UWITS Tip Sheet - SLCo · Admission Profile 1. In order to initiate the Admission process, you This information prefills from the Client Profile screen. To edit this. must complete

K:\UWITS Documentation\UWITS Current Website\UWITS Admission Tip Sheet March 2019.docx Date: July 11, 2019, Ver: 2 Rev: 5

UWITS Tip Sheet Admission

Admission Outcome Measures/ASAM Program Enrollment

This tip sheet focuses on the elements required to admit a client to a facility and enroll a client in a program.

Total Pages: 24

Admission Profile 1. In order to initiate the Admission process, you This information prefills from the Client Profile screen. To edit this must complete the Client Profile and Intake information, go back to the Client Profile screen, make the changes screens (open an Episode of Care). and then return to the Admission screen. 2. Entry Steps: Login, Select Facility, Select Client List from left Menu Bar to view the Client Search Screen, find client, and click Activity List. 3. From the left menu bar, click Admission. 4. Complete all the yellow system and state required fields. All other white fields may not be required by UWITS but may be required by your agency. Therefore, check with your program administrator about other fields required by your agency. Note: All required field’s dark or light yellow. Return to the Client Profile screen to correct client information inaccuracies, i.e., name, DOB, etc. 5. When the Admission is complete, click Finish. Note: clicking Next will save each screen.

Outcome Measures – Client Status An Outcome Measure (OM) needs to be completed before a Client Program Enrollment (CPE) can be done, and the domain of the OM must match the domain of the intended CPE. The Outcome Measure data elements should be reviewed at each client visit to determine whether there have been any changes. If anything has changed a new OM should be completed. The data in the Outcome Measure should be accurate as of the OM Date. If you later discover some of the originally entered information was incorrect, the OM for that time period (and all subsequent OMs) should be corrected if necessary.

• Reporting Differences between Mental Health (MHE) & Substance Use Disorder (TEDS/NOMS) Domains o SUD

TEDS/NOMs Reporting: Enrollment based - Snapshots at each Program Enrollment and Dis-enrollment • (An OM is linked to each enrollment and to each disenrollment) • Example: Criminal Justice involvement during a Tx episode requires a dis-enrollment/re-enrollment into the same level of care

for this data is captured and reported to the state: Client not previously Compelled to Tx is now compelled - non-DORA/Drug Court client becomes DORA/DC

o MH MHE Reporting: Service based - Snapshots of all billed encounters.

• (All OMs are relevant – The OM previous to each encounter is reported in the MHE data)

o RSS Recovery Support Services- This utilizes the voucher programs and any others that entails recovering of the client. Outcome Measure

requirements are minimal and no ASAM is required.

Required components for SUD, MH and RSS:

SUD MH RSS Outcome Measure

Outcome Measure

Outcome Measure

ASAM Client Diagnosis

Client Diagnosis

Client Diagnosis

Program Enrollment

Program Enrollment

Program Enrollment

Outcome Measures -Substance Use Disorder (SUD) (Fields in yellow are

required for State reporting and must be completed prior to any program enrollment/disenrollment.)

