CommonwealthofMassachusetts
DepartmentofPublicHealth-SubstanceAddictionServices
IndependentPeer Review2018
Self-StudyQuestionnaire
Program’sName:
Level of Care participating in this Peer Review (check one): / ClinicalStabilization
OpioidTreatment Program
Residential / Detoxification
Outpatient
TransitionalSupport
ProgramParticipant(s):
Note:Thequestionsincluded in thisprojectweredesignedtobebroadlyapplicable,butweunderstandthatLevelsof Careand individualprogramsoperatedifferently –use your judgmentabouthowbest toanswerthe question oreven reframe it to be useful to you.Thefirstquestion asks fordata,therestcan beanswered basedonyour understanding ofyourstaff’sexperience.Ifyou havealready providedrelevantinformationona priorquestion,write“seeItem #”–wedonotwantyou tohaveto duplicateanswers.

1.PopulationsServed

1a / Approximately how many clients does your program serve annually?
1b / Who do you serve? Please describe (in general terms) the demographics of the populations you serve (for example: age, where they live, languages spoken, physical ability, co-occurring mental health conditions, military service, race/ethnicity/culture, gender identity, LGBTQI2-S)

2. Assessment, Treatment, Discharge and Follow-up

2a / Whichassessmenttoolsdoyouuse? Which are “evidence-based”?Which aredeveloped in-house or by others?Which tools do you find most useful and why?
2b / How does your program make accommodations/adaptations for clients’ culture and language during assessment, treatment planning and discharge?
2c / How has the opioid epidemic affected your program (operationally and effect on staff and community)? How has your program responded?
2d / How does your program address the potential for relapse and/or overdose? For example:
  • Does assessment include history of overdose or witnessing overdose as part of assessing risk for overdose and working to ensure the person has access to Medication-Assisted Treatment?
  • What relapse and overdose prevention education is provided to clients, either individually or in groups? Does it cover overdose prevention, recognition and response, including use of naloxone?

2e / How does your program engage clients in treatment planning and discharge planning? How does your program engage family or other social supports?
2f / Please describe how your program addresses medications throughout the treatment process? For example,
  • Do assessments document all of a client’s current medications in the admissions and discharge process?
  • What is the process for ensuring continuity of medication when someone is admitted? How soon are medications re-assessed and adjusted (if need be) after admission?
  • How does your program access physicians to assess and/or prescribe medications?

2g / On-going assessment: How does your program assess continuing care needs and document them in a client’s discharge plan?How, and how often do you check in to see how a client is doing with another outside service during their treatment in your program? At what point in your program’s treatment do you seek consent for such contact with other services?
2h / Who determines if a client has met their service goals, or should be discharged from the program for other reasons?
2i / For clients who completed your program, do you hear how they are doing after leaving? If so, how? How do you use the information?
2j / What formal and informal processes does your program use to get feedback from current and former clients(for example, follow-up surveys or calls, consumer advisory board, other)? How is this used to change the program? Please give an example.

3. Integrated Care

3a / Howisyourprogramintegratedwithotherproviderswhooffermentalormedical/physicalhealthservices?Considerthevarietyofoptionsforintegratedcare:
  • no regular forms of collaboration
  • frequent interactions, formal referral/collaboration policies
  • out-stationed staff, co-location
  • part of a fully integrated system
  • part of an ACO

3b / In your experience, which other state agencies, or other services, serve your clients before, during or after their participation in your program (for example, those with justice-involvement, or co-occurring mental or physical health conditions treated by another service)? Do you take any special approaches with these clients or the other Agencies/services involved?
3c / Does your program have an Electronic Health Record? Yes No
If Yes, which Electronic Health Record does your program use, and how long has it been in use? Is the entire record electronic, or are parts still in paper form? Is it customizable? Does it interface with any other system’s EHR?
What do you like and dislike about it?

4. Wellness and Health Promotion

4a / How do you promote staff self-care? How do you support staff in recovery to sustain their own recovery while helping others? How do you support staff in times of grief? Work-life balance?
4b / Do you have any policies related to wellness including tobacco, nutrition, physical activity, access to nature etc.? Are there different policies for staff and clients?
4c / What resources do your staff and clients have related to wellness and health promotion?
-What wellness activities are covered under your staff benefits?
-What wellness activities are offered for staff? For clients? (e.g. nutrition, sleep, music, mindfulness, yoga, art, meditation, movement)
4d / How do you include wellness strengths and challenges in your initial assessment?
4e / How are you addressing the new electronic devices for substance use( e.g. vaping, …)
4f / Whatwellness related training/supervision for staff do you offer? (e.g. related to tobacco, nutrition, grief, and/or wellness and health promotion?)
4g / For those who provide food (either residential or snacks for OP), what do you provide? How do you decide what to provide?
4h / What is your protocol for the death of a client? How do you help people cope with grief and loss?
5. StaffDiscussion: What wedo well and whatwe could changerelated to wellness and health promotion? Please discuss these questions with your staff and give a brief summary of the discussion. Please be specific. If you prefer, submit a bulleted list of topics covered, and any potential change projects considered.
5a / What do we do wellrelated to wellness and health promotion?
5b / What could we do better related to wellness and health promotion?
5c / What changes would your staff like to try related to wellness and health promotion?

Peer Review 2018 Self-Study – v1/23 1