Essential Principles and Outcomes

PURPOSE: This rule describes the essential principles and outcomes applicable to Opioid Treatment Programs, Comprehensive Substance Treatment and Rehabilitation Programs (CSTAR), Gambling Disorder Treatment Programs, Institutional Treatment Centers, Recovery Support Programs, Substance Awareness Traffic Offender Programs (SATOP), Substance Use Disorder Treatment Programs, Required Education Assessment and Community Treatment Programs (REACT), Community Psychiatric Rehabilitation Programs (CPR), and Outpatient Mental Health Treatment Programs. The performance indicators listed in this rule are examples of how an essential principle can be measured and do not constitute a list of specific requirements. The indicators include data that may be compiled by a program as well as areas a surveyor may observe or monitor, including satisfaction and feedback from individuals served, and other data the department may compile and distribute. A program may also use additional or other means to demonstrate achievement of these principles and outcomes. (1) Applying the Essential Principles. The organization’s service delivery practices shall incorporate the essential principles listed in this rule in a manner that: (A) Is adapted to the needs of different populations served; (B) Is understood and practiced by staff providing services and supports; (C) Is consistent with clinical studies and practice guidelines for achieving positive outcomes; (D) Supports individuals in improving their capacities in all areas of functioning; and (E) Assists individuals in achieving their goals for recovery/ resiliency and successfully managing their symptoms. (2) Outcome Domains. Services shall be delivered in a manner that promotes positive outcomes in the emotional, behavioral, social, and family functioning of individuals served. Positive outcomes for individuals served are expected in the following domains: (A) Emotional and physical safety for themselves and others in his or her environment; (B) Improved functioning and management of daily activities including management of the symptoms associated with a behavioral health disorder; (C) Abstinence from drug and/or alcohol use or decrease in harmful use of substances; (D) Satisfaction with services; (E) Increased/sustained employment or return to/remain in school; (F) Decreased involvement with the justice system; (G) Increased stability in housing; (H) Increased family, natural support, and social connections; (I) Increased parenting capacities; (J) Increased retention in services for substance use disorders, decreased inpatient hospitalization for mental health treatment, and reduction in out-of-home placement services; (K) Improved physical health and wellness; and (L) Increased sense of empowerment in management of their lives in all domains. (3) Measuring Program Effectiveness. An organization shall measure outcomes for the individuals it serves and collect data related to the domains listed in paragraph (2) of this rule. The data assists the organization in monitoring the quality of its services and determining their impact on the emotional, physical, social, and behavioral health of individuals served. In order to promote consistency and the wider applicability of outcome data, the department may require, at its option, the use of designated outcome measures and instruments for services funded by the department. (4) Essential Principle—Therapeutic Alliance. (A) The organization shall promote easy and timely access to services, engagement in services, and development of an ongoing therapeutic alliance by— 1. Treating people with respect and dignity; 2. Enhancing motivation and self-direction through identification of meaningful goals that establish positive expectations; 3. Working with family members and other natural supports, parents/guardians, courts, and other support systems to promote the individual’s participation in services; 4. Addressing barriers to accessing treatment and other support services; 5. Providing education to individuals, family members/ natural supports, and parents/guardians to promote understanding of services and supports in relationship to individual functioning or symptoms and to promote understanding of individual responsibilities in the process; 6. Empowering individuals to assume an active role in developing and achieving productive goals and identification of services; 7. Delivering services in a manner that is responsive to each individual’s developmental needs, cultural background, gender identity, gender expression, language and communication skills, sexual orientation, and other factors as indicated; and 8. Recognizing the unique needs and priorities of individuals served as well as the challenges he or she may face in their journey of recovery/resiliency. (B) Performance indicators may include, but are not limited to— 1. Convenient hours of operation consistent with the needs and schedules of individuals served; 2. Geographic accessibility, including transportation arrangements, as needed; 3. Rate of attendance at scheduled services; 4. Individuals consistently reporting that staff listen to and understand them; 5. Treatment retention rate; 6. Rate of successfully completing treatment goals and/or the treatment episode; and 7. Satisfaction with services as conveyed by individuals served and their family members and other natural supports. (5) Essential Principle—Person- and Family-Centered Care. Services shall be provided in a manner that addresses each individual’s needs, goals, preferences, cultural traditions, family situation, and values. (A) Individuals served and family members/natural supports of their choice shall be provided with information about the treatment options available in order to make informed decisions about the type