1. Client Status: Date: Today’s Date Type: Initial, Update or Final Pregnant- Yes or No (*Note this field is grayed out if client is a male, if female then due date is required) Selected Domains: Substance Abuse, Mental Health, Recovery Support Specialist 2.Profile: -Codependent/Collateral: ‘Yes’ only for child of a parent in Treatment -Co-Occurring SA & MH Problem: client has a psychiatric problem in addition to alcohol or drug use problem. -#of Days on Waitlist- -Medication Assisted Tx: use of methadone, LAAM, Buprenorphine or other opioid replacement therapy as part of client’s TX Plan. -# of Prior SA Tx Episodes: # previous TX episodes client received in drug or alcohol program (only since 1/1/1990) -# of times the client has participated in a self-help program in 30 days: clients participating in drug or alcohol self-help groups, support groups 30 days prior to TX. 3.Education: -Education Status: Highest level of education completed. -Enrolled in Education: Enrolled in an education program that upon completion degree or certificate is issued. 4. Financial/Household: -Current Employment Status: Employment status -Funding Source: Expected Primary source of payment for TX -Marital Status: Client’s Marital Status -Client's Monthly Gross: Client’s monthly salary before Taxes -Medicaid Eligibility Determined: Yes or No -# of People Living With Client, including the client: # of legal family members with whom the client lives, including the client (Min = 1, Max = 10) -Primary Income Source: Where does client get their income from -Client Health Insurance: Clients Primary Insurance source -Living Arrangement: Client’s living situation -Household Monthly Income: Income for entire household -# of Children Under 18 Living/Not Living w/Client: # of children, age 17 or less, by birth or adoption. 5.Legal: -#Compelled to Tx: Yes, No, Not collected -Criminogenic Risk: Derived from risk assessment tool. -Drug Court Participation: which drug court, if any, is the client current involved -# of Arrests in Past 30 Days: #of times client has been arrested in the last 30 days. 6. Substance Abuse:HC -Substances: Client’s Primary, Secondary, Tertiary substance use -Severity: How serious the substance problem is for each substance listed. -Frequency: # times indicated substance was used while client was not in a controlled environment. (Verified by treatment staff) -Method: the way the client usually administers the indicated substance. -At what age did the client FIRST use the substances indicated above: Use the actual age unless the related Substance is NONE. (Unknown is not an option)

7.Tobacco/Nicotine: YES -Have you ever used Tobacco/Nicotine products? Yes -Smoker Status: 4-Current Every Day, 3-current some day smoker,2- Former Smoker, 6-Use smokeless tobacco only, 99-Unknown if ever smoked

-Age of First Use: age first used tobacco ever (Enter 98 if never used) In the past 30 days, what tobacco/nicotine product did you use most frequently? None, cigarettes, cigars, chewing tobacco, piple, snuff, other(specify), NA, Unknown Other (Please Describe) –(Grayed out field) In the past 30 days, how often did you use tobacco/nicotine product(s)? , ½ pack, > 2packs, 1-2 packs, ½-<1 pack

8.Tobacco/Nicotine: NO Have you ever used Tobacco/Nicotine products? No Smoker Status: 1-Never Smoked

Age of First Use: (Grayed Out) In the past 30 days, what tobacco/nicotine product did you use most frequently? N/A Other (Please Describe) -: (Grayed Out) In the past 30 days, how often did you use tobacco/nicotine product(s)? N/A

Treatment Summary-SUD

Treatment Summary is the summary of services provided over

the episode of care for a client. Initially, no information required and is populated after a program

enrollment is completed. (No required fields are needed.)

Finished treatment ADD .

Treatment Summary contains:

• Treatment Summary • Program Enrollment • Services Rendered

Outcome Measures – ASAM-SUD Outcome Measures-ASAM must be filled out and signed to complete the admission UWITS.

Each OM has its own distinct copy of the ASAM, so any existing ASAM will be copied forward into new OMs in its present state (signed or unsigned.) It is recommended to complete and sign any unsigned ASAMs before adding a new OM, otherwise they will have to be completed and signed separately.

If a Multi-Dimensional Assessment (MDA) has been completed and signed the ASAM data can be copied in from it by using the provided link. Requirements for signing ALL ASAMs must be signed before an SUD encounter can be released to billing.

Make sure the ASAM has been completed accurately before signing. Level of Risk, Level of Care and Comments must be filled out to generate the Sign ASAM under Administrative Actions.

***Once signed an ASAM cannot be re-opened except by a WITS administrator under very specific circumstances. Requests to re-Open ASAMs should include OM Date.

Client Diagnosis–Substance Abuse Disorder (SUD)

1. To add a diagnosis to the Behavioral Category, click “Edit Diagnosis” on the main Diagnosis screen.

a. Note: This replaces the old “Edit Axis Evaluation” link that used to be on the bottom of the diagnosis

2. “Effective Date” field will default to today’s date and time.

3. In the “Type” field, choose “Behavioral”.

a. Note: The principal diagnosis field defaults to “no”. b. By choosing the Type, the “Diagnosis” dropdown values will be limited to those your administrator has mapped to the Behavioral category. (These were formerly referred to as Axis I and Axis II.)

4. In the “Principal Diagnosis” field, choose ‘Yes”. The diagnosis will populate into the Behavioral Category on the grid. (If you wish to add Medical or Psychosocial/ Behavioral diagnoses, use the same steps, but simply select a different “Type”.)

