DAANES Lite Manual - Minnesota Department of Human Services

DAANES Lite Manual - Minnesota Department of Human Services
DAANES
Web User Manual
For
Chemical Dependency
Treatment Programs
MINNESOTA DEPARTMENT OF HUMAN SERVICES
PERFORMANCE MEASUREMENT & QUALITY IMPROVEMENT
February 2013
DAANES Contact Information
Web Address: https://DAANES.DHS.STATE.MN.US
For assistance: DAANES Data Coordinator (651) 431-2631
DAANES System Administrator (651) 431-2630
Email:
[email protected] or
[email protected]
Mail:
DAANES Data Processing Unit
Performance Measurement & Quality Improvement Division
Minnesota Department of Human Services
PO Box 64986
Saint Paul, Minnesota 55164-0986
Site Location: Elmer L. Andersen Building
540 Cedar Street
Saint Paul, Minnesota 55155
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CONTENTS
Page
Introduction and Overview of DAANES
4
Data Privacy
5
Notification of Data Collection
6
General Instructions
7
Client Identifiers
9
User Management
10
Provider Contact Information
13
User Login Screen
15
Home Screen / Navigation buttons
16
Search Screen
17
Admission Form
18
Six-Month Review Form
34
Discharge Form
40
Batch Uploading of Data
56
Reports
58
Obtaining client PMI numbers
60
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INTRODUCTION AND OVERVIEW OF DAANES
The purpose of this manual is to assist program staff in using the DAANES web application in order to
comply with mandatory data reporting requirements.
The manual contains a detailed discussion of all forms and procedures. All program staff should
familiarize themselves with the instructions contained in this manual before using the DAANES data
collection system. Staff members should contact their local DAANES administrator for additional
information and assistance.
The Drug and Alcohol Abuse Normative Evaluation System (DAANES) has been designed to provide
policy-makers, planners, service providers and others in Minnesota with access to current information
about chemical dependency treatment activities across the continuum of care. The Department of Human
Services is required by statute to collect sufficient information to evaluate the efficiency and
effectiveness of treatment for chemical dependency. In addition, the federal Substance Abuse and
Mental Health Services Administration (SAMHSA) of the Department of Health and Human Services
has mandatory reporting requirements through the National Outcomes Measurements (NOMs)
monitoring system. SAMHSA requires that all treatment providers who receive any state or federal
funds report on this system for all treatment admissions regardless of funding source. In Minnesota,
DAANES is used to meet both state and federal reporting requirements.
Information is collected and submitted on clients using web forms at three points in time: Admission,
Six-Month Review (opioid replacement therapy clients only), and Discharge. Additionally, DAANES
requires one paper form for administrative purposes: Notification of Data Collection form (DHS-2598)
Admission form
The purpose of the admission form is to obtain basic client demographic and background information at
admission. Only one admission form needs to be completed for the total episode of treatment per
site regardless of changes in level of care or the intensity of service provided to the client. The
admission form provides information on the client’s conditions surrounding admission, legal status,
referral sources, demographics, living arrangements, education, veteran status, occupational status,
source of financial support, involvement in peer support groups, previous treatment and detoxification
admissions. A substance use history details substance use frequency, age of onset, and route of
administration for a variety of substances. It also includes a clinical determination of primary,
secondary, and tertiary substances of abuse. Legal questions address whether the client is currently
under court jurisdiction, driver's license revocations, lifetime arrests, recent arrests/convictions, and child
protection involvement. The admission form also captures the clinical results for the six dimensions
associated with the chemical health severity ratings. Finally, key information is collected for linking to
the Consolidated Chemical Dependency Treatment Fund (CCDTF). These fields include the client’s PMI
number, and service agreement number. The admission form should be completed within the first 5 days
after admission to the program.
Six-Month Review form (opioid replacement therapy clients only)
The purpose of the six-month review form is to assess the progress of the opioid replacement therapy
client after every six months of treatment services. The six-month review form collects information on
living arrangement, labor force status, job training status, services provided, peer support group
participation, arrests, and alcohol and drug usage. The six-month form also captures the current status of
the six dimensions associated with the chemical health severity ratings. The six-month review form
should be completed at the end of every six-month period (approximately 180 days) that the client is in
treatment.
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Discharge form
The purpose of the discharge form is to obtain information on the client's status at discharge. This form
includes reason for discharge, clinical chemical dependency diagnoses, medication and other therapies
provided, disabilities or barriers to treatment, post-treatment environment and living situation,
occupational status at discharge, involvement in peer support groups, discharge referrals, child protection
involvement, physical/sexual abuse history, length of stay, cost of treatment, and payment sources . The
discharge also captures the current status of the six dimensions associated with the chemical health
severity ratings. The discharge form should be completed on the day the client is discharged from the
program.
Notification of Data Collection form
The purpose of the Notification of Data Collection form is to inform the client that the program will be
collecting and disclosing client-specific information to the Department of Human Services for the
purposes of research and program evaluation. The notice also informs the client that confidentiality will
be maintained and that their identity will not be disclosed.
DATA PRIVACY
The Department of Human Services is authorized and directed under Minnesota Statutes 254A.03(d) to
"gather and disseminate facts and information about alcoholism and other drug dependency and abuse to
public and private agencies and the courts so requesting such information for guidance to and assistance
in prevention, treatment, and rehabilitation."
Authorization to collect chemical dependency information is also granted under Title 42 Part 2.52(a) of
the Code of Federal Regulations which states that information on alcohol and drug abuse patient records
"may be disclosed, whether or not the patient gives consent, to qualified personnel for the purpose of
conducting scientific research, management audits, financial audits, or program evaluation."
Safeguarding the client's rights to data privacy and confidentiality, as provided under the Minnesota Data
Practices Act and the Code of Federal Regulations, is of primary concern to the DHS. DAANES has
been designed to protect these rights. The client's name is not used on the data forms. Instead, a special
client identifier is used which maintains the anonymity of the client while still enabling DAANES to
track clients across the continuum of care. The DAANES client identifier consists of initials from the
client's name (first and third letters from the first and last name and middle initial), the client's date of
birth and the last four digits of the client's social security number.
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NOTIFICATION OF DATA COLLECTION
The Minnesota Data Practices Act requires that clients be informed that the treatment facility will be
disclosing client information to DHS for the purposes of research and program evaluation. To facilitate
this, program staff present and explain the DAANES Notification of Data Collection form to the client at
admission. After the client has reviewed the form and any questions have been answered, the staff
person dates and initials the form. The client is given a copy to keep and a copy is placed in the client's
file. Since this is not a consent form it does not require the client's signature.
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GENERAL INSTRUCTIONS
♦ Provide as much information as possible. The client's consent is not required in order to release
information. Any information known to the program staff or available from the client record should
be completed.
♦ The DAANES web application uses six types of data entry controls:
Text box: To enter information in a text box, move the mouse pointer over the text box
and click the left mouse button. A curser will appear in the text box. Then
type the alpha or numeric information requested.
Date box: To enter information in a date box, move the mouse pointer over the date box
and click the left mouse button. A curser will appear in the date box. Then
type the date in month/day/year format or use the calendar function by
moving the mouse pointer to the right side of the box over the down arrow,
click the left mouse button to reveal a calendar.
Radio buttons: To select a radio button response, move the mouse pointer over the word
or button and click the left mouse button. The circle will darken next to
the choice you selected.
Drop down lists: To select a response, move the mouse pointer to the right side of the
box over the down arrow, click the left mouse button and the list will be
shown, use the scroll bar on the right side to see all possible choices.
Control button: To execute a control button function, move the mouse pointer over the
button and click the left mouse button.
Check box: To select a check box response, move the mouse pointer over the check box or
label and click the left mouse button. The box will fill with a check in the
choice you selected.
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♦
Completion of the DAANES data collection forms
All forms should be completed on an ongoing basis as clients are admitted and discharged from the
treatment facility. DAANES data collection forms should be completed in the following manner:
The Admission form should be completed on the day of admission or within the first 5 days
after admission to the program.
The Six-Month Review form should only be completed for opioid replacement therapy
clients. Opioid replacement therapy clients are identified on the admission form under the
Placement Information tab. The Six-Month Review form should be completed on the day
that the client has been in treatment for six months (180 days) from the date of admission or
within 3 days following each 180-day time period.
The discharge form should be completed on the day the client is discharged from the
program.
All data must be entered and completed, free of errors, by the 5th day of the month following the
event being recorded.
DAANES information may be revised at anytime within 4 months after the discharge record is
completed. After 4 months you will need to contact the DAANES support staff at the Department of
Human Services to make changes. You will need to provide DHS with your ISATS provider number,
the admission ID number of the record which needs correction along with the current response and
the updated response for the field. The admission ID may be found on the far right column of the
Search form or in the upper right area of any of the data entry screens.
♦ Deletion of Erroneous DAANES Records
Erroneously created records may be deleted from the system by contacting the DAANES support
staff. You will need to provide DHS with your ISATS provider number and the admission ID
number of the record you wish to delete. The admission ID may be found on the far right column of
the Search form or in the upper right area of any of the data entry screens.