and duration of services and providers. (B) Development and implementation of a treatment plan that assists each individual in achieving his or her personal goals of recovery and resilience is a collaborative process MENTAL HEALTH involving the individual, family members/natural supports of his/her choice, and treatment team. (C) For children and youth, person-centered planning is incorporated into a family-driven, developmentally appropriate, and youth-guided approach that recognizes the importance of family in the lives of children and the impact of services and supports on the entire family. (D) When the family or natural support system may jeopardize safety (such as domestic violence, child abuse and neglect, separation and divorce, and/or financial and legal difficulties), services shall be available to educate family members/natural supports about the impact of these issues and strategies to reduce risk factors. (E) Assistance in finding options for transportation, childcare, and safe and appropriate housing shall be utilized as necessary in order for individuals to participate in services and meet recovery/resiliency goals. (F) For adults with children, services to enhance their parenting capacities shall be provided or arranged. (G) Performance indicators may include, but are not limited to: 1. Variability in the type and amount of services an individual receives consistent with his/her needs, goals, and progress; 2. Hospital readmission rates; 3. Rate of family/natural support engagement in direct services (such as family therapy) and continuing care; 4. Number of individuals receiving withdrawal management/detoxification services who continue treatment; and 5. Satisfaction with shared decision-making as conveyed by individuals served and their family members and other natural supports. (6) Essential Principle—Least Restrictive Environment. (A) Individuals shall be served in the most appropriate setting available based on their personal goals for recovery/ resiliency and readiness to change, while assuring emotional and physical safety and protection from harm. (B) Performance indicators may include, but are not limited to— 1. Utilization rate of inpatient hospitalization, residential support, and out- of-home placement; 2. Length of stay for inpatient hospitalization, residential support, and out-of-home services; 3. Consistent use of admission eligibility criteria; 4. Distribution of individuals served among settings; 5. Ongoing assessment of individuals to ensure the appropriate and least restrictive environment; and 6. Satisfaction with services as conveyed by individuals served and their family members or other natural supports. (7) Essential Principle—Promoting Recovery and Resilience. Services and supports shall be delivered in a manner consistent with the concept of recovery as defined by the Substance Abuse and Mental Health Services Administration (SAMHSA) as a process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential. Services are provided that build, enhance, and activate skills for recovery and resilience for individuals, families, and other natural supports. (A) Staff shall offer support and encouragement and model recovery/resilience from a behavioral health disorder, serious emotional disturbance, and/or substance use disorder in ways that are specific to the needs of each individual served. Services are provided in a safe, welcoming, culturally sensitive, trauma-sensitive, and age-appropriate environment where all individuals are engaged as equal partners. (B) Individuals are educated about their illness, coping skills, and strategies to prevent a recurrence of symptoms and are encouraged to accomplish tasks and goals in an independent manner without undue staff assistance. (C) The four dimensions of recovery shall be incorporated into the organization’s service delivery practices: 1. Health—overcoming or managing one’s disease(s) or symptoms such as: A. Abstaining or reducing harmful use of alcohol, illicit drugs, and non-prescribed medications; B. Participating in appropriate health care services to lower the incidence of diabetes, cardiovascular disease, coronary artery disease, HIV, and hepatitis C; and C. Making informed, healthy choices that support physical and emotional well-being. 2. Home—having a stable and safe place to live; 3. Purpose—conducting meaningful daily activities such as a job, school volunteerism, family caretaking, or creative endeavors, and the independence, income, and resources to participate in society; and 4. Community—having relationships and social networks that provide support, friendship, love, and hope. (D) Performance indicators may include, but are not limited to— 1. Measures of symptom frequency and severity; 2. Improved functioning related to— A. Health, wellness and nutrition; B. Personal care (hygiene, grooming, dress); C. Communication; D. Money management; E. Safety; F. Occupational/educational status; G. Legal situation; H. Social and family/natural support relationships; I. Housing stability, maintenance; J. Problem solving, decision making, and coping skills; and K. Managing time, leisure skills, and productivity; 3. Tapering the intensity and frequency of services, consistent with individual progress; and 4. Satisfaction with services as conveyed by individuals served and their family members and other natural supports. (8) Essential Principle—Peer Support and Social Networks. Individuals served and their parents/legal guardians, family members, and other natural supports shall have access to peer support services, social networks, and resources in the community. (A) Peer support encompasses a range of activities and interactions between people who share similar experiences of being diagnosed with a mental health condition, substance use disorder, or