fully participate in the residential treatment process.
Behaviors consistent with behavioral stabilization may include the following outcome measures:
	     
	*3-1. 	Client currently abstains from illicit and non-prescribed drugs/alcohol
*3-2. 	Client currently abstains from illegal behavior (not including drug use)
*3-3. 	Client currently addressing pending legal issues
*3-4. 	Client currently addressing outstanding debts and/or financial obligations

Section 4: 	Treatment Acceptance/Resistance
Any ‘No’ response in this section indicates that the client does not accept treatment.

4a.	The client agrees to abstain from alcohol and/or non-prescribed psychoactive substances as evidenced by a willingness to contract to follow the rules and policies of the program, AND
4b.	The client agrees to participate in an environment that promotes recovery through peer interaction, counseling and educational forums.

Section 5: 	Relapse Potential
Any ‘Yes’ response indicates significant risk for substance addiction relapse and the need for a structured residential setting. The client’s relapse potential is significant outside the residential setting as evidenced by ONE OR MORE of the following:
	
5a.	Lack of awareness of relapse triggers
5b.	Ambivalence towards treatment
5c.	Difficulty postponing immediate gratification
5d.	Preoccupation with alcohol and other drugs
5e.	History of multiple treatments
5f.	History of relapse
5g.	Lack of membership in 12 step or other self-help

Section 6:	Recovery Environment
Any ‘Yes’ response in this dimension indicates the need for the client to be in the safe recovery environment of a Residential Recovery Program.
	
6a.	Client has engaged in behavior or occupation in which recovery is unlikely
6b.	Recovery is jeopardized by lack of social and sober contacts

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 Smart Recovery
*6b-3.	Involvement in women for sobriety
*6b-4. 	Involvement in other self help
*6b-5.	Support of family
*6b-6.	Involvement with religious/spiritual/faith activities
6c.	Client lives in an environment that is a threat to the attainment of abstinence

Section 7:	Diagnostic Criteria
The client is assessed as meeting the diagnostic criteria for a Psychoactive Substance Use Disorder as defined by the current Diagnostic and Statistical Manual of Mental Disorders (DSM) or other standardized, widely accepted criteria.

7a.	The individual is assessed with an alcohol and/or other drug addiction and/or dependency disorder based on established diagnostic criteria