♦ DAANES Web Administrator
Each chemical dependency treatment provider who reports on the DAANES web information system,
is required to designate a staff person to be the local DAANES web administrator. The local
DAANES web administrator is the designated individual who is responsible for facilitating the
DAANES data collection efforts at the facility. They provide onsite training to counselors and other
staff who are responsible for completing the DAANES forms. They are responsible for managing
staff access to the DAANES web system as described in the User Management section of this manual.
Finally, they are the liaison between the CD treatment provider and the Department of Human
Services for all communications related to the DAANES information system.
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CLIENT IDENTIFIERS
Client Identifiers consist of the Client's Initials (5 characters), Date of Birth, Last 4 Digits of Social
Security Number, and Admission Date. The client identifying information is entered on the Home form
to create a new admission record and may be revised at the top of any of the Admission screens.
Review carefully the instructions for completing the specific elements that comprise the Client
Identifiers.
Client's
Initials:
Using the client's legal name (not a nickname) will help ensure consistency, as well as
facilitating analysis of client readmission patterns across the continuum of care.
In the text box, from left to right across the five spaces, enter the client's initials in the
following manner:
In the first space enter the 1st letter of the client's Last name.
In the second space enter the 3rd letter of the client's Last name. If the client does not
have a third letter in the last name enter an asterisk (*).
In the third space enter the 1st letter of the client's First name.
In the fourth space enter the 3rd letter of the client's First name. If the client does not
have a third letter in the first name enter an asterisk (*).
In the fifth space enter the first letter of the client's Middle name or the Middle initial.
If the client does not have a middle initial enter an asterisk (*).
For two-letter names or no middle initial:
If the client's first or last name has only one or two letters, fill the second space of the
two designated spaces with an asterisk (*). Similarly, if the client does not have a
middle name or initial, fill that space with an asterisk (*).
Date of birth: In the date field, enter the client's date of birth in MM/DD/YYYY format.
Last four digits of Social Security Number (SSN#):
Enter the last four digits of the client's Social Security Number in the text box provided.
If the client does not have a Social Security Number, cannot remember, or refuses to
provide it, enter "9999."
Admission
Date:
PMI
number:
In the date field, enter the client's date of admission into the treatment program in
MM/DD/YYYY format or click on the down arrow on the right side of the text box to
access the calendar function.
In the text box provided, enter the 8 digits of the client's Personal Master Index (PMI)
Number. Only the eight digits of the PMI number should be entered, not the initial letter
(usually an M, G, or X). The PMI number for CCDTF clients may be obtained from the
service agreement letter sent to the provider for each client placed under the CCDTF
program. If the client is enrolled in MA, GAMC or MinnesotaCare, this item must be
completed. The PMI number is located on the Minnesota Health Care Program (MHCP)
card.
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USER MANAGEMENT
Each chemical dependency treatment provider is responsible for managing staff access to the DAANES
web application and maintaining facility contact information. This is accomplished by using the User
Management form and the Facility form. The User Management form permits the local DAANES web
administrator to add, modify and deactivate staff access to the application. Providers need to contact the
DAANES system administrator to have a staff member registered as the local DAANES web
administrator.
Click on the Admin button to activate the User Management form.
Add User
To add a staff member to the DAANES web application, complete the fields in the Add User area of the
form and click the Add User button.
Login ID: The login ID for a staff member is created with the following structure: the first initial
from the first name, followed by the full last name, followed by an @ sign, followed by
your I-SATS provider number.
Example: Ed Doe with provider number MN999999
[email protected]
Special Note: Login IDs have to be unique to the DAANES web system. Two staff
members cannot have the same login ID. If John W. Smith and Jane E. Smith are
employed by the same provider, the local web administrator will need to use their
middle initials to create unique login IDs for each staff member:
[email protected] and [email protected]
Name: Enter the full name of the staff member, first name and last name.
Password: Enter the initial password for the staff member. Staff members should change their
password when they log into the DAANES web application for the first time or anytime
after the password is reset by the administrator.
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Confirm Password: Reenter the password to verify that the password was entered correctly.
Password Requirements:
The Department of Human Services requires complex passwords for users. The following
requirements are to be incorporated into the password structure:
1. Must be a minimum of 8 characters in length
2. Must contain alpha and numeric characters
3. Must contain upper and lower case characters
4. Must contain at least one special or punctuation character, for example, @, $, &, #
The login ID associated with a password will be locked after three unsuccessful login
attempts. Once locked, the local DAANES web administrator will need to be contacted
to have the login ID unlocked.
Group: Select your ISATS provider ID from the list.
Select System: This is set to Treatment by the system.
Email: Enter the staff member’s email address. Leave this field blank if the staff member does
not have an email address.
After all fields are completed, click the Add User button to add the user to the system. A message will be
displayed either indicating that the user was added successfully or that an error was encountered.
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Modify/Unlock/Reset Password/Deactivate Users
To perform any of the following tasks (Modify/Unlock/Reset Password/Deactivate Users) associated
with an existing user login ID, use the Search for User function to locate the staff member to be
modified. From the search results, select the login ID to be edited by clicking on the login ID located in
the first column of the list.
After clicking on the login ID, the Modify User form will be displayed. From this form, the local web
administrator can change the user’s name, reset the user’s password, change the user’s email address,
lock/unlock the user’s access to the system, and activate/deactivate the user’s login ID. Once changes
have been made, click on the Update button to submit the changes to the system. To unlock a staff
member, uncheck the Locked Out check box and check Active check box. When a staff member leaves
employment with your program, uncheck the Active check box and check the Locked Out check box, then
click the Update button to submit the change.
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PROVIDER CONTACT INFORMATION
Each chemical dependency treatment provider is responsible for maintaining their contact information.
This is accomplished by using the Facility screen. The local DAANES web administrator will have
access to this form for updating contact information.
Click on the Admin button to activate the User Management screen, then click on the Facility tab and
finally click on the Update Facility button to activate the Facility screen. Once you have updated the
information, click on the Save button at the bottom of the screen to save your changes and return to the
User Management screen. The following items are updateable: phone and fax numbers, mailing
information, director information, coordinator information and email addresses.
(screen continues to the next page)
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(continuation of the Facility screen from the previous page)
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USER LOGIN SCREEN
Enter HTTPS://daanes.dhs.state.mn.us/ in the address field of your browser to access the DAANES web
application and start by logging into the application.
Enter your User ID (login ID) and password, then click the OK button with the left mouse button to log
into the DAANES web application. If you enter your password incorrectly three times, your login
ID will be locked out and you will need to contact your local web administrator to have your login
ID unlocked. If you are a local web administrator, you will need to contact the DAANES system
administrator at the Department of Human Services to have your login ID unlocked. If you are
successful in logging into the DAANES application, you will be forwarded to the main DAANES web
page (Home screen).
The Home screen is the control center for the DAANES web application. The Home screen is the
starting point for entering new admissions by first entering the date of admission, client initials, date of
birth, last four digits of social security number, then selecting the client’s funding coverage type, and
finally clicking the Submit button. All other functions are accessed from the Home screen by clicking on
the appropriate navigation button. The Home screen is illustrated on the next page along with
descriptions of the navigation buttons.
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HOME SCREEN
Main Navigation Buttons
Returns the user to the main
DAANES screen (Home screen).
Logs the user off the
DAANES application and returns the user to the login
screen. Warning – make sure you click the Click to
Update button to save your data before logging
out.
Activates the search screen
for locating a specific client record to updating.
Found at the bottom of all
data entry screens, clicking on this button will SAVE
the data entered on the screens and will return the
user to the main DAANES screen (Home screen) or
the search screen. An message will be displayed in
the upper left area of the indicating that the record
was updated.
Activates the upload screen
for batch submission of data.
Activates the reports screen
for running standard reports.
Warning – the data will not be SAVED if there
are errors identified in the information you have
entered when the record is marked complete and
you click the Update button. Either correct the
errors or uncheck the record complete box to save
your data. When checked the record is edited for
errors. If errors are found by the system, the errors
will be listed at the top of the screen. If no errors are
found, the system will return you to either the Home
screen or the Search screen and a message will be
displayed in the upper left hand area of the screen
indicating that the record has been updated. The
record status will be update to a value of ‘2’ on the
Search screen for that client’s record.
Activates the user
management form for adding, modifying and
deactivating users. Facility contact information is
also updated from this screen This button is only
visible if the user is a local web administrator.
Activates a separate window
which permits the user to change their password.
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SEARCH SCREEN
The search screen is used for locating and selecting admission records for updating and for entering sixmonth review and discharge information into the system. The search screen permits the user to search on
one or more of the following items: PMI number, client initials, date of birth, SSN, date of admission or
admission ID. To search for a record, enter the criteria in the appropriated text boxes and click the
Search button. Click on the Clear button to start a new record search. The search results may be sorted
in either ascending or descending order by any of the columns which have their titles underlined. Select
a record to edit or to add new information by moving the mouse pointer over the Edit or Add button
located in the designated column on the left side of the screen and clicking the left mouse button. The
selected screen (admission, six-month, or discharge) will be displayed. On the right side of the list are
status columns which indicate the completeness of the admission and discharge information. A ‘1’
indicates incomplete information, a ‘2’ indicates a complete and error free record. An Add button will
appear in the discharge or six-month columns when the admission form is a complete, error free record.