5. Once the appropriate values have been selecedted, the option to “SAVE” which saves the diagnosis or “CLEAR” to clear the fields and start over.

Program Enrollment -Substance Abuse Disorder (SUD)

Program Enrollment will default to today’s date but is editable. Make sure an Outcome Measure has been done no more than 14 days prior to an Enrollment or Disenrollment.

1. From the Navigation Panel, select ‘Program Enroll.’

2. Default program enrollment dates are set to the past 12 months. Additional criteria can be used to narrow search.

3. ADD Enrollments based on level of care and type of treatment (SUD or MH).

4. Select existing Enrollments to edit

using the icon. Program Enrollment will default to today’s date but is editable. Make sure an Outcome Measure has been done no more than 14 days prior to an Enrollment or Disenrollment. 5. Clear button clear the search

criteria in fields. Go button allows you to search with the criteria specified in Program Name, Modality, Facility and Active Program Enrollments During Date range.

6. Select Program Name which is the

Program the client will be Enrolling in.

7. Select dropdown for Program Staff (Staff Member who is doing the enrollment)

8. Start Date is auto populated with today’s date.

1. Start Date -Populated with todays date 2. End Date-Select calendar or enter appropriate date in the mm/dd/yyyy format . 3. Populate- Select date of last contact by selecting calendar or enter date in mm/dd/yyyy format. (Date of Last face to face with client) 4. Program Staff-Auto populated with the current user. 5. Termination Reason-Select the appropriate reason.

SUD Discontinuation Reasons:

• 1=Treatment Completed: The client has completed his/her treatment episode. In most cases, this should mean that the client has completed at least 75% of their treatment objectives.

• 2=Left against professional advice (drop out) • 3=Terminated by the facility: The client was discharged due to facility rule violations, AWOL, criminal behavior, etc. • 4=Transferred to another substance abuse treatment program or service/program type: This code is to be used for all clients who have a change of

service or provider within the SLCO provider network. This would include a change in modality of service (change to a higher or lower level of care) or a lateral-step due to program expertise.

• 5=Incarcerated • 6=Died

Outcome Measures – MH Requirements:(Fields in yellow are required for State reporting and must be completed prior to any program enrollment/disenrollment.) 1. Client Status -Date-Current Date -Type-Initial, Update or Final -Pregnant- Yes or No (*Note this field is grayed out if client is a male) Domains/Selected Domains- Mental Health 2. Profile: -Co-Occurring SA & MH Problem-client has a psychiatric problem in addition to alcohol or drug use problem. # of Days on waitlist- # of days the client has been on the waitlist SMI/SED Status-Specify if client meets the criteria for either SED or SMI (SPMI is a subset of SMI), depending on age Previous MH Tx-If client has had MH treatment- yes or no Previous MH Tx at UT State Hospital- If client has had MH Tx at UT State Hospital -yes or no Previous MH Tx at this Health Center- If client has been at this agency for Mental Health Previously -yes or no Atypical Medication Used- Irregular or unusual medications used 3. Education: -Education Status: Highest level of education completed. -Enrolled in Education: Yes/No (Unknown not allowed) 4. Financial/Household -Current Employment Status: employment status -Funding Source: Expected Primary source of payment for TX -Living Arrangement-: Client’s living situation Expected Payment- Medicaid, Non-Medicaid, Medicaid not covered service, Underfunded, Self-Pay -# of People Living with Client, including the client: # of legal family members with whom the client lives, including the client (Min = 1, Max = 10) -# of Children Under 18 Living/Not Living w/Client: # of children, age 17 or less, by birth or adoption. 5. Legal: -#Compelled to Tx:: Yes, No, Not collected -Criminogenic Risk: Derived from risk assessment tool. -Mental Health Legal Status: Civilly Committed, Not Civilly Committed -# of Arrests in Past 30 Days: #of times client has been arrested in the last 30 days.