both. Through shared understanding, respect, and mutual empowerment, peer support specialists help people become and stay engaged in the recovery process and reduce the likelihood of a return to substance use. Peer support services can effectively extend the reach of treatment beyond the clinical setting into the everyday environment of individuals seeking a successful, sustained recovery process. (B) Peer support services shall be provided in a manner that reflect the core competencies, principles, and values identified in the publication, Core Competencies for Peer Workers in Behavioral Health Services, December 2017, developed by and available from SAMHSA, 5600 Fishers Lane, Rockville, MD 20857, (877) 726-4727. The referenced document does not include any later revisions or updates. (C) Certified peer specialists shall be utilized within the organization’s service array. (D) Performance indicators may include, but are not limited to— 1. Rate of participation in community-based recovery support groups; 2. Involvement with a wide range of individuals in social activities and networks (such as church, clubs, and sporting activities); 3. Number of certified peer specialists employed by the organization and documented delivery of peer support services; and 4. Satisfaction with peer support services and accessibility to social networks as conveyed by individuals served and their family members/natural supports. (9) Essential Principle—Medication Services. Individuals shall have access to medications to treat mental illness and substance use disorders, including tobacco use. (A) The organization shall implement written policies and procedures related to its medication practices. (B) Individuals shall be educated about available medications, their intended benefits, and potential side effects in order to make informed choices regarding their use. Use of medication is not a requirement for receiving behavioral health services. Individuals shall not be denied their medication(s) because they are not participating in treatment. (C) Staff of the organization, including contracted prescribers and providers, must be familiar with the full range of FDAapproved medications available for mental illness, substance use disorders, including tobacco use, and shall not be limited to a single model, approach, category, or formulation of medications. (D) Individuals shall be educated about the importance of taking medication as prescribed and provided with aids such as pill boxes and blister packs, once-a-day long-acting medications, depot injections, and generic or lower-cost alternatives, when appropriate. (E) Medication compliance shall be monitored by staff, as indicated by clinical need, to assist individuals in anticipating early warning signs of a recurrence of symptoms and develop strategies to maintain health and wellness. (F) Routine communication and coordination with other service providers regarding the individual’s medical conditions, test results, and prescribed medications occurs as clinically indicated. (G) Performance indicators may include, but are not limited to— 1. Number of individuals receiving an FDA-approved medication for a diagnosed mental illness and/or substance use disorder, including tobacco use; 2. Variability in the use of FDA-approved medications for mental illness and substance use disorders, including tobacco use; 3. Reduction in rates of recurrence of symptoms among individuals served; and 4. Improvement in treatment retention and completion rates. (10) Essential Principle—Services for Co-Occurring Disorders. Coordinated, evidence-based services shall be provided or arranged for individuals with a diagnosed co-occurring disorder. (A) Each individual seeking services shall be screened and assessed for co-occurring disorders and have access to a full range of services provided by qualified, trained staff. (B) Each individual shall receive services necessary to fully address his/her treatment needs. The program providing screening and assessment shall— 1. Directly provide all necessary services in accordance with the program’s capabilities and certification/deemed status; 2. Make a referral to a program which can provide all necessary services and maintain appropriate involvement until the individual is admitted to the program which he/she has been referred; or 3. Provide services within its capability and promptly arrange additional services from another program. (C) Services are continuously coordinated between programs, where applicable. Programs shall ensure services are not redundant or conflicting and maintain communication regarding the individual’s treatment plan and progress. (D) Performance indicators may include, but are not limited to— 1. Reduction in hospitalization rates; 2. Reduction in incarceration rates; 3. Reduction in readmissions to withdrawal management/ detoxification services; 4. Increased stable housing/independent living arrangements; 5. Increased rates of competitive employment; and 6. Increased access to medical care. (11) Essential Principle—Trauma-Informed Care. Clinical and nonclinical staff shall be competent in recognizing and responding appropriately to the presence of the effects of past and current traumatic experiences in the lives of individuals served. (A) A trauma-informed organization— 1. Realizes the widespread impact of trauma and understands potential paths for recovery; 2. Recognizes the signs and symptoms of trauma in individuals, families/natural supports, staff, and others involved in the continuum of care; 3. Responds by fully integrating knowledge about trauma into its policies, procedures, practices, and environments; and 4. Seeks to actively prevent re-traumatization. (B) Each individual shall receive services necessary to fully address his/her treatment needs. Appropriately