A diagnostic/comprehensive clinical assessment (CCA) is a clinical evaluation performed by a licensed provider to:
Assess the individual's presenting mental, developmental disability, and/or substance abuse conditions and symptoms.
Assist the clinician in gathering the information essential to arriving at a clinical diagnosis and forming a clinical opinion about a recommended course of action in terms of services, support and treatment.
Determine whether an individual is appropriate for and can benefit from services.
A licensed physician is available for evaluations and medication management.
Medication and system education, monitoring and management are primary areas of focus as the Doctor and individual partner to reach the individual's desired treatment outcomes.
Please refer to the psychiatric services operations manual for information on how such services are provided operationally.
Targeted Case Management (MH/SA TCM) is a service for adults and children age 3 (three) and older who have a serious emotional disturbance, mental illness, or substance related disorder and for recipients who have a serious emotional disturbance, mental illness, or substance related disorder and are pregnant. The MH/SA case manager is required to coordinate and communicate with Community Care of North Carolina (CCNC)(if the recipient is enrolled in CCNC), the recipient's primary care physician, and the recipient's OB/GYN as necessary. CCNC and the primary care physician shall be responsible for coordination of the recipient's overall health care. Targeted case management (MH/SA TCM) is an activity that assists recipients to gain access to necessary care: medical, behavioral,, social and other services appropriate to their needs. Case management is individualized, person centered, empowering, comprehensive, strengths-based, and outcome-focused.
Outpatient behavioral treatment includes a wide variety of programs for patients who visit a behavioral health counselor on a regular schedule. Most of the programs involve individual behavioral modification or group session, or both.
The Intensive In-Home (IIH) service is a team approach designed to address the identified needs of children and adolescents who, due to serious and chronic symptoms of an emotional, behavioral, or substance use disorder, are unable to remain stable in the community without intensive interventions. This service may only be provided to beneficiaries through age 20. This medically necessary service directly addresses the beneficiary’s mental health or substance use disorder diagnostic and clinical needs. The needs are evidenced by the presence of a diagnosable mental, behavioral, or emotional disturbance (as defined by DSM-5, or any subsequent editions of this reference material), with documentation of symptoms and effects reflected in the Comprehensive Clinical Assessment and the Person-Centered Plan (PCP).
CST services consist of community-based mental health and substance abuse rehabilitation services and the necessary support provided through a team approach to assist adults in achieving rehabilitative and recovery goals. It is intended for individuals with mental illness, substance abuse disorders, or the combination of both who have complex and extensive treatment needs. CST is designed to reduce presenting psychiatric or substance abuse symptoms and promote symptom stability, restore the individual’s community living and interpersonal skills, provide first responder intervention and deescalate the current crisis, and ensure linkage to community services and resources.
Substance Abuse Intensive Outpatient Program (SAIOP) for Youth and Adults means structured individual and group addiction activities and services that are provided at an outpatient program designed to assist adult and adolescent beneficiaries to begin recovery and learn skills for recovery maintenance. The program is offered at least 3 hours a day, at least 3 days a week, with no more than 2 consecutive days between offered services, and distinguishes between those beneficiaries needing no more than 19 hours of structured services per week (ASAM Level 2.1). The beneficiary must be in attendance for a minimum of 3 hours a day in order to bill this service. SAIOP services shall include a structured program consisting of, but not limited to, the following services: a. Individual counseling and support; b. Group counseling and support; c. Family counseling, training or support; d. Biochemical assays to identify recent drug use (e.g. urine drug screens); e. Strategies for relapse prevention to include community and social support systems in treatment; f. Life skills; g. Crisis contingency planning; h. Disease Management; and i. Treatment support activities that have been adapted or specifically designed for beneficiaries with physical disabilities; or beneficiaries with co-occurring disorders of mental illness and substance use; or an intellectual and developmental disability and substance use disorder. SAIOP can be designed for homogenous groups of beneficiaries e.g., pregnant women, and women and their children; individuals with co-occurring mental health and substance use disorders; individuals with human immunodeficiency virus (HIV); or individuals with similar cognitive levels of functioning. Group counseling shall be provided each day SAIOP services are offered.
The expected outcome of SAIOP is abstinence.
Secondary outcomes include: