C.M.R. 14, 193, ch. 2, app 193-2-B

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Current through 2024-51, December 18, 2024

Appendix 193-2-B - Progressive Treatment Program Initial Self Assessment

The ACT Team wishing to be certified to provide community involuntary treatment services must complete this form.

ACT Team: Date:

1. Please list all staff currently working on ACT team.

Name of Person Position Title FTE for this Person

20. ______________________________________________________________________

21. ______________________________________________________________________

22. ______________________________________________________________________

23. ______________________________________________________________________

24. ______________________________________________________________________

25. ______________________________________________________________________

26. ______________________________________________________________________

27. ______________________________________________________________________

28. ______________________________________________________________________

29. _____________________________________________________________________

30. _____________________________________________________________________

31. _____________________________________________________________________

32. _____________________________________________________________________

33. _____________________________________________________________________

34. _____________________________________________________________________

(If you need additional space, please add more sheets)

2. Currently, how many recipients does the team serve" ________________

3. During the last two weeks, how many ACT recipients saw more than one member of the team" ____________

4. How often does the ACT team meet as a full group to review services provided to each recipient" _____________ times/week

5. How many ACT recipients are reviewed at each meeting" _______________

6. Does the ACT team leader provide direct services to ACT recipients" Yes _________ No ________

6a. During the past two weeks, on average, how many hours per week did the ACT team leader provide direct services" _______________

7. How many team members left in the past 2 years" _______________

8. How many have been on leave for more than 1 month during the last 12 months" _______________________

8a. When did this leave begin and end" __________________________________________________

9. Does your Substance Abuse Specialist have . . .

9a. Over 1 year of SA clinical experience" Yes _________________ No _________________

9b. Over 1 year of training in SA treatment" Yes ________________ No __________________

10. Does the ACT team assist with housing" Yes _______________ No __________________

11. Does the ACT team assist with Psychiatric services" Yes _____________ No _____________

12. Does the ACT team assist with Counseling and Psychotherapy" Yes _____________ No _____________

13. Does the ACT team assist with Substance Abuse treatment" Yes ____________ No _____________

___

14. Does the ACT team assist with Employment/Rehabilitative services" Yes _______________ No ______________

1. What is the ACT team's role in providing 24-hour emergency services"

________________________________________________________________________________

15a. Is there a team member on call 24/7"

Yes ________________ No ________________

Notes/Comments: _________________________________________________________________

_________________________________________________________________________________

15b. Do team members get emergency call information from the Agency's crisis line"

Yes _________________ No __________________

Notes/Comments: _______________________________________________________________

_______________________________________________________________________________

15c. Does the ACT team have direct involvement during after-hours crisis"

Yes __________________ No _______________

Notes/Comments: _______________________________________________________________

______________________________________________________________________________

35. How many individuals receiving ACT services have a substance use disorder" ___________

36. Of these individuals, how many address this by including individual counseling in the treatment plan"

______________________________________________________________________________

17a. Does one or more of the ACT team members provide individual substance abuse counseling for those individuals" If yes, when" _______________________________________________________________