6.Tobacco/Nicotine: YES -Have you ever used Tobacco/Nicotine products? Yes -Smoker Status: 4-Current Every Day, 3-current some day smoker,2- Former Smoker, 6-Use smokeless tobacco only, 99-Unknown if ever smoked

-Age of First Use: age first used tobacco ever (Enter 98 if never used) In the past 30 days, what tobacco/nicotine product did you use most frequently? None, cigarettes, cigars, chewing tobacco, piple, snuff, other(specify), NA, Unknown Other (Please Describe) –(Grayed out field) In the past 30 days, how often did you use tobacco/nicotine product(s)? , ½ pack, > 2packs, 1-2 packs, ½-<1 pack

7.Tobacco/Nicotine: NO Have you ever used Tobacco/Nicotine products? No Smoker Status: 1-Never Smoked

Age of First Use: (Grayed Out) In the past 30 days, what tobacco/nicotine product did you use most frequently? N/A Other (Please Describe) -: (Grayed Out) In the past 30 days, how often did you use tobacco/nicotine product(s)? N/A

Treatment Summary-Mental Health

Treatment Summary is the summary of services provided over the episode of care which includes clinical information,

program enrollment, and services rendered.

Treatment Summary contains:

• Treatment Summary • Program Enrollment • Services Rendered

Outcome Measures – ASAM-MH

NOTE: An ASAM is no longer required for the Mental Health Domain Outcome Measures or

Program Enrollments.

Client Diagnosis–Mental Health (MH)

1. To add a diagnosis to the Behavioral Category, click “Edit Diagnosis” on the main Diagnosis screen.

a. Note: This replaces the old “Edit Axis Evaluation” link that used to be on the bottom of the diagnosis

2. “Effective Date” field will default to today’s date and time.

3. In the “Type” field, choose “Behavioral”.

a. Note: The principal diagnosis field defaults to “no”. b. By choosing the Type, the “Diagnosis” dropdown values will be limited to those your administrator has mapped to the Behavioral category. (These were formerly referred to as Axis I and Axis II.)

4. In the “Principal Diagnosis” field, choose ‘Yes”. The diagnosis will populate into the Behavioral Category on the grid. (If you wish to add Medical or Psychosocial/ Behavioral diagnoses, use the same steps, but simply select a different “Type”.)

5. Once the appropriate values have been selecedted, the option to “SAVE” which saves the diagnosis or “CLEAR” to clear the fields and start over.

Recording a Primary Diagnosis in UWITS

Program Enrollment-Mental Health (MH)

Program Enrollment will default to today’s date but is editable. Make sure an Outcome Measure has been done no more than 14 days prior to an Enrollment or Disenrollment.

1.From the Navigation Panel, select ‘Program Enroll.’

2. Default program enrollment dates are set to the past 12 months. Additional criteria can be used to narrow search.

3. ADD Enrollments based on level of care and type of treatment (SUD or MH).

4. Select existing Enrollments to edit

using the icon. Program Enrollment will default to today’s date but is editable. Make sure an Outcome Measure has been done no more than 14 days prior to an Enrollment or Disenrollment.

5. Clear button clear the search criteria in fields. Go button allows you to search with the criteria specified in Program Name, Modality, Facility and Active Program Enrollments During Date range.

6. Select Program Name which is the Program the client will be Enrolling in.

7. Select dropdown for Program Staff (Staff Member who is doing the enrollment)

8. Start Date is auto populated with today’s date.

Program Disenrollment-Mental Health

1. Select “Start Date” and input in mm/dd/yyyy format or choose from calendar.

2. Select” date of last contact” by selecting calendar or enter date in mm/dd/yyyy format.

3. Select the program staff who is dis-

enrolling user in program.

4. Termination Reason MHE Treatment completion at discontinuation: 1 = Completed/substantially completed 2 = Mostly completed 3 = Only partially completed 4 = Mostly not completed 5 = Does not apply (Evaluation only)

5. Select “Referral” for appropriate referral reason. Then “Save” then finish. ***Make sure an Outcome Measure has been done no more than 14 days prior to an Enrollment or Disenrollment.

Outcome Measures – Recovery Support Services

(RSS) (Fields in yellow are required for State reporting and must be completed prior to any program enrollment/disenrollment.) 1. Client Status -Date-Current Date -Type: Initial, Update or Final -Pregnant- Yes or No (*Note this field is grayed out if client is a male) Domains/Selected Domains- Recovery Support Services (RSS) 2. Education: -Enrolled in Education: Yes/No (Unknown not allowed) 3.Financial/Household: -Current Employment Status: employment status -Living Arrangement: -# of Children Under 18 Living/Not Living w/Client: # of children, age 17 or less, by birth or adoption.

