Outpatient Treatment

PURPOSE: This rule describes the levels of outpatient care that may be certified and the goals, eligibility criteria, and available services. Discharge criteria and performance indicators for outpatient programs are also identified. (1) Available Services. An array of services shall be available on an outpatient basis to persons with substance abuse problems and their family members. The program shall provide all services and comply with the functions required under 9 CSR 30-3.110. (2) Certified Levels of Care. Outpatient services shall be organized and certified according to levels of care. Each of the levels of care shall vary in the intensity and duration of services offered. (A) The levels of care may include— 1. Community-based primary treatment. This level of care is the most structured, intensive, and short-term service delivery option with services offered on a frequent, almost daily basis; 2. Intensive outpatient rehabilitation. This level of care provides intermediate structure, intensity and duration of treatment and rehabilitation, with services offered on multiple occasions per week; 3. Supported recovery. This level of care provides treatment and rehabilitation on a regularly scheduled basis, with services offered on approximately a weekly basis unless other scheduling is clinically indicated. (B) All outpatient services and levels of care offered by an organization shall be certified in accordance with this rule. An organization shall be certified as providing one of the following methods of outpatient service delivery: 1. Supported recovery; 2. Intensive outpatient rehabilitation and supported recovery; or 3. Community-based primary treatment, intensive outpatient rehabilitation and supported recovery. (C) Outpatient services shall be provided in a coordinated manner responsive to each person’s needs, progress and outcomes. 1. The organization shall ensure that individuals can access an appropriate level of care. A. If all three (3) outpatient levels of care are not offered, the organization shall demonstrate that it effectively helps persons to access other levels of care that may be available in the local geographic area, as needed. B. The organization must demonstrate that it effectively helps persons to access detoxification and residential treatment services, as needed. 2. An organization with multiple service sites shall not be required to offer its certified levels of care at every site, if it can demonstrate that an individual has reasonable access to its levels of care through coordinated service delivery. 3. A light meal shall be served at a site to those individuals who receive services for a period of more than four (4) consecutive hours. Additional meals shall be provided, if warranted by the program’s hours of operation. (3) Individualized Treatment Options. The levels of care shall be used in a manner that provides individualized treatment options and offers service intensity in accordance with the needs, progress and outcomes of each person served. (A) A person may enter treatment at any level of care in accordance with eligibility criteria. (B) A person can move from one level of care to another over time in accordance with symptoms, progress, outcomes and other clinical factors. 1. The duration of each level of care shall be time-limited and tailored to the individual’s needs. 2. A person may be transferred to a more intensive level of care if there is a continuing inability to make progress toward treatment and rehabilitation goals. (4) Community-Based Primary Treatment. This level of care is the most structured, intensive, and short-term service delivery option. Structured services shall be offered at least five (5) days per week and should approximate the service intensity of residential treatment. (A) Eligibility for primary treatment shall be based on— 1. Evidence that the person cannot achieve abstinence without close monitoring and structured support; and 2. Need for frequent, almost daily services and supervision. (B) Expected outcomes for primary treatment are to— 1. Interrupt a significant pattern of substance abuse; 2. Achieve a period of abstinence; 3. Enhance motivation for recovery; and 4. Stabilize emotional and behavioral functioning. (C) The program shall offer an intensive array of services each week. 1. Each person shall participate in at least twenty-five (25) hours of service per week, unless contraindicated by the individual’s medical, emotional, legal, and/or family circumstances, and unless residential support is provided. 2. Where residential support is provided, each person shall be offered additional structured therapeutic activities in accordance with residential treatment standards. 3. Each person shall participate in at least one (1) hour per week of individual counseling. Additional individual counseling shall be provided, in accordance with the individual’s needs. 4. For community-based primary treatment that is funded by the department or provided through a service network authorized by the department, day treatment may be specified as the applicable service for this level of care. (5) Intensive Outpatient Rehabilitation. This level of care offers an intermediate intensity and duration of treatment. Services should be offered on multiple occasions during each week. (A) Eligibility for intensive outpatient rehabilitation shall be based on— 1. Ability to limit substance use and remain abstinent without close monitoring and structured support; 2. Absence of crisis that cannot be resolved by community support services; 3. Evidence of willingness to participate in the program, keep appointments, participate in self-help, etc.; and 4. Willingness, as clinically appropriate, to involve significant others in the treatment process, such as family, employer, probation officer, etc. (B) Expected outcomes for intensive outpatient rehabilitation are to— 1. Establish and/or maintain sobriety; 2. Improve emotional and behavioral functioning; and 3. Develop recovery supports in the family and community. (C) The program shall offer at least ten (10) hours of service per week. 1. Each person shall be expected to participate in at least ten (10) hours of service per week, unless contraindicated by the individual’s medical, emotional, legal, and/or family circumstances. 2. Each person shall participate in at least one (1) hour per week of individual counseling. (6) Supported Recovery. This level of care offers treatment on a regularly scheduled basis, while allowing for a temporary increase in services to address a crisis, relapse, or imminent risk of relapse. Services should be offered on approximately a weekly basis, unless other scheduling is clinically indicated. (A) Eligibility for supported recovery shall be based on— 1. Lack of need for structured or intensive treatment; 2. Presence of adequate resources to support oneself in the community; 3. Absence of crisis that cannot be resolved by community support services; 4. Willingness to participate in the program, keep appointments, participate in self-help, etc.; 5. Evidence of a desire to maintain a drug-free lifestyle; 6. Involvement in the community, such as family, church, employer, etc.; and 7. Presence of recovery supports in the family and/or community. (B) Expected outcomes for supported recovery are to— 1. Maintain sobriety and minimize the risk of relapse; 2. Improve family and social relationships; 3. Promote vocational/educational functioning; and 4. Further develop recovery supports in the community. (C) The program shall offer at least three (3) hours of service per week. Each person shall be expected to participate in any combination of services determined to be clinically necessary. (7) Continued Services. The treatment episode or level of care shall be reviewed for the appropriateness of continued services if the person presents repeated relapse incidents, a pattern of noncompliance or poor attendance, threats or aggression toward staff or other clients, or failure to comply with basic program rules. (8) Discharge Criteria. Each person’s length of stay in outpatient services shall be individualized, based on the person’s needs and progress in achieving treatment goals. (A) An individual should be considered for successful completion and discharge from outpatient services upon— 1. Recognizing and understanding his/her substance abuse problem and its impacts; 2. Achieving a continuous period of sobriety; 3. Absence of immediate or recurring crisis that poses a substantial risk of relapse; 4. Stabilizing emotional problems, when applicable (for example, not experiencing serious psychiatric symptoms, taking psychotropic medication as prescribed, etc.); 5. Demonstrating independent living skills; 6. Implementing a relapse prevention plan; and 7. Developing family and/or social networks which support recovery and a continuing recovery plan. (B) A person may be discharged from outpatient services before accomplishing these goals if— 1. Commitment to continuing services is not demonstrated by the client; or 2. No further progress is imminent or likely to occur. AUTHORITY: sections 630.050, 630.655 and 631.010, RSMo 2000.* Original rule filed Feb. 28, 2001, effective Oct. 30, 2001. Amended: Filed Oct. 15, 2001, effective April 30, 2002. Amended: Filed July 29, 2002, effective March 30, 2003. *Original authority: 630.050, RSMo 1980, amended 1993, 1995; 630.655, RSMo 1980; and 631.010, RSMo 1980.