Client records are frozen 120 days after the discharge form has been completed. Frozen records are
available for viewing by clicking on the word Display. Errors identified on frozen records may be
corrected by contacting the DAANES support staff at DHS. Provide DHS with the admission ID number
of the record which needs correction along with the current response and the updated response.
Erroneously created records may be deleted from the system by contacting the DAANES support staff
with admission ID.
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ADMISSION FORM
A new admission record is started on the Home screen by entering the admission date, client’s initials,
date of birth, last four digits of the SSN, and the source of funding which will cover the client’s treatment
episode; Consolidated Chemical Dependency Treatment Fund (CCDTF), Minnesota Healthcare
Programs (MHCP), or self pay (all other sources). After selecting the coverage type, enter the additional
information requested (If not available at this time, the information may be entered later on the admission
screen, under the placement information tab). For CCDTF clients, enter the client’s PMI number and
service agreement number and for MHCP, enter the client’s PMI number. Then click the Submit button
to activate the Admission form. When the Admission form is activated, the system assigns an admission
identification number to the record which is displayed in the upper right area of all the data entry screens
and is also located in the far right column of the Search screen. The admission ID number is useful for
tracking clients on the DAANES system and for communicating with DAANES support staff at DHS..
The admission form has seven tabs: Placement Information, Criminal Justice, Client Profile, Prior CD
Treatment Experience, Child Protection, Alcohol and Drug Use, and Chemical Health Severity Ratings.
After entering information, remember to SAVE your data by clicking on the Click to Update button in
the lower right corner. To check for errors, check the box next to the label “Check if record is Complete”
and then click the Click to Update button. After the record has been saved by the system, the system will
return the user to either the Home screen or the Search screen with a confirmation message that the
information has been updated. Warning – the data will not be SAVED if there are errors identified in the
information you have entered when the record is marked complete and you click the Update button. Either
correct the errors or uncheck the record complete box to save your data.
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Placement Information Tab
Client Coverage Type:
Select the payment source for the client’s treatment services. This is auto-filled from the
information selected on the Home screen, but may be changed here.
CCDTF: Consolidated Chemical Dependency Treatment Fund
MHCP: Minnesota Health Care Programs – Managed Care
All other sources
Client’s Personal Master Index number (PMI)
For CCDTF or MHCP clients, enter the client’s eight digit Personal Master Index (PMI) number
found on the service agreement for CCDTF clients or the insurance card for MHCP clients. Only
the eight digits of the PMI number should be recorded for MHCP clients and not the initial letter
(usually M, G, or X). The PMI is auto-filled from the information entered on the Home screen.
Service Agreement number
For CCDTF clients only, enter the eleven digits of the service agreement number for the client
found on the service agreement letter. Fill this field with 8’s for all other clients. This is autofilled from the information selected on the Home screen.
Note: The DHS claims payment system will deny payments on claims associated CCDTF
service agreements where a DAANES admission record has not been entered and validated on
the DAANES system. The DAANES system will update the DHS claims payment system for
validated admission records, Monday thru Friday nights. Claims may be entered into the claims
payment system on the following day after the service agreement has been updated by the
system. Check the “CTF Service Agreements Previously Processed” list box to verify the service
agreement number has been cleared for reimbursement.
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Multiple service agreements for one episode of treatment:
Some clients may have multiple service agreements for one DAANES admission record. In
order to receive reimbursement for the additional service agreements associated with a treatment
episode you will need to replace the current service agreement number shown on the placement
information tab with the new service agreement. You may only replace the service agreement
number on an admission record once each day and each new number enter will need to be
validated by checking the record complete box and clicking the update button. The DHS claims
payment system will be updated each night, Monday thru Friday, for the currently active service
agreement which is entered on the placement information tab. Check the “CTF Service
Agreements Previously Processed” list box to verify the service agreement number has been
cleared for reimbursement.
CTF Service Agreements Previously Processed
This text box lists all previously processed CCDTF service agreement numbers entered for this
admission record. The service agreement numbers listed have been updated on the DHS claims
payment system by DAANES system.
Current Chemical Dependency Treatment
Select the type of chemical dependency treatment that is planned for the client at the time of
admission. After the admission record has been completed and validated, this item may be
updated to reflect a change in the client’s intensity of treatment service such as a transition from
residential to non-residential so long as the services occur within the same location and episode
of treatment. A change in this item also requires a date to be entered in the Date of Change item.
Hospital inpatient
Residential, less than 30 days planned
Residential, more than 30 days planned
Non-residential
Methadone
Date of Change
This item is locked (grayed out) and is initialized with the date of admission. Once the
admission record has been completed and validated, this item may be updated, if the client
transitions to a different intensity of treatment services such as change from residential to nonresidential so long as the services occur within the same location and episode of treatment.
Select the type of chemical dependency treatment that the client is transitioning to and then enter
the date of the change. The date must be at least one day greater than the date of admission for
the first transition entered and must be at least one day greater than the previous transition date
for each additional entry. Note: Do not change this date when entering additional service
agreement numbers, only if there is a change in treatment services.
Is opioid replacement therapy planned for treatment?
Select the appropriate radio button.
Note: Answering “Yes” to this item will create an ADD button under
the Six-month (Six-month Review form) column on the search screen.
Yes, methadone
Yes, buprenorphine
Yes, other
No
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Primary and secondary source of referral:
Select up to two sources of referral which led to the client being admitted to this facility. If only
one source of referral is identified, then selected “No secondary” on the secondary source of
referral. If none of the categories appropriately depicts the client's source of referral, select
Other.
Self/family/relative/friend
School
Employer/EAP
Law enforcement
Courts
Probation/parole
DUI/DWI
Pre-petition screening/
diversion program
Corrections
Health care facility/professional
CD treatment program
Detox center
Mental health center
Other residential facility
County social service agency – CD services
County social service agency – child protection
County social service agency – other services
AA, other support group
Community professional/agency (e.g., clergy)
Information and referral agency
Tribal agency
Other
No Secondary
Did a specialty court refer the client to this episode of treatment?
If the client was referred by the court, select the appropriate category.
No
Yes, Adult drug court
Yes, Juvenile drug court
Yes, DWI court
Yes, Truancy court
Yes, Family dependency treatment court
Yes, Mental health court
Yes, Community court
Yes, Other
Unknown
Primary condition surrounding admission:
Select the primary condition surrounding admission of the client to treatment.
Treatment to avoid jail
Treatment as condition of probation/parole
Treatment to retain driver’s license/license plates
Treatment or lose custody of children
Treatment to regain custody of children
Treatment to avoid loss of relationship or living situation
Treatment to maintain employment/school enrollment
Treatment to retain professional license
Treatment required to retain government benefits
Financial pressures caused by drug/alcohol use
Other
None
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Legal status at admission:
Select the client's legal status at admission.
Emergency/court hold order:
Use this for emergency admissions and court hold orders. Emergency admissions are
made by a peace or health officer on behalf of a person who is chemically dependent and
in danger of harming self or others, or intoxicated in public. Emergency admissions are
governed by Minnesota Statutes, section 253B.05. Court hold orders are made by a civil
court of jurisdiction in order to admit a person either for the protection of the person or
the public, or to assure that the proposed patient is available for a pending commitment
hearing. Civil court hold orders are governed by Minnesota Statutes, section 253B.07,
subdivision 6.
Criminal court order
A directive that a person go to treatment as part of a criminal sentence, as an alternative
to a jail sentence, or as a condition of probation. This response should not be used if the
client is on probation or parole and the court is not requiring that the person go to
treatment. This response should be used if the treatment placement is the result of a
probation or supervised release (parole) revocation proceeding and is a condition of
continued supervised release or probation.
Court commitment – CD
A civil court order requiring a person to participate in a treatment program after a court
commitment process in probate court. This is not to be used for an admission ordered by
a criminal court, juvenile court, or a civil court involved in another process such as child
protection or parental rights issues. Court commitment procedures are governed by
Minnesota Statutes, Chapter 253B.
Civil court order
A court order or consent decree whereby the client is required to participate in chemical
dependency treatment as part of the settlement of a civil matter. This should be used if
the client is required to go to treatment as part of a family court matter involving parental
rights, for example, as a condition of obtaining or retaining the custody of children in a
child protection proceeding.
Juvenile court placement
A court order for a minor to participate in treatment as a result of a juvenile dependency
or delinquency matter. Juvenile courts are provided with broad placement authority
under Minnesota Statutes, Chapter 260. A placement hold is to be considered a juvenile
court placement whenever the court has required that the minor be placed in a chemical
dependency program either by the county or the caretakers of the child.
None
None of the above apply.
Unknown
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Criminal Justice Tab
In the past 30 days, how many times has the client been arrested?
Enter the number of times the client was arrested in the past 30 days. The acceptable range is
from 0 to 98. Enter 99 for unknown.
How many times has the client been arrested in their lifetime?
Enter the number of times the client was arrested in their lifetime. The acceptable range is from
0 to 98. Enter 99 for unknown.
In the past 30 days, was the client in jail?
Select the appropriate radio button.
Yes
No Unknown
In the past 30 days, was the client in prison?
