Substance Abuse Outpatient Care

Provision of Services: A physician or other qualified and licensed professional must supervise Substance Abuse Outpatient Services. In Texas this includes a licensed chemical dependency counselor or one of the practitioners listed below who is licensed and in good standing in the State of Texas and has at least 1,000 hours of documented experience treating substance-related disorders:

• Licensed professional counselor (LPC)
• Licensed master social worker (LMSW)
• Licensed marriage and family therapist (LMFT)
• Licensed psychologist
• Licensed physician
• Licensed physician's assistant
• Certified addictions registered nurse (CARN)
• Advanced practice nurse practitioner recognized by the Board of Nurse Examiners as a clinical nurse specialist or nurse practitioner with a specialty in psych-mental health (APN-P/MH)

Services include and are limited to:

• Pre-treatment and recovery readiness programs
• Harm reduction
• Mental health counseling associated with substance use disorder
• Opiate-assisted therapy
• Neuropsychiatric pharmaceuticals
• Relapse prevention
• Acupuncture (requires a referral from the clients’ HIV medical provider, cannot be the primary treatment modality, and must be provided by a licensed acupuncture provider)

1. Percentage of clients with documentation that services are provided by or under the supervision of a physician or qualified licensed professional. (Pilot Measure)

2. Percentage of clients with documentation that all services provided are allowable under the Ryan White Part-B and State Services program. (Pilot Measure)

Comprehensive Psychosocial Assessment: A Licensed substance use counselor or other qualified professional will complete a comprehensive psychosocial assessment for all clients. 

Staff must complete the comprehensive psychosocial assessment prior to the third counseling session and the assessment must include the following:

• Presenting problems 
• Alcohol and other substance use
• Psychiatric and chemical dependency treatment
• Medical history and current health status
• Relationships with family including domestic or intimate partner violence
• History of trauma
• Experience with HIV or substance use-related stigma
• Housing stability, expelled from home
• HIV treatment adherence 
• Social and leisure activities
• Education and vocational training
• Employment status and history
• Legal issues
• Mental and emotional functioning
• Strengths and challenges

Approved assessment tools such as the Substance Abuse and Mental Illness Symptoms Screener (SAMISS) and Addiction Severity Index (ASI) may be used for substance use and sexual history, and the Mini-Mental State Examination (MMSE) may be used for cognitive assessment. Other industry-recognized assessment tools may be used if approved by the provider agency.

3. Percentage of clients with documentation of initial comprehensive psychosocial assessments completed by the third counseling session.

4. Percent of clients with documentation of a comprehensive psychosocial assessment completed with a licensed professional using industry-recognized assessment tools.

Treatment Plan: Staff must complete a treatment plan specific to individual client needs within 30 calendar days of completing a comprehensive psychosocial assessment. Treatment planning is a collaborative process through which the provider and client develop desired treatment outcomes and identify the strategies and modalities for achieving them.

The treatment plan will include documentation of the following:

• Identification of the identified substance use disorder
• Goals and objectives and progress toward meeting them
• Treatment modality 
• Start date for substance use counseling
• Recommended number of sessions
• Date for reassessment
• Projected treatment end date
• Any recommendations for follow up

The licensed substance use counselor who is providing or supervising the service must sign the treatment plan.

5. Percentage of clients with documentation of a treatment plan completed within 30 calendar days of the completed comprehensive assessment.

6. Percentage of clients with documentation that treatment plans are reviewed or modified midway through the number of determined sessions agreed upon at a minimum.

Progress Notes: Staff should provide services according to the individual's treatment plan and document services in the client's record. For every professional counseling session, the counselor should document a progress note and include:

• Client name
• Session date
• Clinical observations
• Focus of the session
• Interventions
• Assessment
• Duration of session
• Newly identified issues or goals
• Client’s responses to interventions and referrals
• HIV medication adherence
• Substance use treatment adherence
• Documentation of missed visits with attempts to reschedule as applicable

7. Percentage of clients with documented progress notes for each counseling session that the client attended, or documentation of missed visits and attempts to reschedule as applicable.

Referrals: The agency will offer appropriate referrals to clients for support services as applicable to meet goals

8. Percentage of clients with documentation of referrals offered as applicable.

Discharge Planning: Staff will complete discharge planning when treatment goals are met. Discharge planning will include:

• Circumstances of discharge
• Summary of needs at admission
• Summary of services provided
• Goals and objectives completed during counseling
• Referral after completing substance use treatment to a case manager or primary care provider, as appropriate
• Discharge plan
• Counselor authentication, in accordance with TAC Standards and the counselor licensure requirements.

In all cases, providers and case managers shall ensure that, to the greatest extent possible, clients who leave care are linked with appropriate services to meet their needs.

9. Percentage of clients with documentation of discharge planning in collaboration with the client prior to case closure as applicable.

Discharge Summary: Agencies may discontinue services when the client:

• Reaches goals and objectives
• Demonstrates ongoing non-adherence to the treatment plan
• Has missed three consecutive appointments in a six-month period
• Self-terminates services
• Demonstrates unacceptable behavior
• Is deceased

When a client is discharged, staff should document a discharge summary in the client chart that includes the reason for discharge.

10. Percentage of clients with documentation of discharge summary as applicable.