Code of Maine Rules › 14 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 193 - OFFICE OF ADULT MENTAL HEALTH › Chapter 2 - RULES GOVERNING ESSENTIAL STANDARDS AND BASIC PRINCIPLES REQUIRED OF CERTAIN ASSERTIVE COMMUNITY TREATMENT TEAMS FOR PARTICIPATION IN THE PROGRESSIVE TREATMENT PROGRAM › Appendix 193-2-B - Progressive Treatment Program Initial Self Assessment

Current through 2024-29, July 17, 2024
The ACT Team wishing to be certified to provide community
				  involuntary treatment services
must
complete this
				  form.
ACT Team: Date:
1. Please list
all
staff currently
				  working on ACT team.
Name of Person Position Title FTE for this
				  Person
20.
				  ______________________________________________________________________
21.
				  ______________________________________________________________________
22.
				  ______________________________________________________________________
23.
				  ______________________________________________________________________
24.
				  ______________________________________________________________________
25.
				  ______________________________________________________________________
26.
				  ______________________________________________________________________
27.
				  ______________________________________________________________________
28.
				  ______________________________________________________________________
29.
				  _____________________________________________________________________
30.
				  _____________________________________________________________________
31.
				  _____________________________________________________________________
32.
				  _____________________________________________________________________
33.
				  _____________________________________________________________________
34.
				  _____________________________________________________________________
(If you need additional space, please add more
				  sheets)
2. Currently, how many recipients does the team serve"
				  ________________
3. During the last two weeks, how many ACT recipients saw
				  more than one member of the team" ____________
4. How often does the ACT team meet as a full group to review
				  services provided to each recipient" _____________ times/week
5. How many ACT recipients are reviewed at each meeting"
				  _______________
6. Does the ACT team leader provide direct services to ACT
				  recipients" Yes _________ No ________
6a. During the past two weeks, on average, how many hours per
				  week did the ACT team leader provide direct services" _______________
7. How many team members left in the past 2 years"
				  _______________
8. How many have been on leave for more than 1 month during
				  the last 12 months" _______________________
8a. When did this leave begin and end"
				  __________________________________________________
9. Does your Substance Abuse Specialist have . . .
9a. Over 1 year of SA clinical experience" Yes
				  _________________ No _________________
9b. Over 1 year of training in SA treatment" Yes
				  ________________ No __________________
10. Does the ACT team assist with housing" Yes
				  _______________ No __________________
11. Does the ACT team assist with Psychiatric services" Yes
				  _____________ No _____________
12. Does the ACT team assist with Counseling and
				  Psychotherapy" Yes _____________ No _____________
13. Does the ACT team assist with Substance Abuse treatment"
				  Yes ____________ No _____________
___
14. Does the ACT team assist with Employment/Rehabilitative
				  services" Yes _______________ No ______________
1. What is the ACT team's role in providing 24-hour emergency
				  services"
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
15a. Is there a team member on call 24/7"
Yes ________________ No ________________
Notes/Comments:
				  _________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
15b. Do team members get emergency call information from the
				  Agency's crisis line"
Yes _________________ No __________________
Notes/Comments:
				  _______________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
15c. Does the ACT team have direct involvement during
				  after-hours crisis"
Yes __________________ No _______________
Notes/Comments:
				  _______________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
35. How many individuals receiving ACT services have a
				  substance use disorder" ___________
36. Of these individuals, how many address this by including
				  individual counseling in the treatment plan"
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
17a. Does one or more of the ACT team members provide
				  individual substance abuse counseling for those individuals" If yes, when"
				  _______________________________________________________________
______________________________________________________________________________
37. How many individuals with substance use disorder attend a
				  dual disorder treatment group" __________
_________________________________________________________________________________
38. Do these groups focus on integrated treatment"
				  _____________________________________
39. What is the treatment model used to treat individuals
				  with substance abuse problems" _________
________________________________________________________________________________
________________________________________________________________________________
40. Do you refer people to AA"
				  _______________________________________________________
________________________________________________________________________________
41. Detox programs"
				  ______________________________________________________________
________________________________________________________________________________
42. Does your team employ harm reduction tactics"
				  _____________________________________
_______________________________________________________________________________
23a. Some examples"
				  ____________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
43. How does your team view abstinence versus reduction of
				  use" _________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
44. Are you familiar with a stage-wise approach to substance
				  abuse treatment" _______________
________________________________________________________________________________
_______________________________________________________________________________
________________________________________________________________________________
45. Does the team use this approach"
				  _______________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
______________________________________________________________________________
46. Can you give some examples of how your program uses this
				  approach" ________________
____________________________________________________________________________
_____________________________________________________________________________
______________________________________________________________________________
Return this form by mail to:
OAMHS - PTP
Department of Health and Human Services
SHS # 11
Marquardt Bldg., 2nd Floor
Augusta, ME 04333
Or e-mail form to:
DHHS.OAMHS-PTP@maine.gov
FIDELITY MEASURES: PTP INITIAL SELF
							 ASSESSMENT
Fidelity Measure-HR Structure &
							 Composition
Progressive Treatment Plan (PTP)
							 Application
H1
Small Caseload: Client/Provider Ration of
							 10:1
1. Please list
all
staff
							 currently working on ACT team. (Name of person, Position Title, FTE for this
							 Person).
