6. Level 4: Continuum Of Care (Treatment)

6.1 Standard: Patient/Client assessment/treatment

6.1.1Standards statement

All patients/clients receive a comprehensive, accurate, timely assessment of their physical, psychiatric and psychosocial functioning and a regular review of such functioning.

6.1.2 Outcome

The subjection of all patients/clients to holistic assessment processes.

6.1.3 Programme practice

• Assessment of competencies: Assessments are undertaken by professional staff with the adequate mental health and social work skills and experience to undertake the prescribed components of the assessments.

Notes and examples: A medical or psychiatric diagnosis should not be made by an accredited addiction counselor.

• Intake assessment: Intake assessment/screening is undertaken by a medical practitioner within 24 hours, or, in the case of patients/clients admitted with alcohol, benzodiazepine or opiate dependency, within 8 hours of admission.

The assessment includes:

• a)Personal details and brief personal history.
• b)Mental state examination, including intoxication status and needs.
• c)Physical examination and history of medical conditions, including tests to facilitate evaluation.
• d)Brief history of substance abuse (and other mental health problems).
• e)Provisional psychiatric history and diagnosis.
• f)Assessment of risk potential (i.e. for suicide and other forms of self- harm) and specifications for detoxification (if offered)

Comprehensive assessment: A comprehensive assessment is undertaken in a timely manner by qualified and experienced professionals.

The assessment includes:

• Psychiatric and physical assessment and diagnosis, with special reference to any co-morbid conditions.
• Comprehensive psychosocial, developmental and functional assessment including an evaluation of the patient’s/client’s social situation (e.g. family, employment, housing and legal situation) and vocational and developmental needs (especially in the case of adolescents/children and the elderly).
• Referral for a more in-depth psychological, social work, psychometric or physical evaluation, as appropriate.
• Provisional treatment goals and prognosis.
• Psychiatric diagnosis: Identified patients/clients receive as part of the comprehensive assessment a psychiatric diagnosis, according to DSM-IV or ICD 10, made by an appropriately qualified and experienced professional staff member. All psychiatric diagnoses are provisional until they have been reviewed by the psychiatrist and the interdisciplinary team.
• Specialist and team review: The results of each patient’s comprehensive assessment are reviewed by a case manager and the centre’s multidisciplinary team.
• Documentation: The assessments are recorded in the patients’/clients’ case records in a timely and accurate manner.
• Assessment panel: The results of the comprehensive assessment and the treatment plan are presented and discussed at case conferences. This occurs within the first ten days of admission.
• Patient/Client feedback: Patients/Clients receive feedback during the assessment process on the results of the process.
• On review of progress: A formal review of the patients’/clients’ treatment progress (including psychiatric status) is done weekly by the multidisciplinary team Multidisciplinary team. The review is made available weekly by the case manager and monthly by the Multidisciplinary team.

6.1.4 Management actions

Policy and procedures: Documented, up-to-date policies and procedures support, monitor and regulate the assessment and review process.

Patients/Clients may submit reasons to the multidisciplinary team for a change in case manager should they be dissatisfied with therapeutic relationship or the counselling provided. (Management ensures that patient are given this option.) Management attends to letters written by patients/clients in this regard.

6.2 Individualized treatment planning (IDP)

6.2.1 Standards statement

All patients/clients have a documented, individualized treatment plan that encourages their participation, motivation and recovery.

6.2.2 Outcome

Treatment plan: All patient/clients have an individualized treatment plan/programme.

6.2.3 Programme practice

• Informed consent and information: Informed consent is sought from all patients/clients prior to the onset of any treatment. Patients/Clients are given the opportunity, as far as possible and appropriate, to make choices regarding their care and are provided with adequate information on the specific treatment (e.g. medication used) and risks, benefits and options of the treatment offered.