trained staff shall screen for each individual’s history of trauma and current personal safety in accordance with a model approved by the department. The agency providing the screening shall— 1. Directly provide necessary services to address the impact of trauma in accordance with the program’s capabilities and certification; 2. Make a referral to a provider that can offer the necessary trauma services and continue to provide other needed services and maintain appropriate involvement until the individual is admitted to the agency which he/she is being referred; or 3. Provide services within its capability and promptly arrange additional services from another provider. (C) Services shall be continuously coordinated between providers, as applicable, to ensure services are not redundant or conflicting and to maintain communication regarding the individual’s treatment plan and progress. (D) Individual trauma counseling shall be provided by a licensed mental health professional with specialized training in trauma services and/or equivalent work experience. MENTAL HEALTH (E) Performance indicators may include, but are not limited to— 1. Decrease in trauma and mental health symptoms and substance use; 2. Improvement in daily functioning; 3. Improvement in relationships and self-esteem; 4. Decrease in utilization of crisis-based services; and 5. Improvement in housing stability. (12) Essential Principle—Easy and Timely Access to Services. Services are easy to find, affordable, and readily available to individuals in the community. (A) Services are available at convenient times and locations for individuals and their family members/natural supports, with prompt screening and engagement regardless of ability to pay. (B) Interim services are made available to eligible individuals, when possible, by the organization or through referral to other community resources when immediate admission cannot be provided. (C) Outreach and educational activities shall be conducted on a regular basis to educate the public about behavioral health issues, prevention strategies, diagnoses, and the availability of services in the community. (D) Telehealth/telemedicine and other forms of technology are utilized in accordance with federal confidentiality regulations to increase access, engagement, and retention. (E) Partnerships and affiliations among physical and behavioral health providers, law enforcement, courts, schools/ universities, hospitals, family services, and other community resources shall be developed and actively implemented to educate staff, improve communication, and provide for easier access to the range of services and supports needed by the population served. (F) Individuals shall be informed of available resources for housing, transportation, and childcare to assist them in accessing and engaging in necessary services and supports. (G) Performance indicators may include, but are not limited to— 1. Same-day access to services; 2. Reduced wait time to set a first or subsequent appointment(s); 3. Increased retention in services; and 4. Satisfaction with accessibility to services as conveyed by individuals served and their family members/natural supports, referral sources, and other community partners. (13) Essential Principle–Qualified and Competent Workforce. A core workforce (employed or contracted) shall be maintained that is appropriately qualified and determined competent to adequately address the needs of the population served and deliver the behavioral health services the organization is certified/deemed certified to provide. (A) Staff shall have opportunities to participate in continuing education, training, technical assistance, or other workforce development activities related to evidence-based and best practices, federal, state and/or department initiatives, stateof-the-art technology, and other advances in the behavioral health field to enhance service delivery practices and improve individual outcomes. (B) Direct service staff shall demonstrate competency in the areas identified by the Centers for Medicare and Medicaid Services, National Direct Service Workforce Resource Center, Final Competency Set, December 2014, 7500 Security Blvd., Baltimore, MD 21244, available at https://www.medicaid.gov/ medicaid/ltss/workforce/index.html. The referenced document does not include any later updates or revisions. Competent staff shall— 1. Communicate in a respectful and clear manner, verbal and written, to build trust and productive relationships with individuals/families, co-workers and others; 2. Use person-centered practices, assist individuals to make choices and plan goals, and provide services to help individuals to achieve their goals; 3. Closely monitor an individual’s physical and emotional health, gather information about the individual, and communicate observations to guide services; 4. Identify risks and behaviors that can lead to a crisis, and use effective strategies to prevent or intervene in the crisis in collaboration with others; 5. Be attentive to signs of abuse, neglect, or exploitation and follow procedures to protect an individual from such harm. Help individuals avoid unsafe situations and use appropriate procedures to assure safety during emergency situations; 6. Work in a professional and ethical manner, maintaining confidentiality and respecting individual and family rights; 7. Provide advocacy and empower and assist individuals to advocate for what they need; 8. Help individuals to achieve and maintain good physical and emotional health essential to their well-being; 9. Help individuals to manage the personal, financial, and household tasks that are necessary on a day-to-day basis to pursue an independent, community-based lifestyle; 10. Help individuals to be a part of the community through valued roles and relationships, and