Select the appropriate radio button.
Yes
No Unknown
Is the client currently under the jurisdiction of the court or on probation/parole?
Select the appropriate radio button.
Yes, if the client is currently under the jurisdiction of the court or on probation/parole.
No, if the client is neither under the jurisdiction of the court nor on probation/parole.
Unknown, if the client left before you could get the information.
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Has driver's license been revoked because of a DWI?
Select the category which corresponds to the answer that best describes the status of the client's
driver license. Use Not Applicable only if the client has never had a license. If the client has a
license but has never had a revocation, use Never Revoked. For purposes of this question, a
revocation includes a formal revocation or a license that has been denied while formal
proceedings are pending.
Currently under revocation
Revoked during past 12 months (but not currently revoked)
Revoked at least once in lifetime (but not in the past 12 months)
Never Revoked
Not applicable
Unknown
Client Profile Tab
Sex:
Select the client’s gender:
Male
Female
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Race:
Select the category which corresponds to the race of the client based the client’s self
identification. For Hispanic clients select the race and indicate the ethnicity on the next item.
Choose Other if none of the first seven categories accurately depicts the client's race.
White
Black
American Indian
Asian
Native Hawaiian/Pacific Islander
Alaskan Native
Mixed
Other
Hispanic ethnicity:
Select the category which corresponds to the client's ethnicity regardless of race.
Not of Hispanic origin
Puerto Rican
Mexican
Cuban
Other Hispanic
Current marital status:
Select the category which corresponds to the current marital status of the client on the day of
admission.
Single, never married includes those whose only marriage was annulled.
Divorced; if remarried or cohabiting, code that response instead.
Separated refers to married persons not living together, whether or not the separation is
legal.
Widowed, if remarried or cohabiting, code that response instead.
Married refers to persons who are legally married.
Cohabiting refers to common-law marriages, and those individuals who live together as
sexual partners.
Unknown
In the past 30 days, where has the client been living most of the time?
Select the category which corresponds to where the client has been living.
Homeless – no fixed address including shelters
Dependent living – dependent children and/or adults living in a supervised setting
Independent living – including on own, self supported and non-supervised group homes
Children living with their family
Unknown
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Usual living situation:
Select the category which corresponds to the client's usual type of living situation.
Alone - means that the client is living alone and independently.
This excludes institutional and group living situations.
With spouse or partner only
With minor children only
With spouse/partner and children
With one parent
With two parents
With foster parents
With relatives
With friends
With others - means that the client is living in an institutional or group living situation.
Unknown
County or State of Residence
Select from the lists the client’s county or state of residence. For a client who is a Minnesota
resident select the client's county of residence. For a client who is not a Minnesota resident
select the client's state of residence, Canadian or other Foreign Citizen.
Tribal Enrollment
Select the category which corresponds to the client's tribal enrollment.
Not Enrolled
Bois Forte
Fond-du-Lac
Grand-Portage
Leech Lake
Lower Sioux
Mille-Lacs Band
Prairie Island
Red Lake
Shakopee
Upper Sioux
White Earth
Other
Unknown
Reside on the Reservation
Select the category which corresponds to the client's reservation residency.
Not residing on reservation
Bois Forte
Fond-du-Lac
Grand-Portage
Leech Lake
Lower Sioux
Mille-Lacs Band
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Prairie Island
Red Lake
Shakopee
Upper Sioux
White Earth
Other reservation
Unknown
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February 2013
Pregnancy status at admission
Select the category which corresponds to the client's pregnancy status.
Pregnant
Not Pregnant
Not sure
Male
Veteran status
Select the category which corresponds to the client's veteran status. Code Yes, served in combat
zone if the client was exposed to combat during any war or other international conflict.
No
Yes, no combat
Yes, served in combat zone
Unknown
Education
Select the category associated with the client's highest level of educational attainment.
Grade School
Some high school but no degree
High school graduate/GED
Associate degree/vocational certificate
Some college but no degree
College graduate
Graduate/professional degree
Unknown
Years of schooling
Enter the highest grade completed by the client. A GED would be equivalent to 12 years. Years
of technical school, college and graduate school should be added to 12 to get the total years of
schooling.
Is the client currently enrolled in school or a job training program?
Select the category that best describes the client's current enrollment.
Not enrolled
Enrolled, full-time
Enrolled, part-time
Unknown
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Primary source of income or support during the 30 days prior to treatment
Select the category which corresponds to the client's primary source of income for the 30 days prior
to admission. If the client had no source of income prior to admission, indicate None. If the client
has income but none of the categories accurately depicts the primary source, use Other. If the source
of income is unknown, select Unknown.
Disability benefits
Job
Retirement/pension
Spouse/parents
Relatives/friends
Savings or investments
Public Assistance
Other
None
Unknown
What is the client's current labor force status?
Select the category which corresponds to the client's primary labor force status during the month
prior to admission. If none of the categories is appropriate use Other.
Employed full-time means paid employment including self-employment, 35 hours or more per
week.
Employed part-time means paid employment including self-employment, less than 35 hours per
week.
Occasional/seasonal work means paid employment on a seasonal or otherwise irregular basis.
Sheltered employment is used only for disabled clients in structured work training settings.
Homemaker can be used only if there is one or more dependents in the household besides the
client. Paid employment and student status supersede this category.
Student is used when the client is enrolled in school (or on summer or holiday break). Full-time
employment status supersedes this category, but other categories do not.
Retired is used only when the client has met the minimum retirement age and has retired from
the work force.
Disabled is used if the client is unable to work because of a physical or mental condition.
Sheltered employment status supersedes this category.
Inmate of an institution is to be used if the client was in a jail, prison or other institution.
Laid off/unemployed--looking for work means that the client is laid off from a position or is
otherwise not employed, but is physically and mentally able to work, and is looking for work.
Unemployed--not looking for work means that the client is not employed, but is physically and
mentally able to work, but is not looking for work.
Other means that none of the categories listed above accurately describes the client.
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Prior CD Treatment Experience Tab
Number of lifetime detoxification admissions:
Enter the total number of admissions to any detoxification facility in the client's lifetime.
If unknown, enter 999
Number of lifetime treatment episodes:
Enter the total number of previous admissions to any chemical dependency treatment program in
the client's lifetime. Do not count detoxification and aftercare admissions. If unknown, enter 99.
In the past 30 days, how many times did the client attend self-help programs (e.g., AA, NA)?
Select the category which corresponds to the client's attendance to self-help programs
No attendance past month
1-3 times past month
4-7 times past month
8-15 times past month
16-30 times past month
Some attendance, but frequency unknown
Unknown
In the past 30 days, did the client have interaction with family and/or friends that are supportive of
recovery?
Select the appropriate radio button
Yes
No
Unknown
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Child Protection Tab
The child protection questions relate to children who are under 18 years of age for whom the client is
the natural or adopted parent or for whom the client has legal guardianship.
Does the client have children under 18 years of age?
Select the appropriate radio button
Yes
No
Unknown
Note: If “No” or “Unknown” is selected the system will auto fill the balance of the child
protection items when you check the record is complete box and click the update button.
How many children?
Enter the number of children up to 10. Code 10 if the client has more than 10 children. Enter 88
if no children, and 99 for unknown.
Is the client currently involved with child protection services?
Select the appropriate radio button
Yes
No
Not applicable, no children
Unknown
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Does the involvement result from:
Select the category which corresponds to the reason for involvement with child protection
services
Alleged abuse or neglect by client
Alleged abuse or neglect by someone else
Alleged abuse or neglect by client and someone else
Some other reason
Not applicable, no children/no child protection involvement
Unknown
Are any of the children living with someone else due to a child protection court order or other
actions by child protection services?
Select the appropriate radio button
Yes
No
Not applicable, no children/no child protection involvement
Unknown
How many of the children are living with someone else for these reasons?
Enter the number of children up to 10. Code 10 if the number is more than 10 children. Enter 88
if no children/no child protection involvement and 99 for unknown.
For how many children has the client lost parental rights?
Enter the number of children up to 10. Code 10 if the number is more than 10 children. Enter 88
if no children/no child protection involvement and 99 for unknown, if all items are unknown.
Alcohol and Drug Use Tab
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During the past 30 days, how many days has the client used the following?
Enter the number of days the client used alcohol and/or illicit drugs in the past 30 days:
Responses may range from 0 to 30.
Any alcohol
Illicit drugs
Client's history of injection drug use
Select the category which corresponds to how recently the client has injected drugs. Code the
appropriate time frame even for a single instance of injection use.
Within the past 30 days
Within the past 6 months, but not in the past 30 days
Within the past 12 months but not in the past 6 months
More than 12 months ago
Never injected
Unknown
Does the client currently smoke cigarette?
Select the appropriate radio button
Yes
No
Unknown
Primary Substance Abuse Problem
Secondary Substance Abuse Problem
Tertiary Substance Abuse Problem
First select primary substance of abuse, which corresponds to the substance associated with the
most severe problems the client has experienced. Then select the secondary, which corresponds
to the substance next in problem severity. Finally select the tertiary, which corresponds to the
third substance in problem severity. The secondary and tertiary categories may indicate no
identified substances. Nicotine/Tobacco may be coded as a secondary or tertiary substance
abuse problem.