Notes and examples. See relevant legislation for the rights of children under 18 years to provide Informed consent

• Health promotion/prevention: The centre seeks to promote optimal patient/client health and well-being and to prevent the onset and negative impact of health and mental health/substance-related problems among patients/clients (and their families and caregivers). The following is included:
  • a) Information and practical support to maintain a healthy, alcohol and drug-free lifestyle (e.g. exercise, better nutrition, stress management).
  • b) Information and practical support to prevent the onset and spread of HIV/AIDS and other sexually transmitted and infectious diseases (e.g. voluntary testing, counselling and education regarding needle use and exchange).
  • c) Access to reproductive health care and support of pregnant patients/clients.
  • d) Access to nutritional support and supplements for chronic alcohol- dependent patients/clients.
• Individual treatment selection: Treatment is selected for all patients/clients according to the nature of their substance addiction/dependency and/or other psychiatric or psychological conditions (symptoms, severity and history), their personal preferences, strengths and characteristics, and their social needs and circumstances
• Care plan: Based on the comprehensive assessment, a written individual treatment plan or provisional development treatment plan is developed in partnership with the patients/clients and recorded. The plan contains the following:
  • a) Clear and concise statement of the patients’/clients’ current strengths and needs.
  • b) Clear and concise statements of the short- and long-term goals the patients/clients are attempting to achieve.
  • c) Type and frequency of therapeutic activities and treatment programme in which the patients/clients will be participating.
  • d) Staff responsible for the patients’/clients’ treatment and their individual counsellor.
  • e) The patients’/clients’ responsibilities and commitment to the rehabilitation process.
  • f) The plan is dated and signed by the individual counsellor and the patient; a copy of the plan is given to the patient/client.
• Participation: As far as possible, patients/clients (and their families and caregivers, as appropriate) participate in the development and regular review of the treatment plan and referring agencies to ensure that family reconstruction services are rendered while the patients/clients are still in the treatment programme.

6.2.4Management actions

• Treatment standards: All treatment offered is safe and evidence based and reflects internationally accepted standards.

Notes and examples. This includes any homeopathic or complementary therapies offered at the centre (e.g. aromatherapy and hypnotherapy). These therapies may only be used as prescribed by the medical doctor or psychiatrist. All alternative therapy practitioners should be officially registered end recognized by the appropriate statutory body.

• Case manager: All patients/clients are assigned a case manager who is a professional staff member or addiction counsellor. Basic requirements here are the following:
  • a) The individual counsellor is responsible for assisting patients/clients to develop their treatment goals (and other individual treatment tasks), for providing regular documented support and motivation, and for acting as a liaison person for other families and caregivers and role players.
  • b) The individual counsellor meets weekly with the patient/client for a minimum of 30 minutes.
  • c) The individual counsellor is reasonably accessible to patients/clients for support and crisis intervention (i.e. outside of fixed counselling sessions).
  • d) The centre stipulates the optimum and maximum case load for each individual counsellor (e.g. 20 patients/clients) – the ratio is 1:15 for short-term treatment programmes and 1:20 for long-term treatment.

6.3 Standard: Pharmacotherapy and medical care

6.3.1 Standard statement

Medication and other medical care are provided in a timely, accessible and expert manner in accordance with professional and statutory requirements and patient/client safety.

6.3.2 Outcome

Medical coverage: Routine medical and mental health care is available through employed or contracted medical and mental health professionals.

6.3.3 Programme practice

• Medical coverage: Emergency medical and mental health care is available to patients/clients 24 hours a day, 7 days a week (e.g. through telephonic consultation with a medical doctor (e.g. a psychiatrist) and/or access to emergency services).
• Clinical/Case record: A medication record, with appropriate signatures, is kept in the patients’/clients’ case records in accordance with statutory regulations. This includes at least the
  • a) name of the medication,
  • b) method of administration,
  • c) dose and frequency of administration,
  • d) name, date and signature of prescribing doctor,
  • e) name, date and signature of person administering or dispensing drug.

Notes and examples: Refer to the Pharmacy Act (No. 53 of 1974) regarding the prescribed method of recording the use of schedule 6 and 7 drugs This includes additional requirements such as the doctor’s qualifications and the written names of the drugs and written doses.

