A Division of the Office of Substance Abuse Data System

TDS Web Based Training

a division of the Office of Substance Abuse Data System OSADS

Office of Substance Abuse 41 Anthony Ave Augusta, ME 04333-0011

Last Updated: February 13, 2009 Prepared by FEI.com Inc, for the Staff of the Office of Substance Abuse

Stacey M. Chandler, Data Specialist, Data & Research Team

Debra Brucker, MPA, PhD., Supervisor, Data & Research Team 1.Lesson 1: Chapter 1-Susans Story 1.1. Chapter 1 – Disclaimer (Screen 1/12)

The characters and events depicted and the names herein are fictitious. Any similarity to any person living or dead is entirely coincidental and unintentional.

This chapter contains audio portions that require a computer system that is audio capable. Check your system's audio settings and speaker volume levels before beginning, and please use head phones when appropriate. 1.2. Chapter 1 – Meet Susan (Screen 2/12)

Hi, I’m Susan. Telling you this story is one of the hardest things I’ve ever done. Well, actually kicking my drug habit is probably the hardest, but I’m getting ahead of myself. You see, I just can’t believe that I got myself into such a mess. I’m so thankful there were people to help nearby, and that’s why I’m willing to tell you my story.

I live with my two kids in that small house right over there, right outside of Calais. Since my husband left us three years ago, it’s been rough, but we manage. Most of the time, anyway.

But that year, my baby had been sick. I missed so much work, and my boss kept telling me I couldn’t miss any more. But the daycare won’t take sick kids --- It just seemed like things kept getting harder, you know? The price of everything goes up, more than the money you bring home. Sometimes, I just couldn’t figure out how to hold it all together for my kids. 1.3. Chapter 1 – Mounting Problems (Screen 3/12)

When you’re down, sometimes it feels like life kicks you. I had pressure from my boss, and it just didn’t let up. Thank God my baby will be okay, but the bills that piled up. I don’t get any health insurance at the factory, and doctors and medicine sure can add up. It was eating away at my paycheck. That made it hard to pay the rent, gas prices were going up, oh, you know the story. 1.4. Chapter 1 – More Problems (Screen 4/12)

Then that no-good ex-husband started calling and talking about custody. Why does he care after three years? I didn’t need that, and it made me so anxious I couldn’t even sleep most nights.

One day my friend Marcy showed me some pills she had. Her boyfriend had had surgery, and the doctors gave him the pills to help his pain. She called it OxyContin, and she knew how to get more.

She said taking one once in a while would make me feel better. I wasn’t so sure about it, but as Marcy said, it is a prescription. I put some in my pocket to make her happy. I didn’t think I’d ever really take them. 1.5. Chapter 1 – A Bad Day (Screen 5/12)

One evening after a really bad day at work, my ex called again. We had a huge fight and he threatened to come and take my kids. He’s a little scary, and I wouldn’t put it past him. And then my landlord banged on the door to remind me my rent is two months behind. As if I could forget!

I’ve always paid my bills on time, but the money – there just never seems to be enough. The cable’s been shut off and the phone company threatens. How will I raise these kids and give them a better life if I can’t hold it together?

I reached into my pocket and found – you guessed - those pills. I had totally forgotten they were there. I set them on the counter and just looked at them. Marcy said they would lift the weight, and the weight was heavy. Would it hurt to take just one? Would it really matter – just one? 1.6. Chapter 1 – Taking OxyContin (Screen 6/12)

So I took it. And guess what? I felt better, happier, more relaxed! Wow, I hadn’t felt that good in a very long time. It’s like all the problems of the world melted away. All from one little pill.

I went to bed feeling peaceful, and I slept like a baby that night. I know now that the drug has that effect on your brain, but it doesn’t last long. Unfortunately, it took me a while to figure out that this peace was only temporary. 1.7. Chapter 1 – Getting More OxyContin (Screen 7/12)

Yeah, you guessed right. The next day, the stress was back. Of course, this time it was a little easier to justify another pill.

Before I knew it, I was hooked. I couldn’t get through my day without them. But I felt good – I thought I could handle things. I ran out of the drugs Marcy gave me pretty quickly, but she showed me how to get more – doctors who would prescribe it, even people in our neighborhood who sold it. It was expensive, but I needed it.

Looking back, I can see how crazy it was – trying to get more OxyContin when I had no money for my rent, or for things my kids needed. But I thought it made me feel better. It sure seemed to help with the burdens of barely making it. Even when I needed more of it to get the same high, I still thought it was the answer to my problems. 1.8. Chapter 1 – Addicted! (Screen 8/12)

I was an addict. I'm a nice person, with a decent job and two great kids. But I was still an addict.

Before I knew it, I couldn’t take care of my kids. Once, I left them at the day care by mistake because I passed out in my bedroom. People were calling and I didn’t even hear them.

I sure didn’t play with my kids, and I started to miss work. My boss wasn’t happy about that, and he told me if I couldn’t straighten up, I would lose my job. 1.9. Chapter 1 – Out of Money (Screen 9/12)

Out of money, I tried to shoplift some things we needed and, wouldn’t you know, I got caught.

The last straw came when my ex started up the custody fight again. Only this time, he started using my behavior and addiction as weapons against me. That’s the day I looked at myself in the mirror, and realized I had to get help. 1.10. Chapter 1 – Seeking Assistance (Screen 10/12)

I called a number in the phone book and made an appointment.

The people at the office were nice, and asked me questions about myself and my problems. Then they told me that a new treatment center had opened right in our town. They told me that a year ago, I would have had to drive all the way to Bangor for the same treatment.

Imagine! How in the world could I ever do that, and still hold down a job? Since the treatment place was nearby, I was able to go every day and get the help I needed to get better. 1.11. Chapter 1 – A Local Choice (Screen 11/12)

You know what I learned from being in treatment? That many people didn’t want this facility to be built.

The counselors told me that they collected lots of information about addictions and the drugs that people use all over Maine. Then they used that information to convince people in this area that a clinic was a really good idea.

And that’s why I’m telling you my story, ‘cause I’m so grateful to be able to get the help I need without driving all the way to Bangor and back every day. If you’re going to be putting all that information in the system, where it can be used to help people like me, I want you to know how thankful we are for your support. 1.12. Chapter 1 – Credits (Screen 12/12)

Special thanks to Maine Office of Substance Abuse, the Department of Health and Human Services, RTI and FEI.com Inc.

Director / Designer / Graphics and Animation: Ludwing Najera

Written By / Voice Actor: Jennifer Conrad

Programming and Development: John Comberiate 2.Lesson 1: Chapter 2-Data Entry Overview 2.1. Chapter 2 – It’s not just Susan’s problem (Screen 1/12)

Chances are, you know someone like Susan. Maybe the problem isn’t OxyContin. Maybe it isn’t caused by divorce or family issues. But we all know someone who might be using illegal substances, or abusing alcohol in a way that is harmful to themselves or others. We see the damage it does to families, and its affect on violent crime, and in intoxicated driving statistics.

You are now part of the system that works to help people, like Susan, overcome their substance abuse problems. 2.2. Chapter 2 – The Basic Idea (Screen 2/12)

To be really involved in your new job, it’s important to know what some of the key words are and how they are used. In Substance Abuse Treatment, a client is any person that is formally getting help from your agency for their problems. It’s kind of the same thing as being a patient at a doctor’s office. Substance Abuse as we mentioned before, is the misuse of a legal substance like alcohol or prescription drugs, or the use of illegal substances like pot or cocaine.

Because drugs and alcohol often cause people to want to use them over and over, we call this behavior an Addiction. 2.3. Chapter 2 – Admission (Screen 3/12)

People end up in substance abuse treatment for a variety of reasons. Sometimes a judge tells them to come, or they might have gotten an OUI (operating a vehicle under the influence of drugs or alcohol) and have to enter treatment through the state’s DEEP (Driver Education/Evaluation Program). Some people decide they need treatment and seek it on their own.

Whatever the reason, an Admission to treatment happens when the person has been formally accepted into your treatment program. Special information is collected when a person has an admission – but we’ll get to that later. 2.4. Chapter 2 – Discharge (Screen 4/12)

Clients go through many different things in treatment, but at some point, their treatment in your agency will end. They will either be sent to a new agency for a different type of treatment, or will be able to use basic community services to support their recovery – the getting-better process. In some cases, people stop coming to treatment without telling the agency.

When the treatment ends, the client is Discharged from the agency. You’ll be recording special information at that time, too. 2.5. Chapter 2 – Hey, who pays for this anyway? (Screen 5/12)

You probably have health insurance that you use when you go to the doctor’s office. That health insurance doesn’t always pay for Substance Abuse Treatment, so much of the funding for treatment is provided by state or federal government grants. Grants are pretty much like pots of money that your agency can use as it has clients in treatment. As part of getting this money, your agency is required to report certain data back to the state about the clients at admission and discharge.

By comparing admission and discharge information, the state can look at outcomes. Outcomes are basically a measurement of what changed – what got better – for the client during treatment. Let’s look at some of Susan’s outcomes. 2.6. Chapter 2 – Susan’s Story – Back on Track (Screen 6/12)

“Before I started treatment, I was using OxyContin every day – I couldn’t stop. I spent my spare money trying to get more, even when my kids needed stuff. My job had cut back on my hours, and I was having trouble making my rent and car payments. I had a couple run-ins with the police and my ex-husband was threatening to take my kids away! That’s when I knew I had to do something. The Calais facility helped me to get my life back together. My employer took me back full time, and I can keep my kids. Best of all, I’m not using OxyContin anymore! And I’m still in touch with a counselor who’s helping to keep me on track.” 2.7. Chapter 2 – NOMS (Screen 7/12)

Susan’s outcome? Besides a better future, the state looks at the fact that her job is better, her kids are with her, and that she’s not abusing drugs anymore. This information is important to see how treatment programs and grant dollars are working in the state to make people’s lives better.

All the information agencies report to the state gets put into a monthly report called the TEDS Extract, and that gets sent to the federal government. This big report gives the government information called National Outcomes Measures, or NOMs. Since they’re giving money for treatment, they want to know what’s working, too. 2.8. Chapter 2 – Client Privacy (Screen 8/12)

Now before you get worried, be assured that when the state and the federal governments look at information for outcomes, they don’t look at names, social security numbers, addresses, or anything else. In fact, when the big report is sent to the federal government, there isn’t anything in it that identifies any particular person.

Why secrecy? Because people’s business is just that – their business. There are federal laws that protect our personal health information from others (remember that “privacy form” at your doctor’s office?), and even stronger laws protecting substance abuse health information. 2.9. Chapter 2 – Safeguarding Information (Screen 9/12)

As a person who will have access to information about the clients in your agency, it’s your job to uphold their privacy too. In fact, it’s illegal for you to share private health information you see at work with others. 2.10. Chapter 2 – What’s in it for me? (Screen 10/12)

If you’re not abusing substances, you might be asking – “What’s in this for me? It’s a lot of work to collect and enter all this information!” Here are some answers:

Between 2000 and 2007, the records collected by Maine showed a rise in the use of opiates including OxyContin and OxyCodone among citizens of Maine. In fact, OxyContin was second only to Alcohol as one of the most widely used and abused substances. One way to treat OxyContin addiction is to use Opioid Replacement Therapy, like Methadone or Buprenorphine. 2.11. Chapter 2 – Data At Work (Screen 11/12)

At the same time, Maine officials noticed that many of the OxyContin clients admitted to the Bangor treatment facilities were coming from the city of Calais. Using the state data collected, public officials were able to make informed decisions and open the Treatment Centers in the city of Calais. 2.12. Chapter 2 – Real Results (Screen 12/12)

“Remember me? Without the information that provided the new center in Calais, I’d have to drive all the way to Bangor for treatment. That’s hours I couldn’t spend with my kids or on my job.”

