Provider Manual


Providers should adhere to the following specific requirements for an assessment/evaluation:

  1. Assessments/Evaluations
    1. Assessments must be documented and include at a minimum, the following:
      1. History of presenting problem;
      2. Chief complaints and symptoms;
      3. Past mental health and/or substance abuse;
      4. Current or past involvement with other community/state agencies (e.g. Children and Youth Services, Juvenile Probation, County/State Probation/Parole, Mental Retardation Services);
      5. Past medical history;
      6. Family, social history and linguistic and cultural background;
      7. Current substance abuse;
      8. Mental status exam;
      9. Present medications and any allergies (or lack of allergies);
      10. Diagnosis;
      11. Level of functioning;
      12. Initial treatment plan;
      13. Name of primary care physician; and
      14. Discharge issues and plans.
    2. For D&A clients, assessments must cover the six dimensions of the PCPC (or six dimensions of ASAM PPC-2 for adolescents):
      1. Acute intoxication/withdrawal potential;
      2. Bio-medical conditions and complications;
      3. Emotional/behavioral conditions and complications;
      4. Treatment acceptance/resistance;
      5. Relapse/continued use potential; and
      6. Recovery environment.
  2. Treatment Planning
    1. Treatment plans must be formulated within the following timeframes:
      1. Acute inpatient treatment – within 24 hours of admission;
      2. Diversionary services – within 48 hours of admission; and
      3. Outpatient treatment – before the third outpatient visit.
    2. For acute inpatient stays, treatment plans must be documented and include at a minimum, the following:
      1. Specifies all services required during the acute inpatient stay;
      2. Identifies discharge plan;
      3. When appropriate, indicates the need for continuing care services; and/or other state agencies, and
      4. Evidence that members, their guardians and family members are given the opportunity to participate in the development and modification of the treatment plan, the treatment itself, and to attend all treatment plan meetings according to the bounds of consent.
    3. For acute inpatient stays, multidisciplinary treatment teams must, at a minimum, do the following:
      1. Be assigned to each member within 24 hours of an admission;
      2. Meet and review the treatment plan within 24 hours of an admission;
      3. Modify the treatment plan as needed;
      4. Periodically meet during the member’s acute inpatient stay to review and modify the treatment plan; and
      5. Include family members in treatment/discharge planning process.
  3. Discharge Planning
    1. Clinical records must demonstrate evidence of consideration of discharge planning needs and issues at initial assessment, treatment plan initiation and periodically throughout the treatment process.
    2. Discharge plans must be documented and, at a minimum, demonstrate the following:
      1. Incorporation of the member’s needs for continuity in existing therapeutic relationships;
      2. Member’s outpatient providers, family members and other identified supports are involved in developing the discharge plan, when appropriate and according to the bounds of consent;
      3. Members requiring medication monitoring will be seen within seven days of discharge from an inpatient setting by a clinician, who is duly qualified and licensed to provide a medication management follow-up visit.