• Medicine administration: Medication is administered only by a registered professional nurse or medical practitioner according to the documented instructions of the attending doctor/psychiatrist. Self- administration of prescribed medication is observed by or is done under the supervision of such registered staff members.
• Medicine-related monitoring: Patients/Clients are carefully monitored by professional staff to prevent and/or respond promptly to adverse effects of prescribed and non-prescribed medication.

Notes and examples: Adequate review of the patients’/clients’ condition and treatment should take place to ensure prompt response to signs of adverse effects and side-effects.

• Medicine storage and disposal: Storage and disposal of medicines comply with current legislation (i.e. storage of schedule 5, 6 and 7 medicines). Medicine prescribed for one patient/client may not be administered to or allowed to be in the possession of another patient/client.

Notes and examples: All medicines should be kept in locked storage and all controlled substances in a locked box in a locked cabinet. Medicines that require refrigeration should be kept in a refrigerator separate from food and other Items. All unused prescription drugs prescribed for residents should be destroyed by the person responsible for medicines, and such destruction should be witnessed and noted in the patients’/clients’ case record.

Emergency equipment: Emergency and first-aid equipment and medicines in good condition are available, and staff are skilled and equipped to use/administer them.

Medicine records: Records for medicines are accurately maintained according to statutory requirements (e.g. requisition books, register of controlled substances and schedule 5, 6 and 7 substances).

Prescriptions

All patients/clients receive an initial intake assessment (i.e. face-to-face examination) by a medical doctor or psychiatrist before any medicines are prescribed.

Notes and examples: Telephonic prescriptions.

• Medical waste storage and disposal: The centre stores and disposes of medical waste (e.g. syringes and unused medicines) according to current statutory requirements.

6.3.4 Management actions

• Prescriptions: Adequately skilled clinical staff (medical doctors or psychiatrists) are available to evaluate the need for and to prescribe medication in accordance with statutory and centre regulations and policy/procedures.

Notes and examples: Telephonic prescriptions for patients/clients prior to an examination by a doctor/psychiatrist are not acceptable practice.

• Continuity of care: No patients/clients are prevented from continuing with appropriate treatment prescribed prior to admission.
• Policy and procedures: Documented, up-to-date policies and procedures are used to regulate pharmacotherapy and medical care. They include the following:
  • a) Medicine prescriptions according to schedules and including the use of self-administered, over-the-counter drugs (e.g. cough syrups).
  • b) Intoxication and overdose.
  • c) Detoxification and voluntary withdrawal.
  • d) An up-to-date list of staff qualified and authorized to prescribe and administer drugs.
  • e) Medicine administration, including timing, venues and supervision.
  • f) Storage, control, accountability, inspection and documentation of medicines (according to statutory and professional requirements).
  • g) Monitoring of adverse reactions and medication errors.
• Treatment protocols: Documented, up-to-date and scientifically based treatment protocols of established safety and efficacy are used to regulate, monitor and support clinical regimes, including the following:
  • a) Polydrug usage and related complications.
  • b) Intoxication and overdose.
  • c) Detoxification regimes based on type of substance/s abused (including medicine dosage, administration and frequency of administration, patient/client care and monitoring, and required equipment) (type A centres only).
  • d) Assessment and management of HIV/AIDS, tuberculosis and hepatitis.
  • e) Emergency procedures. The development of treatment protocols is the responsibility of the Department of Health and not that of the centre.

Notes and examples: It is not the treatment centre’s responsibility to develop treatment protocols; rather, these protocols should be developed by national and provincial health departments (in collaboration with the Department of Social Development). Centres should approach their provincial Department of Health for relevant protocols.