Alcohol
Cocaine powder
Crack
Marijuana/hashish
Heroin
Non-prescription methadone
Other opiates and synthetics
PCP
Other hallucinogens or psychedelics
Methamphetamine
Other amphetamines
Other stimulants
Benzodiazepines
Other tranquilizers
Barbiturates
Other sedatives or hypnotics
Ketamine
Ecstasy/other club drugs
Inhalants
Over-the-counter medications
Other
No secondary or tertiary substance
Nicotine/Tobacco (secondary or tertiary only)
Unknown
Number of days primary, secondary and tertiary substances used in the last 30 days:
For each of the substances selected as primary, secondary and tertiary enter the number of days
the client used that substance during the past 30 days. Responses for use during the past 30 days
may range from 0 to 30.
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Usual route of the identified primary, secondary and tertiary substances:
Select the usual route of administration (most frequent) for each of the substances selected as
primary, secondary and tertiary
Oral means ingested through the mouth and swallowed.
Smoking refers to inhaling the smoke from substances that are burned.
Snorting refers to inhaling the substance through the nose.
Injection use includes intravenous (IV) use, intramuscular (IM) use, and subcutaneous use
(under-the-skin or "skin-popping").
Age at first use of the identified primary, secondary and tertiary substances:
Enter the age of the client’s first use for each of the substances selected as primary, secondary
and tertiary. For alcohol, enter the age associated with first use to intoxication.
Chemical Health Severity Ratings Tab
For each of the six chemical health severity dimensions, rate the client’s status at the time of admission.
Dimension 1:
Dimension 2:
Dimension 3:
Dimension 4:
Dimension 5:
Dimension 6:
Acute intoxication/withdrawal potential
Biomedical conditions and complications
Emotional/behavioral/cognitive conditions and complications
Readiness for change
Relapse/continued use/continued problem potential
Recovery environment
Select the category from the drop lists which corresponds to the client’s ratings.
No problem
Minor problem
Moderate problem
Serious problem
Extreme problem
Unable to assess
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SIX-MONTH REVIEW FORM
The six-month review form should be completed every six months (180 days) for clients who are
receiving opioid replace therapies by the treating provider. Clients are identified as opioid replace
therapy patients on the Place Information Tab of the Admission Form. The form should be completed
when the client appears on the report listing clients who are due for a six-month review. The six-month
review form contains four tabs: Social Environment, Chemical Health Severity Ratings, Alcohol and
Drug Use, and Service Delivery. Remember to SAVE your data by clicking on the Click to Add or Click
to Update button in the lower right corner. To check for errors, check the box next to the label “Check if
record is Complete” and then click the Click to Add or Click to Update button.
Warning – the data will not be SAVED if there are errors identified in the information you have entered
when the record is marked complete and you click the Update button. Either correct the errors or uncheck
the record complete box to save your data.
Social Environment Tab
In the past 30 days, how many times has the client been arrested?
Enter the number of times the client was arrested in the past 30 days. The acceptable range is
from 0 to 98, and 99 for unknown.
In the past 30 days, how many times did the client attend self-help programs (e.g., AA, NA)?
Select the category which corresponds to the client's attendance to self-help programs
No attendance past month
1-3 times past month
4-7 times past month
8-15 times past month
16-30 times past month
Some attendance, but frequency unknown
Unknown
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In the past 30 days, did the client have interaction with family and/or friends that are supportive of
recovery?
Select the appropriate radio button
Yes
No
Unknown
In the past 30 days, where has the client been living most of the time?
Select the category which corresponds to the client’s living situation.
Homeless – no fixed address including shelters
Dependent living – dependent children and/or adults living in a supervised setting
Independent living – including on own, self supported and non-supervised group homes
Children living with their family
Unknown
What is the client’s current labor force status?
Select the category which corresponds to the client's current labor force status. If none of the
categories are appropriate, use Other.
Employed full-time means paid employment including self-employment, for 35 hours or more
per week.
Employed part-time means paid employment including self-employment, for less than 35 hours
per week.
Occasional/seasonal work means paid employment on a seasonal or otherwise irregular basis.
Sheltered employment is used only for disabled clients in structured work training settings.
Homemaker can be used only if there is one or more dependents in the household besides the
client. Paid employment or student status supersede this category.
Student is used when the client is enrolled in school (or on summer or holiday break). Full-time
employment status supersedes this category, but other categories do not.
Retired is used only when the client has met the minimum retirement age and has retired from
the work force.
Disabled is used if the client is unable to work because of a physical or mental condition.
Sheltered employment status supersedes this category.
Inmate of an institution is to be used if the client is in a jail, a prison or institution.
Laid off/unemployed--looking for work means that the client is laid off from a position or is
otherwise not employed, but is physically and mentally able to work, and intends to or is looking
for work.
Unemployed--not looking for work means that the client is not employed, but is physically and
mentally able to work, but does not intend to look for work.
Other means that none of the categories listed above accurately describes the client.
Unknown
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Is the client currently enrolled in school or a job training program?
Select the category that best describes the client’s current enrollment.
Not enrolled
Enrolled, full-time
Enrolled, part-time
Unknown
Chemical Health Severity Ratings Tab
For each of the six chemical health severity dimensions, rate the client’s status at the time of the twomonth review.
Dimension 1:
Dimension 2:
Dimension 3:
Dimension 4:
Dimension 5:
Dimension 6:
Acute intoxication/withdrawal potential
Biomedical conditions and complications
Emotional/behavioral/cognitive conditions and complications
Readiness for change
Relapse/continued use/continued problem potential
Recovery environment
Select the category which corresponds to the client’s current ratings.
No problem
Minor problem
Moderate problem
Serious problem
Extreme problem
Unable to assess
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Alcohol and Drug Use Tab
During the past 30 days, how many days has the client used the following?
Enter the number of days the client used alcohol and/or illicit drugs in the past 30 days:
Responses may range from 0 to 30.
Any alcohol
Illicit drugs
Primary Substance Abuse Problem
Secondary Substance Abuse Problem
Tertiary Substance Abuse Problem
If the client still has perceived substance abuse problems at the time of the six-month review, select
primary, secondary and tertiary problems. If there are no problems, select None.
First select primary substance of abuse, which corresponds to the substance associated with the most
severe problems the client has experienced. Then select the secondary, which corresponds to the
substance next in problem severity. Finally select the tertiary, which corresponds to the third
substance in problem severity. Nicotine/Tobacco may be coded as a secondary/tertiary substance
abuse problem.
None
Alcohol
Cocaine powder
Crack
Marijuana/hashish
Heroin
Non-prescription methadone
Other opiates and synthetics
PCP
Other hallucinogens or psychedelics
Methamphetamine
Other amphetamines
Other stimulants
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Benzodiazepines
Other tranquilizers
Barbiturates
Other sedatives or hypnotics
Ketamine
Ecstasy/other club drugs
Inhalants
Over-the-counter medications
Other
No secondary or tertiary substance
Nicotine/Tobacco (secondary or tertiary only)
Unknown
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February 2013
Number of days used in the last 30 days of the identified primary, secondary and tertiary
substances:
For each of the substances select as primary, secondary and tertiary enter the number of days the
client used that substance during the past 30 days. Responses for use during the past 30 days
may range from 0 to 30, or 99 for unknown.
Service Delivery Tab
Record the number of service sessions provided in the past 30 days.
For each of the service categories, report the number of occurrences each services was provided to the
client during the past 30 days. There is a count of ONE each time the service is provided, regardless of
the duration of time. This is not an exhaustive list of services, some CD programs may not provide some
of the services listed. If the service was not provided, enter a zero in the quantity box.
Detoxification
A service that provides short-term care on a 24-hour basis for the purpose of detoxifying clients
and facilitating access to chemical dependency treatment as indicated by an assessment of needs.
Alcohol/Drug testing
Alcohol/drug testing is used to determine the presence of biomarkers of substances in the client.
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Education about alcohol and other drugs
An educational event providing information regarding substance use and/or dependence.
Medical Care
Care provided by a licensed medical professional to address a medical health need or prevention.
Living Skills Development
Living skills development to help the client learn basic skills necessary for independent living.
Individual Counseling
A counseling session between one client and treatment staff to address substance abuse problems
including goal setting, treatment plan updates and therapeutic interventions.
Group Counseling
A form of psychotherapy that involves sessions guided by a therapist and attended by several
clients who address their substance abuse problems together.
Relationship/Family Counseling
Any therapeutic activities designed to improve the quality of the client’s family life.
Services for Co-occurring Mental Illness
Coordinated or fully integrated services to individuals who have at least one psychiatric disorder
in addition to a substance abuse disorder.
Spiritual support
Spiritual and motivational activities aimed at helping the client establish a relationship with a
higher power or the Creator and/or connecting/reconnecting with their cultural, spiritual beliefs
and practices.
Coordination of Services
Coordination of client services received outside of the treatment setting, including referral and
follow-up.
Therapeutic Recreation
Therapeutic recreation to provide the client with an opportunity to participate in recreational
activities without the use of mood-altering chemicals and to learn to plan and select leisure
activities that do not involve the inappropriate use of chemicals.