There are other examples out there too: the drunk driver who’s no longer drinking and not endangering you and others on the road. The classmate of your child’s who won’t be tempted to use drugs, or offer them to his friends. The drug user who won’t be committing crime looking for cash to buy more drugs. Your job makes a difference for you and others in Maine. 3.Lesson 1: Chapter 3 – Clinician’s Study 3.1. Chapter 3 - It’s Just not just Susan’s problem. (Screen 1/13)

You’ve seen it all too many times in your job, people just like Susan making a bad situation worse with poor decision making. Chances are, someone you know personally has struggled with a drug or alcohol addiction. As a professional, you see the damage it does to families, as well as its affect on violent crime, intoxicated driving statistics, and in ruined lives.

You work hard to make a difference in people’s lives. Did you know your impact can be even bigger? This training will take you on a journey – one that will show you how the treatment data you collect in your job can help people, like Susan, overcome their substance abuse problems. 3.2. Chapter 3 – Why Me? (Screen 2/13)

You might be wondering why you’ve been asked to do this training. Basically, it’s because you or your agency have clients that must be reported to the state through data entry in the TDS (Treatment Data System).

If you or your agency: are licensed as a Substance Abuse Agency OR receiving federal funds, then all substance abuse and affected other/codependent clients must be reported for state purposes. If you are DEEP (Driver Education/Evaluation Program) certified, Medicaid reimbursable, and/or methadone certified, you must complete state required information on all clients receiving those services. 3.3. Chapter 3 - Admission (Screen 3/13)

You know your job well, so we’re not going to go into depth here on the basics. But we should all have an understanding of the basic definitions of admission and discharge, from the state system perspective.

For state reporting purposes, an Admission to treatment happens when a person has been formally accepted into your treatment program – they’ve been through the screening and intake process and are receiving treatment services. The admission date is the date of the first face-to-face meeting with the client. Except for Evaluation Only clients, the first treatment session date would be the same as the admission date. 3.4. Chapter 3 – Admission and Shelter and Detoxification (Screen 4/13)

The client will either be admitted for regular treatment, or admitted to a Shelter and Detoxification setting. Clients cannot be admitted to more than one substance abuse services setting at a time, even by the same provider. For instance, if you admit the client for detoxification, you must discharge them from detoxification before admitting them for residential rehabilitation. 3.5. Chapter 3 - Discharge (Screen 5/13)

From the state’s perspective, a Discharge occurs when the client completes treatment in your agency, OR if the client leaves without the program’s agreement. A discharge also occurs if you are moving the client from one treatment modality to another (from detoxification to residential rehab).

In the case of a client leaving treatment on their own, you’ll be asked to do an Administrative Discharge. Clients should be discharged within the last 30 days of the last date of contact. A case should never remain open longer than 90 days without the client receiving a face-to-face counseling session unless a specific reason (other than non-appearance for scheduled sessions) is noted in the client record. 3.6. Chapter 3 - TEDS (Screen 6/13)

The data in TDS is used to meet the federal requirements of the Treatment Episode Data Set (TEDS). TEDS was established by the former National Institute on Alcohol Abuse and Alcoholism (NIAAA), now the United States Department of Health and Human Services Substance Abuse & Mental Health Services Administration (SAMHSA) and the National Institute on Drug Abuse (NIDA) to meet requirements specified in the Anti-Drug Abuse Act of 1988. 3.7. Chapter 3 - NOMS (Screen 7/13)

The TEDS data set became a part of the National Outcomes Measures (NOMs) reporting requirements. It is due to the federal requirements of TEDS/NOMs that any agency receiving state funds (including Federal Block Grant) must report all substance abuse clients, regardless of the source of funding for individual clients. Maine’s Office of Substance Abuse (OSA) sends the data to the federal government monthly in a system extract, and we are held accountable for the accuracy and timeliness of our submissions. 3.8. Chapter 3 – Funding – It pays your check (Screen 8/13)

You’re aware that most of your clients don’t pay for their own treatment. So who does? A large chunk of the funding your agency receives comes from grants set out by Maine’s OSA, by Medicaid (funded by federal and state money), and federal block grants. Because other people, especially the state and feds, are paying for substance abuse treatment, we want to know what’s actually working – or what the outcomes are. Outcomes are basically a measurement of what changed – what got better – for the client during treatment.

It’s important for us to look at that, because we know that approximately 50% of the clients who have received services will reenter the substance abuse treatment system. 3.9. Chapter 3 – Using the Data (Screen 9/13)

TDS allows the State to assess client outcomes, trends, costs, etc., related to high and low use populations. The system also allows us to assess health, economic, etc., outcomes for the clients who will not reenter the treatment system. Many treatment programs use the data to apply for grants, and we can also use it to respond to questions that come from the state legislature. In addition, TDS is capable of helping us address needs and service outcomes as they relate to smaller and special needs populations, e.g., the elderly.

Let’s look at some of Susan’s outcomes. 3.10. Chapter 3 – Susan’s Story - Back on Track. (Screen 10/13)

“Before I started treatment, I was using OxyContin every day – I couldn’t stop. I spent my spare my money trying to get more, even when my kids needed stuff. My job had cut back on my hours, and I was having trouble making my rent and car payments. I had a couple run-ins with the police and my ex- husband was threatening to take my kids away! That’s when I knew I had to do something. The Calais facility helped me to get life back together. My employer took me back full time, and I can keep my kids. Best of all, I’m not using OxyContin anymore! And I’m still in touch with a counselor who’s keeping me on track.” 3.11. Chapter 3 – Data At Work (Screen 11/13)

Susan’s outcome? The state, through TDS , looks at the fact that her job is better, her kids are with her, and that she’s not abusing drugs anymore. This information is important to see how treatment programs and grant dollars are working in the state to make people’s lives better. 3.12. Chapter 3 – What’s in it for me? (Screen 12/13)

By looking at data collected, Maine OSA was able to show that between 2000 and 2007, there was a rise in the use of opiates including OxyContin and OxyCodone among citizens of Maine. In fact, OxyContin was second only to Alcohol as one of the most widely used and abused substances. At the same time, Maine officials noticed that many of the opiate replacement clients admitted to the Bangor treatment facilities were coming from the Calais area. Using the state data collected, public officials were able to make informed decisions and open a methadone clinic in the town of Calais. 3.13. Chapter 3 –Real Results (Screen 13/13)

“Remember me? Without the information that provided the new center in Calais, I’d have to drive all the way to Bangor for treatment. That’s hours I couldn’t spend with my kids or on my job.”

There are other examples out there too: the drunk driver who’s no longer drinking and not endangering you and others on the road. The classmate of your child’s who won’t be tempted to use drugs, or offer them to his friends. The drug user who won’t be committing crime looking for cash to buy more drugs.

As a clinician, you know your job makes a difference for you and others in Maine. Now, you can see that the data you collect and report can also have an impact on treatment and decisions within your state. 4.Lesson 2: Chapter 4 – Types of Form Data 4.1. Chapter 4 - Important Tools for Your Job (Screen 1/15)

So now that you understand why we need good data, you’re ready to get started. But it might be important to have a little more information about just how we gather that data as well as the tools that are used.

In order to quickly and easily collect data, you will be using several tools and resources including: Treatment Data System (TDS) forms, TDS and the Client. The two sided TDS forms were specifically designed by Maine’s Office of Substance Abuse to gather the necessary data. On one side of the forms, you’ll see little boxes with instructions on what type of data to collect. We call each of these boxes “fields”. 4.2. Chapter 4 – Three TDS Forms (Screen 2/15)

Some of these fields require specific codes, and in most cases, you’ll find those codes on the back of the form.

In total, there are three TDS forms you’ll be using: TDS A-1 Admission, TDS D-1 Discharge, and A-D Shelter and Detoxification (this form has both the admission and discharge information on it, because fewer fields are collected for clients who are in Shelters or in Detoxification). 4.3. Chapter 4 – TDS (Treatment Data System) (Screen 1/15)

The second tool you will be using is called TDS (Treatment Data System). Each time you have completed filling out a form, it will have to be entered into the TDS for Maine.

The system has a series of screens and fields which are very similar to the ones found on the TDS forms. These screens will allow you to input the data and codes that you collected on the forms directly into the system. Maine uses this data to generate and view reports as well as submit critical information to the Federal government. 4.4. Chapter 4 – The Client (Screen 4/15)

The last and final piece of the puzzle is your most valuable resource of all – the Client. No matter what you use to collect or input the data, the Client is going to be your primary source of all the information going into the system.

Keep in mind that the Client is the person whom we’re trying to help, so it’s important to try to collect the correct information from them in order to improve the way treatment is provided in Maine. 4.5. Chapter 4 – TDS Forms: Basic Information (Screen 5/15)

Since the forms really drive the data collection process, we’re going to focus on those for a while. If you look at the TDS A-1 Admission form, you’ll notice it’s broken into three (3) sections.

The top portion has questions labeled A-K. Many of these items are dates, such as the date of the admission, the date the Client first contacted the agency, etc. Other fields are important numbers for your organization, like the Federal Identifier and the Contract Number.

Then there are fields which are required to ensure your agency gets paid for the treatment and services provided to the Client. 4.6. Chapter 4 – TDS Forms: Demographic Information (Screen 6/15)

The middle portion (questions 1-23), contains questions we use to collect “Demographic” data. “Demographics” are types of data such as age, gender, address, and other personal information.

When collecting demographics, we will want to know things like whether or not the Client has insurance, what are their current living arrangements, and are they currently working. There are also questions such as “Race” and “Referral Source”, which might seem insignificant at first, but are some of the fields that your agency is required to report to the Federal government. The Federal government doesn’t want to gather any more data than what’s really needed. So if it’s on the form, it’s important. 4.7. Chapter 4 – What Should I Do? (Screen 7/15)

Depending on your agency’s setup, you may be asked to complete this section with the client. We’ll give you some tips and suggestions on collecting information from the client later in the training. 4.8. Chapter 4 – TDS Forms: Clinical Information (Screen 8/15)

The final portion of the forms is meant to collect clinical data. You won’t need to worry about collecting this information from the client since it is likely that the Counselors in your agency, whom are licensed to collect clinical information, will gather this information. However, you may be asked to enter the data into the TDS once it has been collected by the Counselor.

Remember that any and all Client data collected is strictly confidential and is protected by law. Sharing this information with unauthorized individuals could be considered a criminal offense. 4.9. Chapter 4 – Connection – Admission and Discharge (Screen 9/15)

The D-1 Discharge and A-D Shelter and Detoxification forms are slightly different. These forms have a “division” between demographic and clinical data, and as we’ll discuss in later chapters, some of the fields found on these forms actually tie directly to fields on the A-1 Admission form – what is put on the A-1 Admission form determines what answers can be put on the D-1 Discharge form. 4.10. Chapter 4 – Stay Organized! (Screen 10/15)

One of the keys to successfully collecting data will be organization. When you are organized, it takes you less time to collect the necessary information from the client and enter it into the TDS forms and System. In fact, you may be required to fix any Client records which have missing information or have been entered incorrectly prior to submitting the data to the State or the Federal government.

It is also important to remember that you’re working with data that impacts people’s lives, like Susan. So proper collection of information the first time should be your goal. 4.11. Chapter 4 – Stay Organized! – Charts and Files (Screen 11/15)

Sometimes agencies have a folder system for their Clients called “charts”. You can help by keeping the information in those folders accurate and easy to use. You’ll need to be able to locate the Admission form when it’s time to enter it in the system, so keep it in the front. 4.12. Chapter 4 – Keeping Up (Screen 12/15)

Remember how we talked about the state reporting to the Federal government?

Well, if the state does not submit the data accurately and on time, it will get penalized. Sometimes, this means a loss of public funding (e.g. MaineCare, Block Grant), which could impact your job as well as the available treatment needed by people in your area.

Make sure to keep all Client data updated frequently (daily if necessary) and enter the data while it is still “fresh” in your mind. Doing so will make it easier to recall Client information and allow you to enter the data correctly. 4.13. Chapter 4 – Keep It Clear! (Screen 13/15)

In some cases a Clinician may give you forms which have codes that are not legible or are incorrect. When this occurs, highlight the fields in question and take time to ask the clinician to clarify or correct the codes!