• Detoxification
• Essential components: For centres that render detoxification services, detoxification (including voluntary withdrawal) occurs according to written policies and procedures. All components of care are available from centres that render detoxification services. Detoxification takes place according to detoxification policy. Components of such policy include
  • a) staff with an informed, non-punitive, non-judgmental and supportive approach to detoxification;
  • b) assessment;
  • c) 24-hour professional nursing and easily accessible medical backup;
  • d) standardized, official, best practice detoxification protocols;
  • e) patient/client information and explanation (i.e. the likely course of withdrawal, length and intensity of symptoms, support and treatment to be offered and associated risks);
  • f) patient/client participation and informed consent in detoxification decision- making process;
  • g) a documented, individualized detoxification treatment plan (including referral if required) based on detoxification protocols, the patients’/clients’ individual needs and preferences and the centre’s capacities;
  • h) a safe, quiet and comfortable space for the detoxification process;
  • i) adequate monitoring and supportive care;
  • j) pharmacotherapy (as per protocol for medicated detoxification) including adequate, individual-specific, prescribed medicines;
  • k) emergency care and equipment, including referral to hospital, if required;
  • l) feedback and support to family and caregivers, if appropriate.

6.4 Structured treatment programmes and daily activities

6.4.1 Standard statement

Patients/Clients participate in a structured treatment and rehabilitation programme that effectively and safely addresses treatment goals and is supported by appropriate activities and routines.

6.4.2 Outcome

A formal treatment and rehabilitation programme that addresses patients/clients’ needs.

6.4.3 Programme practice

Treatment and rehabilitation programme

• Programme models/philosophy: A formal treatment and rehabilitation programme is regularly reviewed and updated in accordance with internationally accepted standards.

Notes and examples: The treatment and rehabilitation programme describes structured weekly and daily activities and individual and group counselling/therapies; and in a time-limited programme (e.g. 3 weeks to 6 months) it also describes programme goals or stages.

• Programme content: The structured programme consists of group counselling/therapies, opportunities for individual and family therapies/counselling, and organized group activities such as sport, health education (e.g. HIV/AIDS), recreation and creative activities.

Notes and examples: Individual and group therapies may be psychotherapeutic, life skills (e.g. anxiety management, social skills training, problem solving and goal setting), self-help, and psychoeducational (e.g. drug information and relapse prevention).

• Programme duration: The duration of the treatment programme offered by the centre is a minimum of 40 hours a week, which includes therapeutic/counselling sessions.

Notes and examples: This can take place as a component of the structured treatment programme (e.g. psychoeducational groups) and individual and family therapy/counselling.

6.4.4 Management actions

Programme communication and participation: The treatment programme and daily activities/expectations are documented and communicated to patients/clients (and families and caregivers). Appropriate opportunities exist for patients/clients to participate in decision making on the daily activities and other issues that affect the centre and patient/client community.

Notes and examples: This can include orientation information, posters and regular staff/patient meetings.

• Daily activities
• Policy and procedures: The centre has documented policies and procedures that it implements to regulate and guide daily activities at the centre. These policies cover the following:
  • a) Patient/Client waking and sleeping times.
  • b) Telephone use for private conversations.
  • c) Visits from families and caregivers, friends, religious leaders and legal counsel.
  • d) Visits and outings beyond the centre.
• Patients/Clients labour: Patients/Clients may be involved in non- exploitative work/labour (including vocational skills training) activities (e.g. meal preparation, cleaning of residential facilities) for no longer than four hours a day.

Notes and examples: All work and vocational activities should support patients’/clients’ rehabilitation needs and individual treatment goals.

• Meals: Patients/Clients are given a minimum of three nutritious meals a day. If patients/clients are allowed to participate in preparing meals, this must be according to documented patient/client labour policies, health regulations and food hygiene.
  • a) The centre should have proof of regular inspection and certification of the kitchen and food preparation area(s) from the local authority environmental health officers.
  • b) Nutritionists from the provincial health department should review menus and meal quality regularly.

6.5 Standard: Release, readmission and aftercare

6.5.1 Standard statement

Patients/Clients can be provided with appropriate programmes and support to enable their effective transition from a treatment centre to their families and their integration into their communities.

6.5.2 Outcome

Patients/Clients who are fully prepared to participate in after care programmes in their communities.