Treatment Summary-RSS

Treatment Summary is the summary of services provided over the episode of care which includes

clinical information, program enrollment, and services rendered.

Treatment Summary contains:

• Treatment Summary • Program Enrollment • Services Rendered

Outcome Measures – ASAM-RSS

NOTE: An ASAM is not required for RSS Domain Outcome Measures. Fields that are not yellow are not required to be filled out.

Client Diagnosis–RSS

1. To add a diagnosis to the Behavioral Category, click “Edit Diagnosis” on the main Diagnosis screen.

a. Note: This replaces the old “Edit Axis Evaluation” link that used to be on the bottom of the diagnosis

2. “Effective Date” field will default to today’s date and time.

3. In the “Type” field, choose “Behavioral”.

a. Note: The principal diagnosis field defaults to “no”. b. By choosing the Type, the “Diagnosis” dropdown values will be limited to those your administrator has mapped to the Behavioral category. (These were formerly referred to as Axis I and Axis II.)

4. In the “Principal Diagnosis” field, choose ‘Yes”. The diagnosis will populate into the Behavioral Category on the grid. (If you wish to add Medical or Psychosocial/ Behavioral diagnoses, use the same steps, but simply select a different “Type”.)

5. Once the appropriate values have been selecedted, the option to “SAVE” which saves the diagnosis or “CLEAR” to clear the fields and start over.

Recording a Primary Diagnosis in UWITS

Program Enrollment-Recovery Support Services (RSS)

Program Enrollment will default to today’s date but is editable. Make sure an Outcome Measure has been done no more than 14 days prior to an Enrollment or Disenrollment.

1. .From the Navigation Panel, select ‘Program Enroll.’

2. Default program enrollment dates are set to the past 12 months. Additional criteria can be used to narrow search.

3. ADD Enrollments based on level of care and type of treatment (SUD or MH).

4. Select existing Enrollments to edit

using the icon. Program Enrollment will default to today’s date but is editable. Make sure an Outcome Measure has been done no more than 14 days prior to an Enrollment or Disenrollment.

5. Clear button clear the search criteria in fields. Go button allows you to search with the criteria specified in Program Name, Modality, Facility and Active Program Enrollments During Date range.

6. Select Program Name which is the Program the client will be Enrolling in.

7. Select dropdown for Program Staff (Staff Member who is doing the enrollment)

8. Start Date is auto populated with today’s date.

1. Select “Start Date” and input in mm/dd/yyyy format or choose from calendar.

2. Select the “Program Name” of

the Program the client will be unenrolling from.

3. Select the “Program Staff” dropdown of the staff who is unenrolling the client.

4. Select “Save” then finish.

HELPFUL HINTS A. Mover Boxes: Simultaneously press the Ctrl key and use your mouse to make multiple selections. Use the right (top) arrow located between the mover boxes to transfer the selected items from the left box to the right. Use the left (bottom) arrow to transfer information from the right box back to the left box. B. Substance Abuse Matrix: Once you have selected a substance, you must complete all yellow fields for Severity, Frequency, and Method to proceed in UWITS. Note: Please be sure to also document the corresponding “Age…” and “# of Days since First Use…” questions immediately below the substance matrix. C. Tobacco/Nicotine- A response of no to “Have you ever used Tobacco/Nicotine Products?” require any additional fields to be filled out. A response of yes to “Have you ever used Tobacco/Nicotine Products?” will then then require “Smoker Status” and “Age of first use.”

D. Pregnancy – Pregnancy field should be automatically grayed out and no if client is a male. Pregnant field with bright yellow indicates client is a female. If the option is no, then no other fields are required. If the option is yes, then “Due Date” field is required.

E. Co-Dependent-This field elates to a child whose parent is in treatment. Once the Codependent/Collateral field” is marked yes then the “Substance Abuse”, the “Rank Substance” fields not required. If “Codependent/Collateral field” is marked no, then all “Substance Abuse” fields will need to be filled out.