2. Currently how many recipients does the team serve"
H2
Team Approach: Provider group functions as team rather
							 than as individual practitioners; clinicians know and work with all clients.
3. During the last two weeks, how many ACT recipients
							 saw more than one member of the team"
H3
Program Meeting: Program meets frequently
							 to plan and review services for each client.
4. How often does the ACT team meet as a full group to
							 review services provided to each recipient"
5. How many ACT recipients are reviewed at each
							 meeting"
H4
Practicing Team Leader: Supervisor of
							 front line clinicians providers direct services.
6. Does the ACT team leader provide direct services to
							 ACT recipients"
6a. During the past two weeks, on average, how many
							 hours per week did the ACT team leader provide direct services"
H5
Continuity of Staffing: Program maintains same
							 staffing over time.
7. How many team members left in the past 2 years"
Staff Capacity: Program operates at full
							 staffing.
8. How many have been on leave for more than 1 month
							 during the last 12 months"
8a. When does this leave begin and end"
H9
Substance Abuse Specialist on Staff: A
							 100-client program includes at least two staff members with one year of
							 training or clinical experience in substance abuse treatment.
9. Does your Substance Abuse Specialist have...
9a. Over 1 year of SA clinical experience"
9b. Over 1 year of training in SA treatment"
Fidelity Measure-Organizational Boundaries
Progressive Treatment Plan (PTP)
							 Application
O3
Full Responsibility for Treatment
							 Services: In addition to case management, program directly provides psychiatric
							 services, counseling/psychotherapy, housing support, substance abuse treatment,
							 employment/rehabilitative services.
10. Ford the ACT team assist with housing"
11. Does the ACT team assist with Psychiatric
							 services"
12. Does the ACT team assist with Counseling and
							 Psychotherapy"
13. Does the ACT team assist with Substance Abuse
							 Treatment"
14. Does the ACT team assist with
							 Employment/rehabilitative services"
O4
Responsibility for Crisis Services:
							 Program has 24-hour responsibility for covering psychiatric crises.
15. What is the ACT team's role in providing 24-hour
							 emergency services"
15a. Is there a team member on call 24/7"
15b. Do team members get emergency call information
							 from the Agency's crisis line"
15c. Does the ACT team have direct involvement during
							 after-hours crisis"
Fidelity Measure-Nature of Services
Progressive Treatment Plan (PTP)
							 Application
S7
Individualized Substance Abuse Treatment:
							 One or more members of the program provide direct treatment and substance abuse
							 treatment for clients with substance use disorders.
16. How many individuals receiving ACT services have a
							 substance use disorder"
17. Of these individuals, how many address this by
							 including individual counseling in the treatment plan"
17a. Does one or more of the ACT team members provide
							 individual substance abuse counseling for those individuals" If yes, when"
S8
Dual Disorder Treatment Groups: Program
							 uses group modalities as a treatment strategy for people with substance use
							 disorders.
18. How many individuals with substance use disorder
							 attend a dual disorder treatment group"
19. Do these groups focus on integrated treatment"
S9
Dual Disorders (DD) Model: Program uses a
							 stage-wise treatment model that is non-confrontational, follows behavioral
							 principles, considers interactions of mental illness and substance abuse, and
							 has gradual expectations of abstinence.
20. What these groups focus on integrated treatment"
21. Do you refer people to AA"
22. Detox programs"
23. Does your team employ harm reduction tactics"
23a. Some examples"
24. How does your team view abstinence versus
							 reduction of use"
25. Are you familiar with a stage-wise approach to
							 substance abuse treatment.
26. Does the team use this approach"
27. Can you give some examples of how your program
							 uses this approach"