6.5.3 Programme practice

• Discharge assessment and review: All patients/clients are assessed and reviewed by the mult-disciplinary team at an appropriate time in their treatment to determine their potential for release and to facilitate release planning.
• Release documentation: Relevant referral agents are timeously supplied with a confidential signed and dated release report to facilitate continuity of care for all patients/clients leaving the centre. A copy of this report is kept in the patients’/clients’ case records. The summary includes:
  • a) Patients’/Clients’ personal details.
  • b) A brief summary of their personal history and family/social background.
  • c) A brief summary of the treatment plan and progress/participation at the centre.
  • d) Reason for release (e.g. completed programme or non-compliance).
  • e) An outline of their aftercare needs and preferences (release plan).
• Aftercare: Prior to release, the centre ensures adequate referral and linking of the patients/clients to their original referral social workers, local community services and self-help groups.

Notes and examples: Wherever possible, patients/clients are given an initial appointment date, address and contact name and number at their local community clinic or CHC and/or at an NGO or other support agency.

Release information: Release information is provided for all patient/client families and caregivers, as appropriate, on release or expulsion.

This includes:

• Details and precautions/guidance on any prescribed medicines at release are not provided. And where inadvisable, e.g. in the case of an addicted person, alternative arrangements must be made, e.g. making a family member responsible for collection of the medication.
  • b) Names and details of aftercare referrals/sources (e.g. local AA branch).
  • c) Names and details of emergency and contact sources for crisis intervention associated with relapse prevention.
  • d) Procedure for readmission to the centre, if sought.
• Caregiver support and information: Families and caregivers are assisted in planning and anticipating the patients’/clients’ release and return to their homes and communities from the onset of inpatient/client care. They are also informed, whenever possible, when patients/clients are to be released, expelled or if they have absconded.
• Relapse prevention: Prior to release, the patients/clients (and their families and caregivers, as appropriate) are provided with information, support and counselling to assist with relapse prevention.

6.5.4 Management actions

• Legislation: Release, expulsion, aftercare and readmission occur in line with current relevant legislation.
• Policy and procedures: Documented policies and procedures are available to guide and regulate release and readmission to the centre. These policies cover:
  • a) Release planning, procedures and related documentation.
  • b) Expulsion from the centre due to serious violation of rules and regulations (e.g. possession of harmful substances or weapons, sexual harassment, violence or repeated threats of violence and substance abuse).
  • c) The release and transfer of patients deemed to be unsuitable for the centre.
  • d) The release of adolescents and children without parental consent
• Expulsion: The criteria and procedures for expelling patients/clients are clearly communicated to patients/clients and their families/caregivers. Patients/Clients have access to a fair investigation and hearing to determine their culpability when expelled for the violation of centre rules and regulations, where appropriate and feasible.
• Transfer and referral: Defined and documented criteria and procedures exist for referring patients/clients in need of alternative services (e.g. outpatient/client treatment) and/or more contained or medically managed care should this be indicated (e.g. detoxification, adverse drug reactions, attempted suicide, emergency medical care and psychosis).

Notes and examples: Patients/Clients who have been transferred to a more contained or specialist health or mental health facility due to the severity or existence of a co-morbid condition may only be considered for readmission to the centre with the written permission (based on an assessment of their stability and the centre’s resources) of a registered health or mental health worker

Self-release Mechanisms exist for patients/clients to release themselves voluntarily at any stage in their treatment unless judged to be a danger to themselves or are legally committed. The centre staff should be satisfied that patients/clients are mentally fit to make such a decision and the consequences of self-release are clear.

• Release planning: The release plans are developed and reviewed in collaboration with patients/clients and with the patients’/clients’ informed consent and that of their families and caregivers. A copy of these plans are kept in the patients’/clients’ case records.
• Readmission: The centre has policies and procedures to support the readmission of appropriate patients/clients. The treatment goals and programme for readmitted patients/clients is clearly stipulated in accordance with their treatment needs.

Staff records: All staff have up-to-date, confidential personal records.