Now that you know how data is used, you’ll understand how critical it is to collect accurate information and how your role is an important part of the process. 4.14. Chapter 4 - Admission and Discharge (Screen 14/15)

When completing an A-1 Admission form, you may want to start filling out the D-1 Discharge form as well. This is because some of the fields on the A-1 Admission form are also on the D-1 Discharge form, so filling them out together will help prevent errors and keep the data consistent between them.

For example, the information that goes in Fields A-E, and Fields G-H, are identical on both forms. You can store the D-1 Discharge form in the chart behind the A-1 Admission form. Note: The Contract Number (Field F) can change if the client is discharged in a different fiscal year than at admission (for OSA funded agencies it needs to be updated). 4.15. Chapter 4 – Looking Forward (Screen 15/15)

Keep in mind that the D-1 Discharge form may contain other fields which will require answers based on the data collected on the A-1 Admission form. Finding them and filling them out now will save time in the future. This will be especially useful for when it is time to input the data in the TDS where error messages are returned as a result of data not matching up correctly. We’ll cover more of these details in the next chapter.

So let’s start to take a look at some of those fields you’ll be working with. 4.16. Chapter 4 – Chapter Test (Screen 1/10)

Help Susan by answering the questions correctly so that the funding can be given to build a new treatment facility in Calais!

Use of the back/next buttons before answering the current question or exiting the test prematurely could negatively affect your score. 4.17. Chapter 4 – Chapter Test (Screen 2/10)

1. What should you do if you come across information on a form that is unclear?

 Take the time to ask!

 Guess what it is

 Erase the information

 Skip it and move on

(Select the correct answer) 4.18. Chapter 4 – Chapter Test (Screen 3/10)

2. What are the three forms that you’ll be using?

 A-1 Admission, D-1 Discharge, A-D Admission and Detoxification

 1-A Admission, 1-D Discharge, D-A Detoxification and Admission

 TDS A, TDS D, A

 TSD A, TSD D, D

3. What is the A-1 Admission form used for?

 Admission

 Discharge

 Shelter and Detoxification

4. What is the D-1 Discharge form used for?

 Admission

 Discharge

5. What is the A-D Shelter and Detoxification form used for?

 Admission

 Discharge

6. What does TDS stand for?

 Treatment Data System

 Tactical Display Set

 Targeted Deployment set

 Tested Delivery System

7. This is the source of all the information for the form.

 The Client

 The Clinician

 The Clinical Supervisor

 You

8. Age gender and address are all examples of what kind of information?

 Demographic

 Clinical

 Drug Use

9. What should you do if you come across information on a form that is unclear?

 Take the time to ask!

 Guess what it is

 Erase the information

 Skip it and move on

(Select the correct answer) 5.Lesson 2: Chapter 5-Collecting Demographic Information 5.1. Chapter 5 – Getting Started (Screen 1/27)

So – you’re ready to start!

First, locate the proper admission forms. For most admissions, this will be the TDS A-1 Admission form (blue color). In the case of a Shelter or Detoxification client, you will use the A-D Shelter and Detoxification form (pink color). We’ll be reviewing fields in both of them.

In this lesson, we’re going to discuss the fields in the top portion of the forms. These are the demographic fields, which gather general information about the person, and help you to know who the form belongs to. 5.2. Chapter 5 – Answering Questions (Screen 2/27)

There are several questions that, when answered, will give the Federal government (and your agency) insight into the types of people that are getting substance abuse services through your agency in Maine. This section also contains information that identifies your agency, and allows it to get paid for the services it provides.

Remember to use your neatest writing, so you can read the form later when you enter it into TDS. If your clinical staff enters information that you can’t read, go back and ask now for clarification, while it’s still fresh in their mind. 5.3. Chapter 5 – Important Agency Fields (Screen 3/27)

The first field you’ll encounter is called Agency Name/Location. You should be able to fill that in easily.

Below that field on the A-1 Admission form, you’ll see two more fields relating to your agency: E: Federal Identifier and F: Contract Number. (On the A-D Shelter and Detoxification form, these are fields F and G and appear on the second line of the form). 5.4. Chapter 5 – Agency Fields- Federal Identifier (Screen 4/27)

E. Federal Identifier : This field is very important. This number identifies your agency and more specifically its physical location, as well as which clients belong to it. Because of federal privacy laws, your agency can only look up its own clients in TDS.

If you enter the wrong agency number, you will not be able to locate the client once you enter him or her into the TDS. Some agencies have more than one Federal Identifier, so you’ll want to check with your supervisor to see which ones might apply to specific clients. This field is auto filled into the D-1 Discharge form from the A-1 Admission form in the system. 5.5. Chapter 5 – Agency Fields-Contract Number (Screen 5/27)

F. Contract Number: This is a code issued to your agency by the state, and determines how your agency will get paid for treating the client. This field is for funded and MaineCare agencies only. If your agency doesn’t have a contract code, just skip this field (don’t fill in with zeroes).

Please note that the Contract Code may be the same at discharge, but will change if the client is discharged in a different State Fiscal Year (Note: MaineCare contract numbers change every three years). Because you don’t know when the client will be discharged, you’ll need to wait to fill this in on the D-1 Discharge form. 5.6. Chapter 5 – Client Fields A-C (Screen 6/27)

Fields A-D are the Demographic fields used to collect basic Client information including:

A. Date of Birth: The client’s date of birth. Use two digits for the month, two digits for the day, and four digits for the year.

B. Last Four SS#: Only the last four digits of the client’s social security number are needed.

C. Gender: You must select only male or female. 5.7. Chapter 5 – Client Fields D (Screen 7/27)

D. County of Residence: The county where the client currently lives. On the back of the A-1 Admission form, you’ll see 2-letter codes for each county, and that’s what you should enter here. There are codes for out-of-state (OS) and out-of-country (OC) clients, too.

Fields A, B and C will not change between admission and discharge, so you should enter those on the D- 1 Discharge form at the same time you enter them on the A-1 Admission form. 5.8. Chapter 5 – Primary Service Codes (Screen 8/27)

On the next line of the A-1 Admission form, you’ll find field G. Primary Service. (On the A-D Shelter and Detoxification form, this is Field H). This field identifies the type of treatment the client will be receiving from your agency. Your agency may always use the same code; or it might vary by client. This is not a question you will ask the client. If you are not sure what to enter, ask a clinician or supervisor.

This field must be identical on admission and discharge for this client. So you should enter it on the D-1 Discharge form as you’re completing the A-1 Admission form. 5.9. Chapter 5 – Evaluation Only (Screen 9/27)

If you choose code “13-Evaluation”, the answer to Field #33 on the A-1 Admission form must be “03- Evaluation Only.” So fill that in at the same time.

If the client is receiving non-intensive outpatient services and is under age 19, use code “18-Adolescent Outpatient”. For Shelter and Detoxification clients, the list of Primary Service codes on the back of your form is much shorter. 5.10. Chapter 5 – Client Fields H-I (Screen 10/27)

Fields H-K are additional Client fields that include the following:

H. Date of First Phone Call (only on A-1 Admission form): Asks for the date of the client’s first phone call to schedule an appointment. You may have this written in the file; just enter it here.

I. Date of First Face to Face Contact (found on both the A-1 Admission form and the A-D Shelter and Detoxification form): Enter the date of the first time the client came into your treatment agency. This field can be filled in on the D-1 Discharge form too. Note: On the A-D Shelter and Detoxification form, this is called the Current Admission Date and is also Field I. 5.11. Chapter 5 – Client Fields J-K (Screen 11/27)

J. Date of First Treatment Session: The date of the first counseling session. This is the date the client starts treatment, after an assessment and admission have been done. If the client is an “Evaluation Only” client, this is the same as the date of the First Face to Face Contact.

K. Payor Code: Payor Codes are found on the back of the form. Please note: If your agency does not have a contract (non-MaineCare) with OSA you cannot enter code 01. Note: This is Field E on the A-D Shelter and Detoxification form. 5.12. Chapter 5 – Demographics-Admission (Screen 12/27)

Now we’ll look at some fields that tell us about the client and their needs in treatment. The following nine (9) fields are also on the A-D Shelter and Detoxification form.

1. Health Insurance: You should record the client’s health insurance, even if it doesn’t pay for substance abuse treatment. If the client has no insurance, record “none”.

2. Referral Source: Enter a code for the type of person (or place) that is responsible for recommending that the client to come to treatment. The possible answers are found on the back of your form. 5.13. Chapter 5 – Demographics-Referral Source (Screen 13/27)

The Primary Referral source can be self (the client decided they needed treatment), family, or could be a court or the DEEP program.

If the referring person is a staff person working at an alcohol/drug abuse service agency, please record this as "substance abuse agency."

If the person is a physician or other health professional but is not involved in the substance abuse field, there are appropriate codes for that as well. 5.14. Chapter 5 – Demographics-Treatment and Needs (Screen 14/27)

3. Prior Treatment Episodes: This is simply the number of times the client has had treatment for substance abuse, at any location.

4. Are Special Accommodations needed to Provide Services?: This question asks whether the client needs various accommodations, such as handicapped access, a translator, etc. You must answer yes or no to each question. 5.15. Chapter 5 – Demographics-Additional (Screen 15/27)

5. Race and 6. Ethnicity: For each of these questions, please ask the client to answer from the choices presented. If they refuse, you must choose the best answer you can from the choices provided.

7. Veteran Status: Complete this question with a “Yes” or “No”. A veteran is a person who served in the military on active duty with an honorable discharge. 5.16. Chapter 5 – Demographics-Education (Screen 16/27)

8. Education Completed: You are being asked to enter a number corresponding to the last grade the client completed. Simply input the grade as the number. If the person has a GED, enter 12. Remember that these are grades completed, and are not necessarily the number of years they attended school.

Note: Codes range from 00 (None) to 20. If more than 20 years have been completed, enter 20. If they attended college, or post college, add those years to the number of grades completed. 5.17. Chapter 5 – Demographics-Marital Status (Screen 17/27)

9. Marital Status: Only one box can be checked. A few notes on this field:

Now married/Cohabitating: The client must be living with a spouse or significant other. Use this code if the person was previously widowed or divorced, but is now married or cohabitating.

Separated: Refers to a client and spouse still married but not living together. It does not refer to temporary separation due to employment, military service, or any similar type of separation.

Widowed: Refers to an individual whose spouse is deceased. 5.18. Chapter 5 – Demographics-Dependent Children (Screen 18/27)

10-14. Enter the Number of Dependent Children the Client Has in Each Age Group Listed Below: For each age group, enter the number of dependents the client has. If the answer is 1, enter “01”.

15. If the Client has Dependent Children, Where are the Children While the Client was in Treatment?: Please answer where the children will be while the client is in treatment. Check only one box. If the client has no dependent children, you should skip this question. Note: These fields are combined into one question, number 11, on the A-D Shelter and Detoxification form. 5.19. Chapter 5 – Demographics-Pregnancy (Screen 19/27)

16. Pregnant at Admission (field 10 on A-D Shelter and Detoxification form): If the client is confirmed pregnant (by doctor or home test), check "yes". If the client is male, you should always check “no”.

17. If Pregnant, is Client Receiving Pre-Natal Care?: For pregnant clients, check "yes" or "no" to answer whether they are receiving prenatal care.

Skip this question if the Client is not pregnant. 5.20. Chapter 5 – Demographics-Living/Employment (Screen 20/27)

18. Living Arrangements at Admission (field 12 on A-D Shelter and Detoxification form): Choose the option that best fits the client’s current living situation. Most adults will be “independent living”, unless they need something other than normal care. Most adolescents (those under 18) would be “dependent living”. "Homeless" is when people are living in places not normally meant for human habitation. It includes people who might have brief periods (30 days or less) of living in a hospital or other institution.

19. Employment Status (field 13 on A-D Shelter and Detoxification form): Check the box that best fits the client’s current situation. "Not in labor force" means people who are homemakers, or are retired, disabled, or incarcerated. 5.21. Chapter 5 – Demographics-Employment (Screen 21/27)

20. Employability Factor: Refers to the client’s ability to get a job. Check only one box that is most appropriate. "Unable to work for physical or psychological reasons" includes clients on SSI or disability. "Unable due to skills/resources" means the client does not have the education, childcare, transportation, etc. needed. "Unable due to program requirements": some clients in halfway houses are not allowed to work.

Some of these fields, like living arrangements and employment, will be asked at discharge as a “comparison.” Please enter what is actually happening with the client right now – not where they hope to be living or hope to have a job soon. 5.22. Chapter 5 – Demographics-Household Income (Screen 22/27)

You’re almost finished with the admission questions. The rest of these apply only to the A-1 Admission form.

21. Household Income (Last 30 Days): - Either fill in the boxes with a dollar amount, or use the codes on the form if the client refuses to answer or doesn’t know. Household refers to a group of friends and/or relatives living together supportively. It does not include all individuals living in hotels or institutions. 5.23. Chapter 5 – Demographics-Source of Income (Screen 23/27)

22. Primary Source of Household Income/Support: The codes are on the back of the form. If the income in question 21 is $0000, then the source of income must be “00”. If you entered any amount (other than $0) in field 21, you must have an entry in field 22 other than “00”.

23. Secondary Source of Household Income/Support if Different from Primary: If there is no secondary source of income, enter the code for “none” in question 23.

Congratulations! That’s the end of the Admission demographics for a client! 5.24. Chapter 5 – What about Discharge? (Screen 24/27)

Now we’ll be looking at a few discharge fields at the top of the TDS D-1 Discharge form that you might be asked to fill out. (Note that on the A-D Shelter and Detoxification form, all discharge information is clinical in nature and will be filled in by a clinician.)

As we covered earlier, some fields on discharge can be filled in as you’re filling out the admission information, like fields A-E and G-H. Please note that field D, the county, might change during treatment. If it does change, the A-1 Admission form must be edited as this field is not currently editable at discharge in TDS. 5.25. Chapter 5 – Discharge-Contract Number (Screen 25/27)

As mentioned earlier, sometimes field F: Contract Number will change during the client’s treatment. If the client is discharged in a different State Fiscal year, the contract number must be updated.

You’ll do this on the D-1 Discharge form, and the system will update admission for you once you input it. OSA funded contract numbers change every year on July 1. MaineCare agency contract numbers change every three years. 5.26. Chapter 5 – Discharge-Face to Face (Screen 26/27)

I. Last Face to Face Contact: This would be the date of the client’s last appointment, and might be something that one of the clinicians at your agency gives you.

Fields 1-4 are some of the fields that help Maine and the federal government measure how well treatment works over time for clients. These are questions that were asked at admission, and now are asked at discharge to see what improvements have been made, if any.

The rest of the D-1 Discharge form is clinical information, which we’ll cover when you actually enter the information into TDS. 5.27. Chapter 5 – Administrative Discharge (Screen 27/27)

If a client does not show up for treatment, usually for 30 days, you might be asked to “Administratively Discharge” them from treatment. This means that you will probably be asked to enter as much of the discharge information as possible onto the TDS form or into the system, even though the client hasn’t finished their treatment.

Typically, a client’s case will never remain open for more than 90 days without a face-to-face counseling session. Your clinical supervisor will direct you on how to fill out the D-1 Discharge form in case you must do an administrative discharge. 5.28. Chapter 5 – Chapter Test (Screen 1/10)

1. What is the number that identifies your agency and more specifically its physical location, as well as which clients belong to it?

 Federal Identifier

 Contract Number

 Date of Birth

 Last Four SS#

2. A code issued to your agency by the state which determines how your agency will get paid for treating the client?

 Contract Number

 Date of Birth

 Last Four SS#

3. These fields are not changed between admission and discharge and should be entered on both at the time of admission?

 Date of Birth, Last Four SS#, Gender, Primary Service, Date of First Face to Face Contact

 Prior Treatment Episodes, Education Completed

 Employment Status, Employability Factor

 Primary Source of Household Income/Support, Secondary Source of Household Income/Support if Different from Primary

4. If you choose code “13-Evaluation”, the answer to Field #33 on the A-1 Admission form must be what?

 03-Evaluation Only

 Blank

 01-Substanc Use Abuse

 02-Affected/Co-Dependent

5. For Evaluation Only clients, the Date of First Treatment Session is:

 The same date as the date of the First Face to Face Contact.

 The same date as the date of the First Phone Call

6. Personnel who served in the military who have been honorably discharged will have what status?

 Veteran

 Discharged

 Dismissed

7. Some of these fields, like living arrangements and employment, will be asked again at discharge. During admission you should enter:

 What is actually happening with the client right now.

 What the client has planned.

 What is happening within the year.

 The best situation the client has ever had.

8. If there is no secondary source of income, enter what code in question 23?

 Blank

 00

 01

9. If a client does not show up for treatment, usually for 30 days, you might be asked to perform what?

 Administrative Discharge

 Clinical Discharge

 Evaluation Discharge

(Select the correct answer) 6.Lesson 2: Chapter 6-Tips and Reference 6.1. Chapter 6 – Tool Kit Review (Screen 1/6)

A reminder that you have three tools for your data collection.

The first tool is a set of three forms:

 A-1 Admission form collects information for most admissions.

 D-1 Discharge form collects information for most discharges.

 A-D Shelter and Detoxification form collects information for Shelter and Detoxification.

All information on these forms eventually (within a month) gets entered into the Treatment Data System (TDS).

In some cases, you’ll be collecting the demographic information on these forms from the client. Other times, you might just be asked to verify or enter the information that a clinician has collected. 6.2. Chapter 6 – Ensuring Good Data (Screen 2/6)

Next, you’ll want to remember a few keys for good data gathering:

 Keep everything organized. It’s a great idea to keep the A-1 Admission form in the front of the client’s chart, and include a D-1 Discharge form, too. This way, you can fill out some fields right at the beginning and save yourself time and frustration at the end.

 Use good handwriting. You’ll need to read the forms when you input data into the system.

 Use the right codes. In many cases, the codes you need are on the back of the forms.

 Ask if you’re not sure. If another person filled in the form, or you’re not sure what to put in the boxes, simply ask. Someone will be glad to help you.

Most of all, remember Susan’s story, and never forget that your attention to detail could really have an impact on the lives of other people. 6.3. Chapter 6 – Key Admission Fields (Screen 3/6)

We won’t review all the fields on the A-1 Admission form, but here are a few key ones:

 E. Federal Identifier : identifies your agency’s physical location; allows you to locate clients in TDS.

 F. Contract Code: For funded and MaineCare agencies only; skip if your agency doesn’t have a contract code. Might change at discharge based on contract year. When you put the new number in at discharge, the system will automatically update the admission field.

 K. Payor Code (Field E on the A-D Shelter and Detoxification form): If your agency does not have a contract (non-MaineCare) with OSA, you cannot enter code 01.

 1. Health Insurance: Record the client’s health insurance, even if it doesn’t pay for substance abuse treatment.

 8. Education Completed: Remember, you’re recording number of grades completed, not years.

 18. Living Arrangements at Admission (Field 12 on A-D Shelter and Detoxification form) AND 19. Employment Status (Field 13 on A-D Shelter and Detoxification form): Make sure you choose the option that best fits the client’s actual, current situation – not what they hope to be doing. 6.4. Chapter 6 – Date Fields (Screen 4/6)

Sometimes it’s hard to keep the key dates clear. They are:

On the Admission form:

 H. Date of First Phone Call (only on A-1 Admission form): Date of client’s first phone call to schedule an appointment.

 I. Date of First Face to Face Contact (called “Current Admission Date” on the A-D Shelter and Detoxification form): The first time the client came into your treatment agency.

 J. Date of First Treatment Session: The date the client starts treatment, after assessment and admission.

On the D-1 Discharge form:

 I. Last Face to Face Contact: This would be the date of the client’s last appointment, and might be something that one of the clinicians at your agency gives you. 6.5. Chapter 6 – Dependent Fields (Screen 5/6)

It’s important to remember that what you enter in some fields impacts what you can put in other fields.

 D. County of Residence: · If updated at discharge, you must update the A-1 Admission form as well.

 F. Contract Code: · Make sure this has not changed since admission, due to a change in the contract year.

 G. Primary Service (Field H on the A-D Shelter and Detoxification form): · This field must be identical on admission and discharge for this client. · If you choose code “13-Evaluation”, the answer to Field #33 on the A-1 Admission form must be “03-Evaluation Only.” · If the client is receiving non-intensive outpatient services and is under age 19, use code “18- Adolescent Outpatient”.

 J. Date of First Treatment Session: · If the client is an “Evaluation Only” client, this is the same as the date of the First Face to Face Contact.

 22. Primary Source of Household Income/Support: · If the income for 21. Household Income (Last 30 Days) is $0000, you must enter “00”. If you entered any amount (other than $0) in 21, you must have an entry in field 22 other than “00”. 6.6. Chapter 6 – Discharge Fields Related to Admission (Screen 6/6)

There are a few fields that you should fill in on the D-1 Discharge form when you are entering them on the A-1 Admission form:

 A. Date of Birth

 B. Last Four SS#

 C. Gender

 E. Federal Identifier

 F. Contract Code (note: Contract numbers change every July1st if an OSA/Block Grant Funded contract)

 G. Primary Service (On the A-D Shelter and Detoxification form, this is Field H).

 I. Date of First Face to Face Contact (called Current Admission Date on the A-D Shelter and Detoxification form)

Note that there are some fields on the D-1 Discharge form that look the same as the admission fields (Fields 1-4), but they are there to make a comparison of changes from admission to discharge. These are just some of the fields that help determine outcomes and can be used to improve future treatment choices and funding for people in Maine. 7.Lesson 3: Chapter 7- Types of Forms Data 7.1. Chapter 7 – Important Tools for Your Job (Screen 1/24)

So now that you understand why we need good data, you’re ready to get started. But it might be important to have a little more information about just how we gather that data as well as the tools that are used.

In order to quickly and easily collect data, you will be using several tools and resources including: TDS Forms, Treatment Data System (TDS) and the Client. The two sided TDS forms were specifically designed by Maine’s Office of Substance Abuse to gather the necessary data. On one side of the forms, you’ll see little boxes with instructions on what type of data to collect. We call each of these boxes “fields”. 7.2. Chapter 7 – Three TDS Forms (Screen 2/24)

Some of these fields require specific codes, and in most cases, you’ll find those codes on the back of the form.

In total, there are three TDS forms you’ll be using: A-1 Admission form, D-1 Discharge form, and A-D Shelter and Detoxification (this form has both the admission and discharge information on it, because fewer fields are collected for clients who are in Shelters or in Detoxification).

7.3. Chapter 7 – TDS (Treatment Data System) (Screen 3/24)

The second tool you will be using is called TDS (Treatment Data System). Each time you have completed filling out a form, someone at your agency will enter it into the TDS for Maine.

The system has a series of screens and fields which are very similar to the ones found on the TDS Forms. These screens will allow you to input the data and codes that you collected on the forms directly into the system. Maine uses this data to generate and view reports as well as submit critical information to the Federal government. 7.4. Chapter 7 – The Client (Screen 4/24)

The last and final piece of the puzzle is your most valuable resource of all – the Client. No matter what you use to collect or input the data, the client is going to be your primary source of all the information going into the system.

Their answers are critical to building a knowledge base that can be used to make future improvements to the way treatment is provided in Maine.

7.5. Chapter 7 – TDS Forms: Basic Information (Screen 5/24)

If you look at the A-1 Admission form, you’ll notice it’s broken into three (3) sections.

The top portion has questions labeled A-K. Many of these items are dates, such as the date of the admission, the date the client first contacted the agency, etc. Other fields are important numbers for your organization, like the Federal Identifier and the Contract Number.

Then there are fields which are required to ensure your agency gets paid for the treatment and services provided to the client.

7.6. Chapter 7 – TDS Forms: Demographic Information (Screen 6/24)

The middle portion (questions 1-23), contains questions we use to collect “Demographic” data, which are types of data such as age, gender, address, and other personal information.

When collecting demographics, we will want to know things like whether or not the client has insurance, what are their current living arrangements, and are they currently working. There are also questions such as “Race” and “Referral Source”, which might seem insignificant at first, but are some of the fields that your agency is required to report to the Federal government. The Federal government doesn’t want to gather any more data than what’s really needed. So if it’s on the form, it’s important. 7.7. Chapter 7 – What Should I Do? (Screen 7/24)

Depending on your agency’s setup, you may be asked to complete this section with the client. We’ll give you some tips and suggestions on collecting information from the client later in the training. 7.8. Chapter 7 – TDS Forms: Clinical Information (Screen 8/24)

The final portion of the forms is meant to collect clinical data. Again, you'll see that these questions are all organized into neat boxes or fields.

Remember that any and all client data collected is strictly confidential and is protected by law. Sharing this information with unauthorized individuals could be considered a criminal offense. 7.9. Chapter 7 – Connection-Admission and Discharge (Screen 9/24)

The D-1 Discharge and A-D Shelter and Detoxification forms are slightly different. These forms have a “division” between demographic and clinical data, and as we’ll discuss in later chapters, some of the fields found on these forms actually tie directly to fields on the A-1 Admission form – what is put on the A- 1 Admission form determines what answers can be put on the D-1 Discharge form.

7.10. Chapter 7 – Stay Organized! (Screen 10/24)

One of the keys to successfully collecting data will be organization. When you are organized, it takes you less time to collect the necessary information from the client for entry onto the TDS Forms, and eventually for entry into the System. In fact, you may be asked by data entry staff in your agency to fix any client records which have missing information or have been entered incorrectly, so they can accurately submit the data to the State or the Federal government. 7.11. Chapter 7 – Stay Organized!-Charts and Files (Screen 11/24)

It is also important to remember that you’re working with data that impacts people’s lives, like Susan. So proper collection of information the first time should be your goal. You can help by keeping the information in your agency's client charts accurate, with all papers and forms in their proper place. 7.12. Chapter 7 – Keeping Up (Screen 12/24)

The timeliness of data reports is critical, because if the state does not submit the data accurately and on time, it will get penalized. Sometimes, this means a loss of public funding (e.g. MaineCare, Block Grant), which could impact your job as well as the available treatment needed by people in your area.

Make sure to keep all client data updated frequently (daily if necessary). Your data entry staff is asked to enter information into TDS in a timely fashion, and they cannot enter incomplete A-1 Admission and D-1 Discharge forms. 7.13. Chapter 7 – Keep it Clear! (Screen 13/24)

In addition, your attention to clearly writing the numbers and letters in each block will help the entry staff properly update TDS. If they can't read your writing, they'll be coming back to you and asking you to clarify your answers.

Now that you know how data is used, you’ll understand how critical it is to collect accurate information and how your role is an important part of the process. 7.14. Chapter 7 – Admission and Discharge-Consistency (Screen 14/24)

Your data entry staff has been instructed to begin filling out certain fields on the D-1 Discharge form when they are completing an A-1 Admission form. Because some fields on the A-1 Admission form are also on the D-1 Discharge form, filling them out together will help prevent errors and keep the data consistent between them.

In addition, the D-1 Discharge form has fields which will require answers based on the data collected on the A-1 Admission form. In the following chapters, we'll focus on these fields in the clinical area of the form. in these cases, answers on the D-1 Discharge form that do not match the A-1 Admission form will cause error messages to be returned when data is input into TDS, which will cause delays and frustration. 7.15. Chapter 7 – Just In Case… (Screen 15/24)

You may never be asked to complete the Agency or Demographic portions of the form in your agency. However, we’ll review the key fields here very quickly, in case you ever need to help out with this portion of the data.

Note: If you are required to collect Demographic Information for your agency, you should complete Lesson 2, Chapters 5 and 6. 7.16. Chapter 7 – Client Fields E-K (Screen 16/24)

E. Federal Identifier: Identifies your agency’s physical location. If the wrong code is entered here, you will not be able to locate clients in TDS, and your client could possibly be located by another agency, breaking confidentiality laws.

F. Contract Code: This is for funded and MaineCare agencies only and should be left blank if your agency doesn’t have a contract code.

K. Payor Code (E. on the A-D Shelter and Detoxification form): If your agency does not have a contract (non-MaineCare) with OSA, you cannot enter code 01. 7.17. Chapter 7 – Health and Education (Screen 17/24)

1. Health Insurance: Record the client’s health insurance, even if it doesn’t pay for substance abuse treatment.

8. Education Completed: Remember, you’re recording number of grades completed, not years. 7.18. Chapter 7 – Important Dates-Admission (Screen 18/24)

Sometimes it’s hard to keep the key dates clear. They are: On the A-1 Admission Form:

H. Date of First Phone Call (only on A-1 Admission form): Date of client’s first phone call to schedule an appointment.

I. Date of First Face to Face Contact (called “Current Admission Date” on the A-D Shelter and Detoxification form): The first time the client came into your treatment agency. 7.19. Chapter 7 – Important Dates-Discharge (Screen 19/24)

J. Date of First Treatment Session: The date the client starts treatment, after assessment and admission.

 If the client is an “Evaluation Only” client, this is the same as the date of the First Face to Face Contact.

I. Last Face to Face Contact: The date of the client’s last appointment. 7.20. Chapter 7 – Filed Impact-G (Screen 20/24)

It’s important to remember that what is entered in some fields impacts what can be put in other fields.

G. Primary Service (Field H on the A-D Shelter and Detoxification form):

 This field must be identical on admission and discharge for this client.

 If the code is “13-Evaluation”, the answer to Field #33 on the A-1 Admission form must be “03- Evaluation Only.” 7.21. Chapter 7 – Primary Service (Screen 21/24)

If the client is receiving non-intensive outpatient services and is under age 19, use code “18-Adolescent Outpatient”. 7.22. Chapter 7 – Primary Source of Income/Support (Screen 22/24)

22. Primary Source of Household Income/Support: If the income for 21. Household Income (Last 30 Days) is $0000, “00” must be entered.

 If any amount is entered in 21 (other than $0), the entry in field 22 must be something other than “00”. 7.23. Chapter 7 – Discharge Overlay Fields (Screen 23/24)

There are a few fields that the Data Entry staff are asked to complete on the discharge form (D-1 Discharge form only), when they are entering them on the admission form. This will ensure that they match at discharge:

A. Date of Birth B. Last Four SS# C. Gender E. Federal Identifier 7.24. Chapter 7 – More Overlap Fields (Screen 24/24)

F. Contract Code I. Date of First Face to Face Contact (called Current Admission Date on the A-D Shelter and Detoxification form)

Finally, please note that while Fields 1-4 look to be the same on the A-1 Admission and D-1 Discharge forms, they are actually there to make a comparison of changes from admission to discharge. These are just some of the fields that help determine outcomes and can be used to improve future treatment choices and funding for people in Maine. 7.25. Chapter 7 – Chapter Test (Screen 1/10)

1. What are the three tools and resources used to collect data?

 TDS Forms, TDS and the Client

 TDS, Client Surveys, Exam Forms

 Client Sample Testing, TDS, Test Forms

2. What form(s) are used for Shelter and Detoxification clients?

 A-D Shelter and Detoxification

 A-1 Admission and D-1 Discharge

 A-D Shelter and Detoxification and D-1 Discharge

 A-D Shelter and Detoxification and A-1 Admission

3. What is the data entered into TDS used for?

 Generate and view reports as well as submit critical information to the Federal government.

 Store information in order to have a client history.

 Save paper by storing everything electronically instead of having to keep the paper records.

4. What is the most valuable resource of all?

 The Client

 The Report

 The Forms

5. All client data is considered what?

 Confidential

 Public

 Private

 Gossip

6. Certain fields are on both the A-1 Admission and D-1 Discharge forms. What should you do with these fields?

 Fill them out at the same time to make sure they are the same.

 Make sure they do not contain the same information.

 Only fill out the A-1 Admission form fields.

7. For the Education Completed field, what are you recording?

 Grades completed.

 Years completed.

8. Date of First Face to Face Contact (called “Current Admission Date” on the A-D Shelter and Detoxification form) refers to:

 The first time the client came into your treatment agency.

 Date of client’s first phone call to schedule an appointment

 The date the client starts treatment, after assessment and admission.

9. Which one of these fields is one that the Data Entry staff should not complete on the D-1 Discharge form when they are entering them on the A-1 Admission form?

 Education Completed

 Date of Birth

 Gender

(Select the correct answer) 8.Lesson 3: Chapter 8-Collecting Clinical Information 8.1. Chapter 8 – Getting Started (Screen 1/24)

Before you start, locate the proper forms. For most admissions, this will be the A-1 Admission form (blue color). In the case of a Shelter or Detoxification client, you will use the A-D Shelter and Detoxification form (pink color). We’ll be reviewing fields in both forms.

In this lesson, we’re going to focus on the fields in the lower portion of the forms, or the clinical fields. Because this is information you’re very familiar with in a treatment evaluation, we won’t go through every field in detail, but will give you some hints about several that may need explanation. The top portion of the form contains demographic information, which may have been collected by another person in your agency. 8.2. Chapter 8 – A Few Key Tips (Screen 2/24)

Remember to use your neatest writing so that the form can be read by the data entry staff. This will save both of you time, and will ensure that the information entered into TDS is accurate and usable for outcomes research. The data entry staff has been instructed to come back to you for clarification if they can’t read your handwriting.

In many fields, you’ll be asked to enter codes, which almost always appear on the back of the form, along with a more detailed explanation. Please read these codes carefully and choose the right one. In other cases, you may be asked to enter numbers, for example in the case of the number of mental health admissions. Unless otherwise directed, fill in all boxes, using leading zeroes (e.g., 01 for 1) if you must. 8.3. Chapter 8 – Your Agency’s Federal Identifier (Screen 3/24)

The first field you should review is actually at the top of the A-1 Admission form – but it is critical for this number to be correctly entered.

E. Federal Identifier (Field F on the A-D Shelter and Detoxification form): This number identifies your agency, and more specifically, its physical location, as well as which clients belong to it. Because of federal privacy laws, your agency can only look up its own clients in TDS. 8.4. Chapter 8 – Federal Identifier (Screen 4/24)

If the wrong number is entered here, your data entry staff will not be able to locate the client once he or she is entered into TDS. Worse yet, your client could possibly be attributed to a different treatment agency and viewed by them – which is a breach of confidentiality.

Some agencies have more than one Federal Identifier, and they are typically based on physical location, so you’ll want to check to make sure this is correct. 8.5. Chapter 8 – Clinical Fields (Screen 5/24)

Now we’ll address some of the fields toward the bottom of the screen; highlighting those that need explanation.

24. Is the Client a Domestic Abuse Survivor: Even if the client denies being a victim of domestic violence, if you feel as a clinician that there is or has been domestic abuse, you should answer “yes”.

25-28: Treated for Medical Reasons: The number of times the client has been treated at each location in the last 12 months. 8.6. Chapter 8 – MH/MR Issues (Screen 6/24)

29. MH/MR Issues Diagnosis (field 14 on the A-D Shelter and Detoxification form): While most substance abuse counselors can’t diagnose MH/MR, you are being asked, if to your knowledge or based on the client’s statement, he or she has been diagnosed as someone with MH/MR issues (DSM-IV criteria).

If you don’t know, you must answer ”None”. This is not a clinical impression question. 8.7. Chapter 8 – MH Issues and Consent (Screen 7/24)

30-31. Treated for MH Issues: The number of times the client has been admitted for treatment in each of the settings listed, for MH issues.

32. Consent Decree 1/1/1989 (field 15 on the A-D Shelter and Detoxification form): Was the client a patient at the Augusta Mental Health Institute on January 1, 1989 or after? Answer only “Yes” or “No” to the best of your knowledge. 8.8. Chapter 8 – Primary Presenting Problem (Screen 8/24)

33. Primary Presenting Problem: Please check the box that best describes the condition that led to the client asking for treatment. (Remember, there can only be one primary presenting problem.)

 If the answer to Question G: Primary Service Code is 13-Evaluation, you must enter “03-Evaluation Only.” 8.9. Chapter 8 – Drugs Used Inappropriately 1 (Screen 9/24)

34-36. Drugs Used Inappropriately (fields 17-19 on the A-D Shelter and Detoxification form): Drug codes are found on the back of the form. The client must at least have a primary drug (you cannot answer “0000 None” for Field 34). The primary drug is defined as the drug, in your clinical judgment, that caused the client’s dysfunction at the time of admission. Rank secondary and tertiary drugs as appropriate.

 If your answer on field 33. Primary Presenting Problem is "02-Affected/Co-Dependent", you may not enter a primary, secondary or tertiary drug. For these clients, skip to question 37. 8.10. Chapter 8 – Drugs Used Inappropriately 1 (Screen 10/24)

Note: Your answers to the Primary, Secondary and Tertiary Drug fields will drive your answers on subsequent fields. If the client has no Tertiary drug, you will enter "00" in the frequency, route of administration and age of first use fields that correspond to tertiary drug.

37. Tobacco (field 20 on the A-D Shelter and Detoxification form): Was the client using a tobacco product at admission? Check “Yes” or “No.”

 This question is to be answered for all clients. Even if the client is codependent/affected other, you must answer questions 37, 41, 45 and 49, relating to tobacco use. 8.11. Chapter 8 – Frequency and Route (Screen 11/24)

38-41. Frequency (21-24 on the A-D Shelter and Detoxification form): For each substance identified in 34-37, enter the number of times used in the last 30 days. You cannot enter “00 None” on question 38. For all others, if no drug is identified (or if Tobacco use is “No” on question 37), you must enter “00 None.” There are different codes on the back of the form for tobacco – please use those for #41 only.

42-45. Route of Administration (25-28 on the A-D Shelter and Detoxification form): For each drug indicated in 34-37, enter the most common route of administration for the client. Codes are found on the back of the form. You cannot enter “00 Not Applicable” for field 42, relating to the primary substance. 8.12. Chapter 8 – Age of First Use (Screen 12/24)

46-49. Age of First Use (29-32 on the A-D Shelter and Detoxification form): Enter the age the client first started using each drug you listed in 34-37. You should enter “00” as the age if “0000 None” was listed for Secondary or Tertiary Drug (questions 35-36) or “No” was chosen for Tobacco (question 37).

50-51. If the frequency of the Primary Substance (question 38) is “02 No use Past Month”, you must answer questions 50 and 51 by checking one box for each question. Otherwise, skip to question 52. 8.13. Chapter 8 – Injections and Legal Status (Screen 13/24)

52. Injection Drug Use (33 on the A-D Shelter and Detoxification form): If the answer to this question is “01 Never”, skip to question 54.

54. Medication Assisted Treatment (34 on the A-D Shelter and Detoxification form): Indicate whether the client is currently receiving or will receive medication assisted therapy, either at your facility or at another facility.

55. Current Legal Status: This refers only to criminal actions—not divorce proceedings or other civil actions. Also, this does not apply to DEEP clients. If the client is a DEEP client but has no criminal actions, answer “00 No Legal Involvement.” 8.14. Chapter 8 – Arrests and DEEP (Screen 14/24)

58. Number of Arrests in the last 12 months (35 on the A-D Shelter and Detoxification form): This number must be equal to or greater than the answer to 60. OUI Arrests in the last 12 months (37 on the A-D Shelter and Detoxification form). 59. Arrests in Prior 30 days (36 on A-D Shelter and Detoxification form): Includes arrests for any reason and should be equal to or less than the answer to question 57. 61. Use Treatment/Evaluation to satisfy DEEP: If the client was DEEP referred, you must answer “01 Yes,” and you must answer question 62. Otherwise, skip to question 63. 62. GAF Scale (16 on the A-D Shelter and Detoxification form): See Appendix E for the full scale.

Once you complete all fields, you must sign and date the form! 8.15. Chapter 8 – What about Discharge? (Screen 15/24)

When the client is ready for discharge, you will need to fill out the clinical section of the D-1 Discharge form (yellow), or the A-D Shelter and Detoxification form. The D-1 Detoxification form will probably have been started by your data entry staff; the discharge fields on the A-D Shelter and Detoxification form comprise the lower half of the form (the admission fields are at the top).

To properly complete the D-1 Discharge form, it will be helpful to refer to answers on the A-1 Admission form. You should first check that all the client fields at the top of the A-1 Admission form match on the D-1 Discharge form. This includes the date of birth, last four of the SSN, gender and county. The Federal Identifier Code, Primary Service Code, and First Face to Face Contact must also be the same as they were at admission. 8.16. Chapter 8 – Discharge-Clinical Fields (Screen 16/24)

Moving on to Clinical Fields:

5.MH/MR Issues: If the client has been diagnosed with a mental illness/disorder or mental retardation based on DSM-IV (even if you did not personally make the diagnosis), answer “01” or “02” as appropriate. Check only one box. 7-9. Primary, Secondary and Tertiary Drugs: The drugs listed at discharge must be the same as those listed at admission. · If you entered a drug in these categories at admission, you must enter a current frequency of use (fields 11-13) at discharge. If the client is not currently using the drug, enter “02-No Use Past month.” 8.17. Chapter 8 – Tobacco (Screen 17/24)

10. Tobacco: If the answer to Tobacco use (question 37 on the A-1 Admission form) was “Yes”, it must be “01-Yes” here as well, even if the client quit tobacco use during treatment.

If the client quit tobacco use, you should indicate that on 14. Tobacco Frequency by entering “09-Not Currently Smoking.” 8.18. Chapter 8 – Discharge 3 (Screen 18/24)

15. Assistance Received During Treatment (41 on the A-D Shelter and Detoxification form): You should indicate “yes” or “no” for each item. Include all care you assisted the client in receiving, even if it was not provided by your agency. 18. Participated in School or Training: You should indicate “yes” if the client was or is currently enrolled in school or any type of formal training program during treatment or at the time of discharge. Students who attended school in the spring and will be going back in the fall are still considered to be in school during the summer. 8.19. Chapter 8 – Self Help (Screen 19/24)

19. Self Help (42 on the A-D Shelter and Detoxification form): Enter “Yes” if the client is attending any type of self-help group or activity that promotes behavioral change facilitating sobriety/recovery, including church groups, retreats, social groups, etc.

The next field sometimes causes confusion. 21. Deliberate Referral (43 on the A-D Shelter and Detoxification form) is provided for you to indicate the Primary service you referred the client to at discharge. “Deliberate” means your program has transported the client, written letters, made telephone calls, etc. to setup appointments, or you’ve taken some similar action to see that the client is actually seen by the program you are referring them to. 8.20. Chapter 8 – Referred Agency Code (Screen 20/24)

This does not include just giving the client a suggestion of facilities or groups for follow up treatment.

 If no deliberate action was taken by your agency, you must answer “00-None” on question 21, and question 22.

 Referring the client to a different level of treatment or a program having to do with Substance Abuse Treatment within your agency counts as a referral.

22. Referred Agency Code (44 on the A-D Shelter and Detoxification form): If you referred the client, go to Appendix C for the list of Referred Agency Codes. Because this list changes frequently, you might need to call the TDS office for the appropriate code. 8.21. Chapter 8 – Status of Discharge (Screen 21/24)

Just a few final fields on discharge –

28. Status at Discharge (field 46 on the A-D Shelter and Detoxification form): Treatment is complete (answer “02”) is used to indicated that the client achieved at least 2/3 of his/her most current agreed upon treatment plan, and that you are in agreement with the discharge.

 If the client is Affected Other or Co-dependent (question 33 on the A-1 Admission form), you may only use code 15- Treatment completed for affected other/co-dependent, or 16-Treatment not completed for affected other/co-dependent. 8.22. Chapter 8 – Source of Payment (Screen 22/24)

 If client is Evaluation Only (question 33 on A-1 Admission form), you may only use code 17- Evaluation Only, or 21-Evaluation incomplete.

 If you answer “30-Left due to lack of child care” you must answer question 29. Reason. Otherwise, skip to question 30.

30-32. Source of Payment: Enter the code for the primary, secondary and tertiary funds or reimbursement you expect to receive for services provided to the client. This includes State contract/grant sources e.g., OSA, DOC, and DHHS. You cannot use code “00-None” as a Primary Source of Enrollment. If ‘01-Office of Substance Abuse” is chosen, you must enter a contract number in Field F. 8.23. Chapter 8 – Total Number of Units (Screen 23/24)

33. Total Number of Units and Cost per Unit (51 on the A-D Shelter and Detoxification form): All service codes can be found on the back of your form. For the Code, enter the code(s) associated with the service(s) provided to the client. Units will either be number of days (for any type of residential or intensive outpatient service), number of doses (for Opioid Replacement Therapy), or number of 15- minute increments for ambulatory services (Individual, group, family and evaluation).

For instance, a one hour individual counseling session equals 4 units. For cost per unit, enter the amount in your agency's contract with the State of Maine. If your agency does not have a contract with the State of Maine, please use the normal cost per unit, regardless of the actual charge to the client. Make sure you sign and date your form. 8.24. Chapter 8 – Non-Completion (Screen 24/24)

One more important note about discharge.

As you’re aware, clients don’t always finish their recommended treatment. This could be due to a variety of reasons. If a client does not show up for treatment, usually for 30 days, you might be asked to “Administratively Discharge” them from treatment. This means that you will probably be asked to enter as much of the discharge information as possible onto the TDS form or into the system, even though the client hasn’t finished their treatment.

Typically, a client’s case will never remain open for more than 90 days without a face-to-face counseling session. 8.25. Chapter 8 – Chapter Test (Screen 1/8)

1. What color is the A-1 Admission form:

 Blue

 Yellow

 Pink

 White

2. What is the condition that led to the client asking for treatment considered?

 Primary Presenting Problem

 Secondary Presenting Problem

 Tertiary Presenting Problem

3. Are divorce proceedings or other civil actions taken in consideration for the field "Current Legal Status"?

 No

 Yes

4. What should you do once you have completed all the fields?

 Sign and date the form.

 Throw the form out.

 Input the form into TDS.

5. What color is the D-1 Discharge form?

 Yellow

 Blue

 Pink

 White

6. What term means your program has transported the client, written letters, made telephone calls, etc. to setup appointments, or you've taken some similar action to see that the client is actually seen by the program you are referring them to?

 Deliberate

 Referral

 Warm Handoff

7. The process of entering as much of the discharge information as possible onto the TDS form or into the system, even though the client hasn't finished their treatment is called:

 Administrative Discharge

 Program Ejection

 Disenrollment

(Select the correct answer) 9.Lesson 3: Chapter 9-Tips and Reference 9.1. Chapter 9 – Tool Kit Review (Screen 1/9)

A reminder that you have three tools for your data collection. The first tool is a set of three forms:

 A-1 Admission form collects information for most admissions

 D-1 Discharge form collects information for most discharges

 A-D Shelter and Detoxification form collects information for Shelter and Detoxification admissions and discharges.

All information on these forms eventually (within a month) gets entered into the Treatment Data System (TDS).

In some cases, you’ll be collecting the clinical information on these forms from the client. Other times, you might be reviewing the information on the form that was collected previously. 9.2. Chapter 9 – Ensuring Good Data (Screen 2/9)

Next, you’ll want to remember a few keys for good data gathering:

 Keep everything organized. It’s a great idea to keep the Admission form in the front of the client’s chart, and include a Discharge form, too. This way, you can fill out some fields right at the beginning and save yourself time and frustration at the end.

 Use good handwriting. Your data entry staff needs to read the forms when they input data into the system, and they’ll be coming to you if they’re not sure what you wrote.

 Use the right codes. In many cases, the codes you need are on the back of the forms.

 Ask if you’re not sure. If another person filled in the form, or you’re not sure what to put in the boxes, simply ask. Someone will be glad to help you.

Most of all, remember Susan’s story, and never forget that your attention to detail could really have an impact on the lives of other people. 9.3. Chapter 9 – Key Admission Fields (Screen 3/9)

We won’t review all the fields on the A-1 Admission form, but here are a few key ones:

E. Federal Identifier: identifies your agency’s physical location; allows you to locate clients in the TDS system.

29. MH/MR Issues Diagnosis (field 14 on the A-D Shelter and Detoxification form): Remember, you’re not being asked to diagnose the client, only to record whether, to your knowledge, a diagnosis has been made based on DSM criteria.

34-36. Drugs Used Inappropriately (fields 17-19 on the A-D Shelter and Detoxification form): Unless the client is Co-Dependent or Affected/Other, the client must at least have a primary drug, which is defined as the drug that caused the client’s dysfunction at the time of admission. It is up to your clinical judgment to rank other drugs, if any, as secondary or tertiary.

55. Current Legal Status: This refers only to criminal actions—not divorce proceedings or other civil actions. Also, this does not apply to DEEP clients. 9.4. Chapter 9 – Key Discharge Fields (Screen 4/9)

5.MH/MR Issues: Again, answer yes even if you did not make the diagnosis.

15. Assistance Received During Treatment (41 on the A-D Shelter and Detoxification form): You should indicate “yes” or “no” for each item. Include all care you assisted the client in receiving, even if it was not provided by your agency.

21. Deliberate Referral (43 on the A-D Shelter and Detoxification form): Remember, this is used to indicate a referral that you have actively made for your client, including to another program in your agency. Codes for Referred Agency are found in Appendix C of the paper manual.

33. Total Number of Units and Cost per Unit (51 on the A-D Shelter and Detoxification form): All service codes can be found on the back of your form. Units will either be number of days, number of doses, or number of 15-minute increments for ambulatory services. Cost per unit is either the amount in your agency's contract with the State of Maine, or your normal and customary rate

9.5. Chapter 9 – Reviewing Forms (Screen 5/9)

Each form must be reviewed and signed to ensure accurate and good data. The D-1 Discharge form should be cross-checked with the A-1 Admission form, as there are several fields on the D-1 Discharge form that must match those on the A-1 Admission form.

These are:

A. Date of Birth B. Last Four SS# C. Gender E. Federal Identifier G. Primary Service (On the A-D Shelter and Detoxification form, this is Field H). I. Date of First Face to Face Contact (called Current Admission Date on the A-D Shelter and Detoxification form) 7-9. Primary, Secondary and Tertiary Drugs 10. Tobacco (Even if client quit smoking during treatment)

9.6. Chapter 9 – Reviewing Date Fields (Screen 6/9)

Sometimes it’s hard to keep the key dates clear. They are:

On the A-1 Admission form:

H. Date of First Phone Call (only on A-1 Admission form): Date of client’s first phone call to schedule an appointment.

I. Date of First Face to Face Contact (called “Current Admission Date” on the A-D Shelter and Detoxification form): The first time the client came into your treatment agency.

J. Date of First Treatment Session: The date the client starts treatment, after assessment and admission.

I. Last Face to Face Contact: This would be the date of the client’s last appointment.

9.7. Chapter 9 – Reviewing Dependent Fields 1 (Screen 7/9)

There are several fields at admission that “drive” acceptable answers either on the same A-1 Admission form, or at discharge.

Admission 33. Primary Presenting Problem: If the admission entry was “03-Evaluation Only”: Admission G. Primary Service Code must equal “13- Evaluation”.

Discharge 26. Improvement at Discharge must equal “02-None”.

Discharge 28. Status at Discharge must equal “17-Evaluation only” or “21-Evaluation incomplete”.

Discharge 33.Units at Discharge must equal “15-Evaluation”.

If the Admission entry was “02-Affected/Codependent”:

Admission 34. Primary Drug must equal “00-None”. There should not be any Secondary or Tertiary drugs listed on the A-1 Admission or D-1 Discharge forms.

Discharge 26. Improvement at Discharge must equal “99-Affected/Other”. 9.8. Chapter 9 – Reviewing Dependent Fields 2 (Screen 8/9)

Admission 37. Tobacco Use: If the answer was “01-Yes”, the answer for Discharge 10. Tobacco Use must also be “01-Yes”. If the client quit tobacco use during treatment, indicate this using the appropriate code on Discharge 14. Tobacco Frequency.

Admission 41. Tobacco Frequency and Discharge 14. Tobacco Frequency: The codes for tobacco are different than those for other drugs. Ensure the proper codes were selected.

Admission 60. Use Treatment to satisfy DEEP: If the client was DEEP referred, the answer to Admission 2. Referral Source must be “08-DEEP” or a Correctional code (12, 13, 14, 20, 21, 26, 27, 28, or 29).

Discharge 30-32. Source of Payment: If ‘01-Office of Substance Abuse” is chosen, there must be a contract number in Field F.

Discharge 33. Units of Payment: Refer to the “key” in the manual which shows which codes are appropriate for each primary service code. 9.9. Chapter 9 – Final Review Points (Screen 9/9)

Before you complete your review of the forms, you should note that a couple fields might change between admission and discharge. When your data entry staff enters the codes at discharge, TDS will automatically update the admission record.

These are: D. County of Residence – if the client moved during treatment. F. Contract Number - the contract number will change if the contract year is different at discharge than at admission.

In addition, if the client’s GAF score (field 62 at admission and 27 at discharge) is lower at discharge, the system will confirm this fact with the user. This is to ensure that an incorrect GAF isn’t entered by mistake. If the client’s actual GAF at discharge is lower than at admission, you may want to make special note of this on the form to help the data entry staff.

Once you’ve completed your review, be sure to sign and date each form. 10. Lesson 4: Chapter 10-Types of System Data 10.1. Chapter 10 – What is TDS? (Screen 1/9)

Before we start entering forms, you need to know a little about TDS.

TDS stands for Treatment Data System. TDS was designed specifically for the State of Maine to capture and report all that important information we’ve been talking about. It’s the system that lets decision makers know about needs – like the one for a new treatment facility in Calais. It also lets the State government, lawmakers, and the federal government, know how many people are getting treatment and how it’s working overall. 10.2. Chapter 10 – Web Based System (Screen 2/9)

TDS is a web based system, which basically means that you access it through the internet. You’ll need a computer with high speed internet access.

TDS is also a database system. This means that it stores lots of information in a very structured way. Each item that you input, for instance your Agency’s Federal Identifier number, is put into a table, and has links to the information you enter about your clients. Making sure you enter the right information will ensure that you can find your clients later when you need to locate them in TDS. 10.3. Chapter 10 – TDS Security (Screen 3/9)

Because all of the information you’re putting into TDS is confidential, it needs to be secure. One of the main ways that data is protected is by requiring you to use a username and password when you log into the system. When your username and password are entered, the system checks behind the scenes to make sure you’re authorized to use TDS. 10.4. Chapter 10 – Change Password (Screen 4/9)

Your initial username information will be set up by Maine’s Office of Substance Abuse. Once you get your initial username and password, you should change your password to something meaningful to you. Once you log into the system the first time, you’ll see a “Change Password” link on the menu that will allow you to change it.

It’s important to keep your password in a safe place, and please don’t ever share it with others. 10.5. Chapter 10 – Final Preparation (Screen 5/9)

Before you begin data entry, you’ll always want to make sure your forms are complete. If you can’t read the form, ask the clinician who filled it out to clarify his or her answers.

If you review each form for completeness and readability it will save you time later. Once you start entering a client’s information in the system, you will not be able to save your work if you have to stop and ask for clarification. So make sure you can read the form and that it is complete before you begin. 10.6. Chapter 10 – Early Entry (Screen 6/9)

Make sure you keep track of all the forms that need to be entered.

Remember that the State of Maine, and your agency, could lose credibility and funding if your forms are not entered in a timely fashion. This includes jail-based services provided by your agency. Completed forms must be electronically entered into the system no later than the 15th of the month following the treatment admission or discharge of the client. 10.7. Chapter 10 – More Rules (Screen 7/9)

Before you log in, we need to review a few simple rules of entry:

Numbers only. You will only be entering numbers in the system. If you try to enter dashes, or slashes, or any other characters, the system will not accept your entry. (The ONLY exceptions are the county, contract and referred agency codes.)

Fill all number spaces. If a code on the form has two spaces for numbers, and there is only one number entered, be sure to fill in the first space with a leading zero. For instance, the month of January should be represented with two digits, or “01” and not simply “1”. 10.8. Chapter 10 – More Rules (Screen 8/9)

Skipping questions. The system allows you to skip some questions (noted on the forms) based on your answers to others. If it doesn’t, you have to enter a numeric code.

Finish all fields. You cannot save a partial record in TDS, so make sure you are prepared to enter every field at the same time. 10.9. Chapter 10 – Logging In (Screen 9/9)

When you want to access TDS, you’ll need to type: http://maine.gov/dhhs/osa/data/tds/index.htm into your browser. It might be helpful to save this site as one of your favorites. This will take you to Maine OSA’s website.

On your left hand menu, you’ll see an item called Treatment Data System (TDS). Right under this is an item called “Connect to the Treatment Data System”. Clicking on that menu item will give you the log in box for TDS.

Enter your username and password, then click “ok”. This will take you to the main screen in TDS. 10.10. Chapter 10 – Chapter Test (Screen 1/8)

1. TDS (Treatment Data System) is NOT used for which of the following:

 Learning people’s spending habits.

 Let’s decision makers know about needs.

 Lets State government, lawmakers, and the federal government know how many people are getting treatment.

 Lets State government, lawmakers, and the federal government know how the treatment is working.

2. TDS can be accessed through the internet, which makes it what type of system?

 Web Based System

 Computer System

 Internet System

 Server System

3. TDS stores a lot of information in a very structured way, which makes it what type of system?

 Database System

 Organized System

 Structured System

 Clean System

4. Who should you tell your password to?

 No one.

 Close, personal friends.

 Officemates.

 Whoever asks.

5. Completed forms must be electronically entered into the system no later than what day of the month following the treatment admission or discharge of the client?

 15th

 1st

 30th

6. These are the rules to be aware of them when entering data into the system:

 Numbers only, Fill all number spaces, Skipping questions, Finish all fields.

 All letters, Speedy entry, Mismatched answers, Select and choose answers.

 Special characters, Pick and choose, Every other answer, Answer all questions.

7. What is the correct item to click on in order to get the login screen:

 Connect to the Treatment Data System

 Transfer to TDS

 Login Here

 Click to connect

(Select the correct answer) 11. Lesson 4: Chapter 11-Entering Admission Data 11.1. Chapter 11 – Getting into TDS (Screen 1/12)

On your first screen in TDS, you will have several choices. The first is Episode List by Client, which allows you to search for a client who might have an active admission in TDS in your agency (you won’t be able to search for clients in other agencies).

If your agency has more than one location, or you think the client might have a current admission, it’s a good idea to search for the client before creating a new one. A quick search can save you time later on.

If you’re sure it’s a new client, simply choose Insert Admissions Form (for the A-1 Admission form). 11.2. Chapter 11 – Search for the Client (Screen 2/12)

As a rule of thumb, search for the client using the date of birth and the last four digits of the social security number. You must enter a two digit month, two digit day, and four digit year, and must tab between each entry on the search screen. Once you've entered the search information, click “Execute Search”.

If your agency is a methadone or other high-volume clinic, or you think the client might have a current admission in your agency, it’s a good idea to search for the client before creating a new one. A quick search can save you time later on. 11.3. Chapter 11 – Starting the Admission Form 1 (Screen 3/12)

If your forms are neat and organized, entering data will be very easy. You should move across the form and then down, answering all questions in order. Don’t skip a question unless the form tells you to.

The most important thing to remember is to enter numbers, including all the leading zeros. The only exception to this is on the County of Residence Field (field D), where you will enter a two-letter code. If the field requires a code, you must enter a valid code. The codes are either the numbers that appear in the boxes on the form, or they appear next to the printed answer on the form. 11.4. Chapter 11 – Starting the Admission Form 2 (Screen 4/12)

TDS has some built in “rules”, that will prevent you from making mistakes when submitting the form. However, the quality of the data that goes in is really up to you. So do your best to carefully follow each field in order, entering the values that are on the client’s paper form. 11.5. Chapter 11 – Key Fields and Rules (Screen 5/12)

We’ll walk you through a form that could belong to Susan, and point out a few key fields along the way.