Employment or Educational Services
Counseling services specifically designed to improve the client’s ability to seek and maintain
employment. Teaches the client skills in interviewing, completing applications, writing resumes,
and searching for jobs.
Childcare
Services provided to the family which help the client to participate in the treatment process.
Transportation Services:
Transportation is provided between the treatment facility and another place or to and from an
activity in the client’s plan of care.
How many take-home doses of narcotic replacement medications was the client given at the
last visit?
Enter the number of take-home doses issued to the client at their last visit to the clinic. The
acceptable range is from 0 to 31.
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DISCHARGE FORM
The discharge form should be completed on the day of discharge or the day after discharge. The
discharge form contains eight tabs: General, Service Delivery, Social Environment, Child Protection,
Alcohol and Drug Use, Chemical Health Severity Ratings, Financial Information, and Client Satisfaction.
Remember to SAVE your data by clicking on the Click to Add or Click to Update button in the lower
right corner. To check for errors, check the box next to the label “Check if record is Complete” and then
click the Click to Add or Click to Update button.
Warning – the data will not be SAVED if there are errors identified in the information you have entered
when the record is marked complete and you click the Update button. Either correct the errors or uncheck
the record complete box to save your data.
General Tab
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Discharge Date: Enter the client’s date of discharge from the program in MM/DD/YYYY format by
either typing or using the calendar function.
Current Chemical Dependency Treatment:
Select the client’s chemical dependency treatment at the time of discharge.
Hospital inpatient
Residential, less than 30 days planned
Residential, more than 30 days planned
Non-residential
Methadone
Reason for discharge:
Select the category which is the most appropriate description of the client's reason for discharge
from the treatment facility.
Completed program means that the client completed the program as scheduled.
Patient left means that the client left the program with or without notice to the staff. This
includes a failure to show for outpatient sessions.
Patient Conduct means that program staff requested that the client leave the program because
the client's behavior was disruptive to or uncooperative in the treatment setting.
Expiration of civil commitment or hold order means that the client left on the expiration of a
civil commitment or hold order without completing treatment.
Transferred to other program means that the client was transferred to another program either
because the client had other problems which needed more immediate attention or because it was
determined that another program could better meet the needs of the client.
Assessed as inappropriate for this program means that the client was assessed as
inappropriate either because the client did not meet admission criteria after evaluation or that the
program could not provide adequate services. If the client was transferred rather than discharged
outright use Transferred to other program.
Lost financial support means that the client was unable to continue in the program because
he/she was unable to pay for further treatment services.
Incarcerated means that the client was unable to continue treatment services because of
confinement in a jail or other correctional facility.
Death is to be used if the client died while in the program.
Other is to be used only when none of the other choices reflect the reason for discharge.
DSM Chemical Dependency Diagnosis:
Select the DSM chemical dependency diagnostic codes from the list. They are identical to those
provided in the DSM IV-TR manual with four exceptions; Phencyclidine Abuse (304.70),
Hallucinogen dependence (304.80), Inhalant abuse (305.80), and Polysubstance dependence
(306.00). Different code numbers have been assigned to these so that statewide and provider
reports can distinguish drugs that DSM IV-TR combines.
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The DSM chemical dependency diagnosis is based on all information available to staff at the
time of the client's discharge. The primary diagnosis should represent the substance associated
with the most severe problems the client has had, whether medical, psychological, social, legal or
occupational. This will often be the substance directly responsible for the treatment admission
but this may not always be the case. Some clients will have only one diagnosis--use of only one
substance meets diagnostic criteria for abuse or dependence. This is true of many alcohol users,
for example. In these cases, secondary diagnosis should be coded as no secondary diagnosis.
For clients who use two or more substances with comparable frequency, one needs to be coded as
primary and one as secondary. Consider all the harmful effects and use patterns to make a
determination of a primary diagnosis even in the case of an apparent "tie."
"Polysubstance dependence" should be avoided as the primary diagnosis; it may be used only
when:
♦
The client uses three or more substances at identical frequency levels, and
♦
One or two of these substances cannot be deemed to have caused more serious problems than the
other(s).
♦
"Polysubstance dependence" should be used as the secondary diagnosis only when:
♦
One substance has been identified and coded as primary, and
♦
The client uses an additional two or more substances at comparable frequency levels, and
♦
One of these substances cannot be deemed to have caused more serious problems than the
other(s).
Disabilities or barriers to treatment:
Select Yes or No for each disability or barrier to treatment which is exhibited by the client.
Hearing impairment is coded if the client has a hearing impairment even if a hearing aid
minimizes the impairment.
Visual impairment is coded if the client has difficulty with vision even while wearing glasses or
contact lenses. If the difficulty is corrected, do not code this response.
Physical handicap includes severe orthopedic impairments resulting from birth defect, disease,
or injury. Code this response if the client uses a wheelchair, cane or walker, or has an artificial
limb even if the client does not consider the condition a "handicap."
Developmental disability means general intellectual functioning significantly below average
existing concurrently with defects in adaptive behavior and manifested during the development
period.
Mental illness means that the client has cognitive, behavioral, or emotional dysfunction
associated with a mental health disorder.
Speech pathology refers to communication disorders, such as stuttering, impaired articulation, a
speech impairment, or a voice impairment.
Learning disability refers to a disorder of one or more of the basic processes involved in
understanding or in using language, spoken or written, which may manifest itself in deficiencies
in the ability to listen, think, speak, read, write, spell, or do mathematical calculation. The term
includes perceptual handicaps, minimal brain dysfunction, and dyslexia. The term does not
include learning problems which result primarily from visual, hearing, or motor handicaps,
developmental disability, or environmental, cultural, or economic disadvantage.
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Brain injury refers to damage to the brain or its coverings from an external force, not of a
degenerative or congenital nature. The damage may produce an altered state of consciousness,
and may result in a decrease in cognitive, behavioral, or physical functioning. Resulting
impairments may be temporary or permanent and may cause partial or total functional disability
or psychosocial maladjustment.
English not primary language means that the client uses a language other than English as a
primary means of verbal or written communication.
Functional illiteracy means that the client's reading and/or writing skills are deficient to the
point of impeding the ability to complete forms or homework assignments, or other reading or
writing tasks associated with treatment.
Has the client been a victim of abuse?
Consider both childhood and adult experiences.
Select the category which corresponds to the client’s experiences
No
Yes, physical only
Yes, sexual only
Yes, physical and sexual
Unknown
Has the client been a perpetrator of abuse?
Consider both adolescent and adult experiences.
Select the category which corresponds to the client’s experiences
No
Yes, physical only
Yes, sexual only
Yes, physical and sexual
Unknown
Which of the following were used as part of CD treatment for the client?
For each category listed, indicate whether the therapy was used during the client's CD treatment,
regardless of frequency or duration of that particular therapy. For example, count even a few days of
antidepressant medication or a single acupuncture visit. If you select “Other prescribed medications”
enter in the name(s) of medication(s) in the text box.
Methadone
Other opioid replacement therapy
Antabuse
Naltrexone
Other anti-craving medication
Anti-depressant medication
Anti-anxiety medication
Other prescribed medications, specify
Acupuncture
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Service Delivery Tab
Record the number of service sessions provided during treatment.
For each of the service categories, report the number of occurrences each service was provided to
the client during treatment. There is a count of ONE each time the service is provided,
regardless of the duration of time. This is not an exhaustive list of services, some CD programs
may not provide some of the services listed. If the service was not provided, enter a zero in the
quantity box.
Detoxification
A service that provides short-term care on a 24-hour basis for the purpose of detoxifying clients
and facilitating access to chemical dependency treatment as indicated by an assessment of needs.
Alcohol/Drug testing
Alcohol/drug testing is used to determine the presence of biomarkers of substances in the client.
Education about alcohol and other drugs
An educational event providing information regarding substance use and/or dependence.
Medical Care
Care provided by a licensed medical professional to address a medical health need or prevention.
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Living Skills Development
Living skills development to help the client learn basic skills necessary for independent living
Individual Counseling
A counseling session between one client and treatment staff to address substance abuse problems
including goal setting, treatment plan updates and therapeutic interventions.
Group Counseling
A form of psychotherapy that involves sessions guided by a therapist and attended by several
clients who address their substance abuse problems together.
Relationship/Family Counseling
Any therapeutic activities designed to improve the quality of the client’s family life.
Services for Co-occurring Mental Illness
Coordinated or fully integrated services to individuals who have at least one psychiatric disorder
in addition to a substance abuse disorder.
Spiritual support
Spiritual and motivational activities aimed at helping the client establish a relationship with a
higher power or the Creator and/or connecting/reconnecting with their cultural, spiritual beliefs
and practices.
Coordination of Services
Coordination of client services received outside of the treatment setting, including referral and
follow-up.
Therapeutic Recreation
Therapeutic recreation to provide the client with an opportunity to participate in recreational
activities without the use of mood-altering chemicals and to learn to plan and select leisure
activities that do not involve the inappropriate use of chemicals.
Employment or Educational Services
Counseling services specifically designed to improve the client’s ability to seek and maintain
employment. Teaches the client skills in interviewing, completing applications, writing resumes,
and searching for jobs.
Childcare
Services provided to the family which help the client to participate in the treatment process.
Transportation Services:
Transportation is provided between the treatment facility and another place or to and from an
activity in the client’s plan of care.
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Social Environment Tab
In the past 30 days, how many times has the client been arrested?
Enter the number of times the client was arrested in the past 30 days. The acceptable range is
from 0 to 98, and enter 99 for unknown.
In the past 30 days, how many times did the client attend self-help programs (e.g., AA, NA)?
Select the category which corresponds to the client's attendance to self-help programs
No attendance past month
1-3 times past month
4-7 times past month
8-15 times past month
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16-30 times past month
Some attendance, but frequency unknown
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In the past 30 days, did the client have interaction with family and/or friends that are supportive of
recovery?
Select the appropriate radio button
Yes
No
Unknown
In the past 30 days, where has the client been living most of the time?
Select the category which corresponds to the client’s living situation.
Homeless – no fixed address including shelters
Dependent living – dependent children and/or adults living in a supervised setting
Independent living – including on own, self supported and non-supervised group homes
Children living with their family
Unknown
Will the client be living in an environment conducive to recovery?
Use both clinical judgment and client perceptions to make a determination.
Select the appropriate radio button
Yes
No
Unknown
What is the client’s current labor force status?
Select the category which corresponds to the client's primary occupational status after leaving
treatment. If none of the categories is appropriate use Other.
Employed full-time means paid employment including self-employment, for 35 hours or more
per week.
Employed part-time means paid employment including self-employment, less than 35 hours per
week.
Occasional/seasonal work means paid employment on a seasonal or otherwise irregular basis.
Sheltered employment is used only for disabled clients in structured work training settings.
Homemaker can be used only if there is one or more dependents in the household besides the
client. Paid employment and student status supersede this category.
Student is used when the client is enrolled in school (or on summer or holiday break). Full-time
employment status supersedes this category, but other categories do not.
Retired is used only when the client has met the minimum retirement age and has retired from
the work force.
Disabled is used if the client is unable to work because of a physical or mental condition.
Sheltered employment status supersedes this category.
Inmate of an institution is to be used if the client is in a jail, a prison or institution.
Laid off/unemployed--looking for work means that the client is laid off from a position or is
otherwise not employed, but is physically and mentally able to work, and intends to or is looking
for work.
Unemployed--not looking for work means that the client is not employed, but is physically and
mentally able to work, but does not intend to look for work.
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Other means that none of the categories listed above accurately describes the client.
Unknown
Is the client currently enrolled in school or a job training program?
Select the category that best describes the client’s current enrollment.
Not enrolled
Enrolled, full-time
Enrolled, part-time
Unknown
Referrals at discharge:
Indicate whether each referral was made by selecting Yes or No. A discharge referral implies
some active involvement of program staff in locating the resource and providing the client with
information or a contact person. Do not count a general recommendation to seek help.
Additional CD treatment
CD aftercare/support group – professionally led
CD aftercare/support group – self-help
CD board and lodging
Non-CD supportive housing
Domestic abuse treatment program
Individual counseling/therapy
Family counseling/therapy
Detox
Medical care/services
Vocational program
Legal assistance
Law enforcement/corrections
Court/court services
County social service agency – CD services
County social service agency – other services
VA/veteran service organizations
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Child Protection Tab
The child protection questions relate to children who are under 18 years of age for whom the client is
the natural or adopted parent or for whom the client has legal guardianship.
Does the client have children under 18 years of age?
Select the appropriate radio button
Yes
No
Unknown
Note: If “No” or “Unknown” is selected the system will auto fill the balance of the child
protection items when you check the record is complete box and click the update button.
How many children?
Enter the number of children up to 10. Code 10 if the client has more than 10 children.
Enter 88 if no children, and 99 for unknown.
Is the client currently involved with child protection services?
Select the appropriate radio button
Yes
No
Not applicable, no children
Unknown
Does the involvement result from:
Select the category which corresponds to the reason for involvement with child protection
services
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Alleged abuse or neglect by client
Alleged abuse or neglect by someone else
Alleged abuse or neglect by client and someone else
Some other reason
Not applicable, no children/no child protection involvement
Unknown
Are any of the children living with someone else due to a child protection court order or other
actions by child protection services?
Select the appropriate radio button
Yes
No
Not applicable, no children/no child protection involvement
Unknown
How many of the children are living with someone else for these reasons?
Enter the number of children up to 10. Code 10 if the number is more than 10 children.
Enter 88 if no children/no child protection involvement, and 99 for unknown.
For how many children has the client lost parental rights?
Enter the number of children up to 10. Code 10 if the number is more than 10 children.
Enter 88 if no children/no child protection involvement, and 99 for unknown, if all items are
unknown.
Alcohol and Drug Use Tab
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During the past 30 days, how many days has the client used the following?
Enter the number of days the client used alcohol and/or illicit drugs in the past 30 days:
Responses may range from 0 to 30.
Any alcohol
Illicit drugs
Primary Substance Abuse Problem
Secondary Substance Abuse Problem
Tertiary Substance Abuse Problem
If the client still has perceived substance abuse problems at the time of discharge, select primary,
secondary and tertiary problems. If there are no problems select None.
First select primary substance of abuse, which corresponds to the substance associated with the
most severe problems the client has experienced. Then select the secondary, which corresponds
to the substance next in problem severity. Finally select the tertiary, which corresponds to the
third substance in problem severity. Nicotine/Tobacco may be coded as a secondary/tertiary
substance abuse problem.
None
Alcohol
Cocaine powder
Crack
Marijuana/hashish
Heroin
Non-prescription methadone
Other opiates and synthetics
PCP
Other hallucinogens or psychedelics
Methamphetamine
Other amphetamines
Other stimulants
Benzodiazepines
Other tranquilizers
Barbiturates
Other sedatives or hypnotics
Ketamine
Ecstasy/other club drugs
Inhalants
Over-the-counter medications
Other
No secondary or tertiary substance
Nicotine/Tobacco (secondary or tertiary only)
Unknown
Number of days used in the last 30 days of the identified primary, secondary and tertiary
substances:
For each of the substances select as primary, secondary and tertiary enter the number of days the
client used that substance during the past 30 days. . Responses for use during the past 30 days,
may range from 0 to 30.
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Chemical Health Severity Ratings Tab
For each of the six chemical health severity dimensions, rate the client’s status at the time of discharge.
Dimension 1:
Dimension 2:
Dimension 3:
Dimension 4:
Dimension 5:
Dimension 6:
Acute intoxication/withdrawal potential
Biomedical conditions and complications
Emotional/behavioral/cognitive conditions and complications
Readiness for change
Relapse/continued use/continued problem potential
Recovery environment
Select the category which corresponds to the client’s current ratings.
No problem
Minor problem
Moderate problem
Serious problem
Extreme problem
Unable to assess
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Financial Information Tab
Hours of treatment services provided:
Enter the total hours of treatment services provided to the client during the treatment episode.
Residential programs enter a zero. Non-residential programs enter the total number of hours
provided.
Days of room and board provided:
Enter the total number of days for which room and board services were provided to the client
during the treatment episode. This field is for residential programs only. Outpatient programs
are to enter a zero.
Total charges (dollars):
Enter the total charges incurred during the client's treatment episode. "Total charges" refers to
the amount billed for services, regardless of source of payment and the amount actually
reimbursed. Round off to the nearest whole dollar (fifty cents or more would be rounded up to
the next whole dollar). If free care is given, estimate what would have been billed.
Source of payment:
For each of the sources of payment categories, enter the percentage of the total costs of the
client’s treatment episode that each source covered. The sum of the nine categories should equal
100%. If the source of payment is an out-of-state government agency source, code Other.
Self-pay includes payment for treatment services made by the client, client's relatives, or friends.
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Private health insurance--non-HMO means that payment for treatment services was made by a
private individual or group (employer) health insurance policy. This category includes
CHAMPUS.
Private health insurance--HMO means that treatment services were covered through a private
or group (employer) HMO health insurance policy.
Consolidated CD Treatment Fund means that payment for treatment services was made
through the Consolidated Chemical Dependency Treatment Fund.
MHCP (MA, GMAC, MinnesotaCare) covers the following public programs where service
delivery is directed by managed care organizations (MCO’s) : Medicaid or Medical Assistance
(MA), General Assistance Medical Care (GAMC), or MinnesotaCare.
Medicare
County funds (non-Consolidated Fund) means that payment for treatment services was made
by the county from county social service funds, Community Social Services Act (CSSA) block
grant funds, or other funds.
Free care (no charges) means that the cost of treatment services was absorbed in full by the
treatment program.
Other means that all or part of the client's charges were paid by sources not listed above.
Client Satisfaction Tab
The following questions should be asked of the client at discharge. This may be accomplished by
creating a paper questionnaire which the client can complete prior to discharge.
How much were you helped by the counseling or treatment you got?
Select the category which corresponds to the client’s response.
Not at all
A little
Somewhat
A lot
Unknown
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Did you receive treatment services in a language that you could understand?
Select the appropriate radio button
Yes
No
Unknown
If no, what language do you usually speak?
Select the category which corresponds to the client’s response. If other is selected, enter the
language in the text box provide.