assist individuals with major transitions that occur in community life; 11. Respect cultural differences and provide services and supports that fit with an individual’s preferences; and 12. Obtain and maintain necessary professional credential(s) and seek opportunities to improve their skills and work practices through further education, training, and selfdevelopment. (C) Staff shall provide services within the scope of their respective state credential(s) and in accordance with all applicable federal, state, or local laws and other regulations. (D) Performance indicators may include, but are not limited to— 1. A qualified and diverse workforce acclimated to the community culture; 2. Delivery of culturally appropriate services and supports; 3. Documented delivery of a broad range of individual and group services including specialized services for co-occurring disorders and trauma; 4. Satisfaction with services and supports as conveyed by individuals, family members/natural supports, referral sources, and other community stakeholders. (14) Essential Principle—Employment. All individuals served who have a desire to work shall have access to appropriate resources to assist them in overcoming or addressing symptoms that interfere with seeking, obtaining, and maintaining a job. (A) Evidence-based and best practices shall be implemented to promote recovery/resiliency and assist individuals in obtaining and maintaining integrated, competitive, and meaningful employment of their choice. (B) Staff shall work collaboratively with individuals and their family members/natural supports, parents/guardians, or other caregivers to include educational, vocational, and/ or employment goals on the individual treatment plan and provide appropriate support to assist the individual in achieving those goals. (C) Performance indicators may include, but are not limited to— 1. Individuals served obtain and maintain a job of their choice; 2. Documented delivery of services that assist individuals with job-seeking skills and symptom-management on the job; 3. Effective working relationships with employment, vocational, and educational resources in the community; and 4. Satisfaction with employment, vocational, and education-related services and supports as conveyed by individuals, family members/natural supports. (15) Essential Principle—Care Planning and Care Coordination. Services shall be coordinated to promote accurate diagnosis and treatment, improve the individual experience of care, enhance health and wellness outcomes, and increase efficiency across healthcare delivery systems. (A) Service delivery staff shall engage in care-planning and coordination activities identified by SAMHSA’s Health Resources and Services Administration, Center for Integrated Health Solutions, 1400 K Street NW, Suite 400, Washington, D.C. 20005, (202) 684-7457, including, but not limited to: 1. Developing integrated treatment plans with the individual and family members/natural supports, parents/ guardians, caregivers of his/her choice, and members of the service delivery team; 2. Monitoring each individual’s participation in and response to treatment on a regular basis in order to match and adjust the type and intensity of services to the individual’s needs and ensure the timely and unduplicated provision of care; 3. Utilizing the treatment plan to link multiple services, healthcare providers, and community resources to meet the individual’s needs; 4. Ensuring the flow and timely exchange of information among the individual, family members/natural supports, parents/guardians, caregivers and linked providers; 5. Working collaboratively to resolve differing perspectives, priorities, and schedules among providers; 6. Providing or arranging access to services that focus on benefits and financial counseling, transportation, home care, social services, peer support, and medication for substance use disorders; 7. Implementing disease management strategies for selected health conditions (such as asthma, diabetes, COPD, cardiovascular disease and hypertension, obesity, tobacco use), combining the use of engagement tools, health risk assessments, cognitive and behavioral interventions, medications, webbased tools, protocols and guidelines, formularies, monitoring devices, shared decision-making aids, illness and whole health self-management strategies, peer support and empowerment approaches; and 8. Effectively connecting individuals who cannot be adequately served by the treatment team or within the setting to other appropriate services. (B) Care planning and care coordination involves active partnerships with community resources to ensure access and seamless transition to other services and supports for individuals and families/natural supports served. Community resources include, but are not limited to, local primary care providers, hospital systems, health homes, schools, and vocational rehabilitation and employment entities. (C) When an individual misses an appointment or drops out of services, steps shall be taken to reengage him or her in services by making reminder calls, addressing basic needs that may be preventing them from participating, and offering peer support. (D) Performance indicators may include, but are not limited to— 1. Reduction in emergency room visits; 2. Reduction in hospitalizations; 3. Reduction in costs and duplication of services; 4. Documented delivery of services related to recovery planning, health and wellness; 5. Satisfaction with services as conveyed by individuals, family members/natural supports. AUTHORITY: sections 630.050 and 630.055, RSMo 2016.* Original rule filed Feb. 28, 2001, effective Oct. 30, 2001. Amended: Filed Nov. 5, 2018, effective June 30, 2019. *Original authority: 630.050, RSMo 1980, amended 1993, 1995, 2008 and 630.055, RSMo 1980.