VHA/DoD Clinical Practice Guideline for the Management of Substance Use Disorders Audit Tool

These guidelines pertain to various delivery settings: Primary Care, Care Management, Addiction-Focused Pharmacotherapy (non-specialty care); Management in Specialty Care; and Physiologic Stabilization (medical care).

Topic	Criteria	Yes	No
Assessment and Management in Primary Care
Screening and assessment	The program obtains the following assessment data: history, physical examination, laboratory tests, mental status examination (MSE), and medication (including over-the-counter [OTC]).
	The program determines if the client is medically or psychiatrically unstable or acutely intoxicated prior to initiating treatment.
	The program provides appropriate care to stabilize the client's condition, orders appropriate consultations, and follows legal mandates.
	The program identifies clients who require clinical intervention related to their substance use beyond routine education and instructs them on relapse prevention.
	The program uses valid and reliable screening tools to identify substance use and abuse (AUDIT, CAGE TICS, DAST).
	The program identifies clients in further need of physiological assessment.
	The program staff presents assessment information to the client in a way that motivates ongoing cooperation with the provider and supports subsequent decisions about referral or brief intervention and the overall treatment approach.
	The program staff educates the client about substance abuse prevention to prevent the development of problematic alcohol or other drug use, abuse, and dependence (primary prevention) or resumption of problems following a period of remission.
Care Management
Care management	The program assesses the need for care management.
	The program begins care management in the setting most conducive to treatment engagement and management of co-morbid conditions.
	The program staff reassesses progress periodically as an opportunity to improve treatment effectiveness.
	The program staff assesses response to the care management plan and appropriateness of other follow-up options and determines if stable remission has been achieved.
	The program staff ensures follow-up with primary care staff as appropriate.
	The program staff educates the client about substance abuse prevention to hinder the development of problematic alcohol or other drug use, abuse, and dependence (primary prevention) or resumption of problems following a period of remission.
Addiction-Focused Pharmacotherapy
Screening and treatment	The program staff establishes that the client is opioid dependent.
	The program staff assures careful consideration of opioid agonist therapy (OAT) as the first-line treatment for opioid dependence.
	The program staff initiates or continues OAT by providing appropriate dosing and relapse monitoring to promote effective outcomes
	The program staff identifies clients who may benefit from naltrexone for opioid dependence.
	The program staff assures that the client is detoxified and opioid-free before continuing or initiating OAT and avoids precipitating an opioid withdrawal syndrome.
Management in Specialty Care
Treatment planning	The program staff ensures complete physiologic stabilization, if necessary, in order to assure patient safety and readiness to cooperate with further assessment.
	The program staff obtains a comprehensive biopsychosocial assessment that identifies the client's current problems, relevant history, and life context as a basis for the integrated summary and initial treatment plan.
	The program staff develops an integrated summary and initial treatment plan that integrates assessment information from various sources as a basis for formulating the diagnosis and treatment recommendations, followed by involvement of the client in prioritizing problems and negotiating the initial treatment plan (including individualized rehabilitation goals).
	The program staff provides motivational interventions and renegotiates the treatment plan to clarify and/or increase patient commitment to change and to address barriers in treatment progress toward rehabilitation goals.
	The program staff determines required intensity of treatment.
	The program staff identifies housing needs and access to treatment (transportation).
	The program staff initiates/continues OAT and initiates/continues treatment of coexisting problems (e.g., medical, psychiatric, family, vocational, and/or legal) and other compulsive behavior (e.g., gambling or spending).
Aftercare	The program staff creates a recovery plan in order to maximize the patient's chances for achieving his or her rehabilitation goals by summarizing, simplifying, and solidifying key recovery ingredients.
	Prior to discharge, the program staff arranges for the client's transition to primary care (if applicable) to ensure the provision of continuity of care and follow-up with primary medical or behavioral healthcare provider(s).
Physiologic Stabilization
Assessment	The program obtains the following assessment data: history, physical examination, laboratory tests, mental status examination (MSE), and medication (including over-the-counter [OTC]).
	The program determines if the client is medically or psychiatrically unstable or acutely intoxicated prior to initiating treatment.
Stabilization	The program provides appropriate care to stabilize the client's condition, orders appropriate consultations, and follows legal mandates.
	The program staff assesses the level of intoxication and/or physiological dependence to guide the patient's detoxification process.
	The program staff determines if there is clinical justification for prescribed opioid or sedative-hypnotic use.
	The program staff adjusts medications as necessary and continuously monitors the client's medical condition.
Follow-up to OAT	The program staff assesses the client's readiness for and willingness to engage in OAT.
TOTALS

Summary of Findings (summarize areas where adherence criteria were not met):

Opportunities for Improvement (summarize opportunities for improvement, including corrective action steps, accountability, and target completion dates):

Person Submitting Report: ____________________________________

Date Findings Reported to Quality Committee: __________________