Spanish
Hmong
Somali
Other, specify__________________
Were the treatment services that you received respectful of your culture?
Select the appropriate radio button
Yes
No
Unknown
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BATCH UPLOADING of DATA
Providers who operate their own computerized case management system may incorporate the DAANES
data elements into their own system and submit the required DAANES data using the batch uploading
procedure. Please contact the DAANES system administrator for specifications on record structures and
data editing requirements.
Click on the Upload button to activate the Batch Upload screen.
Records for each form type (admission, six-month review, and discharge) are uploaded from separate
data files. Upload a file by clicking on the browse button next to the form type you wish to upload. A
file open screen (Choose File) will appear. Navigate to the file’s location, click on the file name and
then click on the Open button. The file name will appear in the text box next to the form type to be
uploaded. Click on the Upload button at the bottom center of the form. The system will upload and
process the data. After processing, a detailed listing of errors for each record will be displayed. Print the
results and correct all errors by accessing the records from the Search screen.
Navigate to the file’s location by clicking the browse button and using the Choose file screen.
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The admission file to be uploaded is shown in the text box.
Error listing after the upload process has completed.
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REPORTS
The DAANES web application currently provides six reports to assist providers in tracking the status of
their client records and two summary reports. Each of the tracking reports lists the client’s initials, date
of birth, last four digits of the social security number, date of admission, the client’s admission ID and
the staff person who last updated the record. The lists can be sorted in ascending and descending order
by moving the mouse pointer over the underlined column headings and clicking the left mouse button.
The two summary reports are similar to the reports DHS distributes semi-annually to providers.
All Clients in Treatment
This report lists all clients who are currently in treatment.
All Clients with an Incomplete Admission
This report lists clients who have admission records with missing information or an unchecked
record complete box.
All Clients with an Incomplete Discharge
This report lists clients who have discharge records with missing information or an unchecked
record complete box.
All Clients with an Incomplete Six-Month Review (methadone clinics only)
This report lists clients who have six-month review records with missing information or an
unchecked record complete box.
All Clients needing a Six-Month Review (methadone clinics only)
This report lists clients who are due for a six-month review. Clients will appear on this report after
180 days from the date of admission.
All Clients who have Completed Treatment
This report lists clients who have been discharged from treatment with records that are complete
and error free.
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Admission Summary Report
This report produces a summary report from the information collect on the admission form. Users
may select either to run the report for their facility or for all facilities labeled Statewide. Users may
also select on a specific CD Treatment Environment, Funding Source and on admission date
ranges. The report is viewable by using Adobe Acrobat Reader software which you will need to
install on your computer.
Discharge Summary Report
This report produces a summary report from the information collect on the discharge form. Users
may select either to run the report for their facility or for all facilities labeled Statewide. Users may
also select on a specific CD Treatment Environment, Funding Source and on admission date
ranges.
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OBTAINING CLIENT PMI NUMBERS
What is the PMI Number?
The Personal Master Index (PMI) number is an 8-digit unique identifier assigned by DHS to an
individual who is eligible to receive health care services through any of Minnesota’s public health care
programs: Medical Assistance (Medicaid; MA), General Assistance Medical Care (GAMC), and
MinnesotaCare. With the transition of the Consolidated Chemical Dependency Treatment Fund into the
Medicaid Management Information System (MMIS), individuals who receive treatment through the
Consolidated Fund are also assigned a PMI number.
How do I know if a treatment client is publicly-funded and how do I obtain the PMI Number?
All treatment clients who are referred through the Consolidated Fund or by a Public Prepaid Health Plan
are publicly funded and have a PMI Number.
For Consolidated Fund referrals, the Notification Letter sent to the treatment provider by DHS
contains the PMI number, called the “Recipient ID Number.”
All Minnesota Health Care Program enrollees (MA, GAMC, MinnesotaCare) have an MHCP ID
Card which includes the PMI number, called the “Member Number.”
For referrals from Prepaid Health Plans (HMOs), the identification of a treatment client as a public
program member can be determined from the client’s health plan identification card. Most Public
Prepaid Health Plans include the PMI number on the card, although there are some exceptions. Here are
the specifics for the eight Public Prepaid Health Plans in Minnesota (not all plans operate in every
county):
Blue Plus and
First Plan Blue
The words “Minnesota Health Care Programs” on the card identify the client as a
public program member. The 9-digit ID number on the card beginning with the digit
“8” incorporates the PMI number, which constitute the last 8 digits.
HealthPartners
The words “HealthPartners Care” identify the client as a public program member.
The PMI number is on the member card.
Itasca Medical Care
Medica
PrimeWest
Health
A 10-digit number beginning with the digits “59” identifies the enrollee as a public
program member. The 8 digits after the “59” constitute the PMI number.
The PMI number is on the member card.
Metropolitan
Health Plan
South Country
Health Alliance
UCare
All enrollees are public program members. The PMI number is on the card.
Public program members are identified by one of 10 group numbers. MHP uses its own
member identification number on the card.
The label “PMI#” and PMI number is on the member card.
The “Care Type” identifies the enrollee as a public program member (UCare MA, UCare
GAMC, or MinnesotaCare). The PMI number is on the card.
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Samples of Minnesota Health Care Programs – Prepaid Health Plan (HMO) Enrollee Cards
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Sample CCDTF Service Agreement Letter
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Eligibility Verification System (EVS)
EVS can be accessed by telephone or from the MN-ITS website on the internet.
EVS uses voice prompts to walk the caller through menu options. If the caller does not respond to the
voice prompts, the menu options will be repeated. EVS confirms each entry by repeating the entry to the
caller and asking for confirmation. Prior to ending the call, EVS allows the caller to request information
on the same client for a different date of service, or to review eligibility information for a different client.
It is important to listen to the entire message because EVS may indicate a client is eligible for multiple
programs (i.e., medical assistance and prepaid health plan).
PROCEDURE
Gather Information
• Provider’s 10-digit National Provider Identification (NPI) number
• Either the client’s 8-digit PMI number OR social security number and date of birth
• Recipient’s first and last name
• Date of service
Contact EVS
• 800/657-3613 (toll free) or 651/431-4399 (metro) or MN-ITS
• Follow the prompts:
EVS …
Caller enters…
Welcomes the caller to the MHCP Automated
Inquiry Service
Prompts the caller to enter their 10-digit NPI
provider number
Asks which information the caller will use for
the Recipient Inquiry
“7” for recipient information
Prompts the caller to enter either the client’s 8digit identification number (PMI), or the
client’s social security number and date of
birth
Asks if the caller is inquiring about today’s date
or a previous date
Identifies the client by gender and date of birth,
or PMI, and asks for confirmation
Client’s 8-digit identification number or the
client’s social security number and date of
birth
Provider’s 10-digit NPI provider number,
followed by the # key
“1” for identification number (PMI)
OR
“2” for social security number and date of birth
Indicates what coverage the client has
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“1” for today’s date
“2” for a previous date
“1” if EVS identifies the correct client
“2” if EVS identifies the wrong client
“3” if the caller wants EVS to spell the client’s
last name
Listen for coverage details
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COVERAGE DETAILS
Funding streams include both fee-for-service as well as state contracted pre-paid mechanisms.
Fee-for-Service
The Consolidated Chemical Dependency Treatment Fund (CCDTF) is the single fee-for-service
funding stream for clients who meet the following eligibility criteria:
Clients are entitled to receive CD treatment services if they meet both
1) Financial eligibility:
- Are eligible for Medical Assistance (MA), General Assistance Medical Care (GAMC), or
Minnesota Supplemental Assistance (MSA), or
- Meet current household size and income guidelines at 100% Federal Poverty Guidelines (FPG)
And
2) Clinical eligibility, according to Minnesota Rules, parts 9530.6600 through 9530.6655 (Rule 25).
Counties and tribes are responsible for providing Rule 25 assessments and determining client
eligibility as of the date of the Rule 25 assessment. Providers bill the CCDTF on a fee-for
service basis. DHS then collects the state and federal share from GAMC and Medical
Assistance. Counties also pay a percentage of the client’s treatment costs.
Pre-Paid
This includes clients who are enrolled in Minnesota State Contracted Pre-Paid Health Plans
(PPHP’s) – Pre-paid MA, Pre-paid GAMC, MinnesotaCare
As of July 1, 2008, state contracted pre-paid health plans are responsible for providing all CD treatment
services to their enrollees. Chemical use assessments must be provided according to Minnesota Rules,
parts 9530.6600 through 9530.6655 (Rule 25). The PPHP pays the provider and bills DHS for room and
board services in non-hospital residential programs.
Mid-treatment enrollment/dis-enrollment
Chemical dependency treatment providers are responsible for monitoring continued client PPHP
enrollment on a month to month basis. This includes continued enrollment, loss of enrollment, or
initiation of new enrollment or re-enrollment.
- If a client loses enrollment during the treatment episode, the provider must contact the client’s
county of financial responsibility (CFR) to determine eligibility for the CCDTF for continued
funding under FFS.
- If a client becomes enrollment in a PPHP during the treatment episode, the provider must contact
the client’s (CFR) as well as the pre-paid health plan for continued funding under the pre-paid
element.
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