______________________________________________________________________________

37. How many individuals with substance use disorder attend a dual disorder treatment group" __________

_________________________________________________________________________________

38. Do these groups focus on integrated treatment" _____________________________________

39. What is the treatment model used to treat individuals with substance abuse problems" _________

________________________________________________________________________________

40. Do you refer people to AA" _______________________________________________________

________________________________________________________________________________

41. Detox programs" ______________________________________________________________

________________________________________________________________________________

42. Does your team employ harm reduction tactics" _____________________________________

_______________________________________________________________________________

23a. Some examples" ____________________________________________________________

_______________________________________________________________________________

43. How does your team view abstinence versus reduction of use" _________________________

_______________________________________________________________________________

44. Are you familiar with a stage-wise approach to substance abuse treatment" _______________

________________________________________________________________________________

_______________________________________________________________________________

________________________________________________________________________________

45. Does the team use this approach" _______________________________________________

_______________________________________________________________________________

______________________________________________________________________________

46. Can you give some examples of how your program uses this approach" ________________

____________________________________________________________________________

_____________________________________________________________________________

______________________________________________________________________________

Return this form by mail to: OAMHS - PTP

Department of Health and Human Services

SHS # 11

Marquardt Bldg., 2^nd Floor

Augusta, ME 04333

Or e-mail form to: DHHS.OAMHS-PTP@maine.gov

FIDELITY MEASURES: PTP INITIAL SELF ASSESSMENT
Fidelity Measure-HR Structure & Composition	Progressive Treatment Plan (PTP) Application
H1	Small Caseload: Client/Provider Ration of 10:1	1. Please list all staff currently working on ACT team. (Name of person, Position Title, FTE for this Person).
		2. Currently how many recipients does the team serve"
H2	Team Approach: Provider group functions as team rather than as individual practitioners; clinicians know and work with all clients.	3. During the last two weeks, how many ACT recipients saw more than one member of the team"
H3	Program Meeting: Program meets frequently to plan and review services for each client.	4. How often does the ACT team meet as a full group to review services provided to each recipient"
		5. How many ACT recipients are reviewed at each meeting"
H4	Practicing Team Leader: Supervisor of front line clinicians providers direct services.	6. Does the ACT team leader provide direct services to ACT recipients"
		6a. During the past two weeks, on average, how many hours per week did the ACT team leader provide direct services"
H5	Continuity of Staffing: Program maintains same staffing over time.	7. How many team members left in the past 2 years"
	Staff Capacity: Program operates at full staffing.	8. How many have been on leave for more than 1 month during the last 12 months"
		8a. When does this leave begin and end"
H9	Substance Abuse Specialist on Staff: A 100-client program includes at least two staff members with one year of training or clinical experience in substance abuse treatment.	9. Does your Substance Abuse Specialist have...
		9a. Over 1 year of SA clinical experience"
		9b. Over 1 year of training in SA treatment"
Fidelity Measure-Organizational Boundaries	Progressive Treatment Plan (PTP) Application
O3	Full Responsibility for Treatment Services: In addition to case management, program directly provides psychiatric services, counseling/psychotherapy, housing support, substance abuse treatment, employment/rehabilitative services.	10. Ford the ACT team assist with housing"
		11. Does the ACT team assist with Psychiatric services"
		12. Does the ACT team assist with Counseling and Psychotherapy"
		13. Does the ACT team assist with Substance Abuse Treatment"
		14. Does the ACT team assist with Employment/rehabilitative services"
O4	Responsibility for Crisis Services: Program has 24-hour responsibility for covering psychiatric crises.	15. What is the ACT team's role in providing 24-hour emergency services"
		15a. Is there a team member on call 24/7"
		15b. Do team members get emergency call information from the Agency's crisis line"
		15c. Does the ACT team have direct involvement during after-hours crisis"
Fidelity Measure-Nature of Services	Progressive Treatment Plan (PTP) Application
S7	Individualized Substance Abuse Treatment: One or more members of the program provide direct treatment and substance abuse treatment for clients with substance use disorders.	16. How many individuals receiving ACT services have a substance use disorder"
		17. Of these individuals, how many address this by including individual counseling in the treatment plan"
		17a. Does one or more of the ACT team members provide individual substance abuse counseling for those individuals" If yes, when"
S8	Dual Disorder Treatment Groups: Program uses group modalities as a treatment strategy for people with substance use disorders.	18. How many individuals with substance use disorder attend a dual disorder treatment group"
		19. Do these groups focus on integrated treatment"
S9	Dual Disorders (DD) Model: Program uses a stage-wise treatment model that is non-confrontational, follows behavioral principles, considers interactions of mental illness and substance abuse, and has gradual expectations of abstinence.	20. What these groups focus on integrated treatment"
		21. Do you refer people to AA"
		22. Detox programs"
		23. Does your team employ harm reduction tactics"
		23a. Some examples"
		24. How does your team view abstinence versus reduction of use"
		25. Are you familiar with a stage-wise approach to substance abuse treatment.
		26. Does the team use this approach"
		27. Can you give some examples of how your program uses this approach"

C.M.R. 14, 193, ch. 2, app 193-2-B