D. County of Residence: This is the only field where you’ll enter a two-letter code.

E. Federal Identifier: Remember it is critical to enter this field correctly. If you put the wrong number in, you will not be able to locate the client at the time of discharge.

Fields H, I and J are date fields. Enter two digits for the month, two digits for the day and four digits for the year. Do not enter dashes or slashes.

NOTICE: This page contains a computer simulation which is not 508/ADA compliant. For additional training information please contact Stacey Chandler (Data Control Specialist) at the Maine Office of Substance Abuse – DHHS at the following telephone number: 207-287-6337 11.6. Chapter 11 – TDS Admission Rules 1 (Screen 6/12)

4. Are Special Services Required to Accommodate Needs? Is actually broken out into five categories, labeled A-E on your form and in the system. You must give a value for each category.

10-14. Dependents: You are entering the number of dependents in each age category. If you enter any numbers for these fields, you may not skip field 15. Skip field 15 if there are no dependents.

16. Pregnant at Admission: TDS will not allow you to save a “yes” value if the gender is 01-Male. If the answer is “yes”, you must answer question 17; otherwise, you should skip 17.

21. Household Income: Enter four numbers only; do not enter a dollar sign. If the value entered on the form is $750, you must enter “0750” in the system.

33. Primary Presenting Problem: If G. Service Code is “13-Evaluation only”, the value here must be “03- Evaluation Only”.

34 – 37. Drugs Used inappropriately: A few key rules apply here:

 If the answer to 33. Primary Presenting Problem is “02-Affected/Co-dependent“, the answer to 34, 35 and 36 must be “0000”. For all other clients, the answer to 34. Primary cannot be “0000”.

 All clients must have entries for the tobacco related questions (37, 41, 45, 49).

 If you enter any value other than “0000” for any of the Drug Fields (34-37), you must enter a value other than “00” on the corresponding Frequency (38-41), Route of Administration (42- 45), and Age of First Use (46-49) fields.

50-51. If the frequency of the Primary Substance (question 38) is “02-No use Past Month”, you must answer questions 50 and 51. Otherwise, skip to question 52. 52. Injection Drug Use: If the answer to this question is “01 Never”, you may skip question 53.

58. Number of Arrests in the last 12 months:

 This number must be equal to or greater than the answer to 60. OUI Arrests in the last 12 months.

 This number must be equal or greater than the answer to 59. Arrests in Prior 30 days.

61. Use Treatment to satisfy DEEP:

 If you enter “01-Yes”, the code entered in 2. Referral must be 08, 12, 13, 14, 20, 21, 26, 27, 28, 29 (which are legal-related fields).

 If the client was DEEP referred (answer to 2. Referral is 08-DEEP), you must answer “01 Yes,” and you must answer question 62. Otherwise, you may skip question 62.

In the beginning, you may need to click "Insert" a few times before everything is corrected, but once you do a few admission forms, you’ll be able to quickly move through this screen and will have a good understanding of the fields and the rules.

NOTICE: This page contains a computer simulation which is not 508/ADA compliant. For additional training information please contact Stacey Chandler (Data Control Specialist) at the Maine Office of Substance Abuse – DHHS at the following telephone number: 207-287-6337 11.11. Chapter 11 – Saving and Fixing Errors (Screen 11/12)

Once you have entered all fields on the admission screen, you need to click “Insert”. This will save your changes if you have no input errors. If you have errors (wrong characters, inconsistent answers, or missed fields), you will get a list of all fields that have errors. You will need to work through these errors and correct them before TDS will save your admission input for the client. 11.12. Chapter 11 – If You Need Help (Screen 12/12)

If you ever need help while you’re entering a form, the TDS Manual is available online, from a link at the bottom of your screen (titled “User Manual”). Once you click on this, it will bring up the User Manual in a pdf file, and you can easily search for the instructions on any field you need.

The TDS helpdesk is available by email link at the bottom of your screen, and by phone as well. 12. Lesson 4: Chapter 12-Entering Discharge Data 12.1. Chapter 12 – Getting Started (Screen 1/8)

To begin, you’ll need to search for the client. Choose “Episode List by Client”, and enter the date of birth and the last four digits of the social security number, then click “Execute Search”. Remember to use only numbers – no dashes or slashes.

The system will give you a list of clients matching your search criteria. If the client matches, choose “Add Disc.”

If you don’t find your client with your first attempt, you might need to try searching using other fields. If you still don't find your client, you’ll need to call the help desk. 12.2. Chapter 12 – Entering the Discharge Form (Screen 1/8)

The first thing you might notice about the discharge screen is that some of the fields are already filled in, based on what you input in admission. Once again, when you enter data you’ll be using number codes only. We’ll use a discharge form that could belong to Susan, and will highlight any critical fields for you. The first field you’ll need to enter is F. Contract Number. This number can change every fiscal year, so it’s important to have the right one.

NOTICE: This page contains a computer simulation which is not 508/ADA compliant. For additional training information please contact Stacey Chandler (Data Control Specialist) at the Maine Office of Substance Abuse – DHHS at the following telephone number: 207-287-6337 12.3. Chapter 12 – TDS Discharge Rules (Screen 3/8)

4. Where were the client’s children during treatment? You may skip this question if the client has no dependent children.

7-10. Drugs listed at admission: Since drugs listed at admission are pre-filled into the discharge form from the admission form, so you may skip straight to question 10.

NOTICE: This page contains a computer simulation which is not 508/ADA compliant. For additional training information please contact Stacey Chandler (Data Control Specialist) at the Maine Office of Substance Abuse – DHHS at the following telephone number: 207-287-6337 12.4. Chapter 12 – TDS Discharge Rules 2 (Screen 4/8)

10. Tobacco Use: If answered "01-Yes” on the Admission form, you must answer “01-Yes” on the Discharge form.

14. Tobacco Frequency: If the client quit smoking during treatment, “09-Quit During Treatment” is the appropriate valid answer.

NOTICE: This page contains a computer simulation which is not 508/ADA compliant. For additional training information please contact Stacey Chandler (Data Control Specialist) at the Maine Office of Substance Abuse – DHHS at the following telephone number: 207-287-6337 12.5. Chapter 12 – TDS Discharge 3 (Screen 5/8)

26. Improvement at Discharge: If the client’s primary presenting concern at admission (field 33) was “03-Evaluation Only”, you must enter “02-No”.

27. Global Assessment of Functioning: When you save the record at the end, you will get a warning if the GAF score you enter is lower than the GAF score entered at admission. The system just wants you to double check your answer, because GAF scores are usually higher at discharge. It will allow you to keep the lower value if that is what is written on the form.

28. Status at Discharge:

 If the client’s primary presenting concern at admission (field 33) was “03-Evaluation Only”, you may only use code “17- Evaluation Only”, or “21-Evaluation not complete”.

 If you enter “30-Left due to lack of child care”, you must answer question 29. Reason. Otherwise, skip to question 30.

30-32. Source of Payment: If ‘01-Office of Substance Abuse” is chosen, you must enter a contract number in Field F.

33. Total Number of Units and Cost per Unit: If the Primary Presenting Problem at admission was “03-Evaluation Only”, you must enter “15” in the Code column.

Remember that cost per unit should be entered with numbers and decimal points. You should not include any dollar signs, but you should input leading zeros if necessary.

The Units of Service Code should correspond with the type of service delivered. For further clarification see page 49 of the User Manual to see which Primary Service codes correspond with each Unit code.

NOTICE: This page contains a computer simulation which is not 508/ADA compliant. For additional training information please contact Stacey Chandler (Data Control Specialist) at the Maine Office of Substance Abuse – DHHS at the following telephone number: 207-287-6337 12.8. Chapter 12 – Saving Your Record (Screen 8/8)

Once you have finished entering all data, you’ll need to save your work by clicking on “Insert”. Like the admission form, if you have incomplete or inconsistent answers, you will get a list of errors that you list of errors which you will need to resolve before you can save the record. Continue to resolve the errors until the form is saved by the system. 13. Lesson 4: Chapter 13-Entering Shelter and Detoxification Data 13.1. Chapter 13 – Getting into TDS (Screen 1/9)

On your first screen in TDS, you will have several choices. The first is Episode List by Client, which allows you to search TDS for a client with an active admission in your agency (Note that you can't search for clients in other agencies).

As indicated with the A-1 Admission form, if your agency has more than one location or you think the client might have a current admission, it’s a good idea to search for the client before creating a new one. If you find your client in the search, you can choose “Add S/D” for the client.

If you’re sure it’s a new client, simply choose Insert Shelter/Detox form (for the A-D Shelter and Detoxification form). 13.2. Chapter 13 – The Form (Screen 2/9)

One thing you’ll notice quickly about the A-D Shelter and Detoxification form entry is that you must complete the admission and discharge elements at the same time. The timing between admission and discharge is very short in these cases, so you can do it all at once.

Just like the A-1 Admission and D-1 Discharge forms, you will be entering only numbers – no dashes or slashes or other characters. The only exception to this is the County Code (field D) where you will enter a two-letter code. Move across the form, answering each question in order, and don’t skip a question unless the system tells you to. For this form, we’ll point out a few key fields along the way. 13.3. Chapter 13 – Starting the Admission Form (Screen 3/9)

D. County of Residence: This is the only field where you’ll enter a two-letter code.

E. Federal Identifier: Remember it is critical to enter this field correctly. If you put the wrong number in, you will not be able to locate the client at the time of discharge.

G. Contract Number: Leave this field blank if your agency does not have a contract with Maine’s Office of Substance Abuse.

Fields A, I and J are date fields. Enter two digits for the month, two digits for the day and four digits for the year. Do not enter dashes or slashes.

NOTICE: This page contains a computer simulation which is not 508/ADA compliant. For additional training information please contact Stacey Chandler (Data Control Specialist) at the Maine Office of Substance Abuse – DHHS at the following telephone number: 207-287-6337 13.4. Chapter 13 –Admission Data (Screen 4/9)

4. Are Special Services Required to Accommodate Needs? This field is actually broken out into five categories that are labeled A-E on your form and in the system. You must give a value for each of the categories.

10. Pregnant at Admission: TDS will not allow you to save a “yes” value if the gender is 01-Male.

11. Where were the Dependents during treatment: You may skip this field if the client has no dependents.

NOTICE: This page contains a computer simulation which is not 508/ADA compliant. For additional training information please contact Stacey Chandler (Data Control Specialist) at the Maine Office of Substance Abuse – DHHS at the following telephone number: 207-287-6337 13.5. Chapter 13 –Admission Data 2 (Screen 5/9)

17 – 20. Drugs Used Inappropriately: A few key rules apply:

 The answer to 17. Primary cannot be “0000”.

 If you enter any value other than “0000” for any of the Drug Fields (17-20), you must enter a value other than “00” on the corresponding Frequency (21-24), Route of Administration (25- 28), and Age of First Use (29-32) fields.

NOTICE: This page contains a computer simulation which is not 508/ADA compliant. For additional training information please contact Stacey Chandler (Data Control Specialist) at the Maine Office of Substance Abuse – DHHS at the following telephone number: 207-287-6337 13.6. Chapter 13 –Admission Data 3 (Screen 6/9)

35. Number of Arrests in the last 12 months:

 This number must be equal to or greater than the answer to 37. OUI Arrests in the last 12 months.

 This number must be equal or greater than the answer to 36. Arrests in Prior 30 days.

NOTICE: This page contains a computer simulation which is not 508/ADA compliant. For additional training information please contact Stacey Chandler (Data Control Specialist) at the Maine Office of Substance Abuse – DHHS at the following telephone number: 207-287-6337 13.7. Chapter 13 –Discharge Data (Screen 7/9)

The discharge information on the A-D Shelter and Detoxification form is very straightforward; there are only a couple fields that need special attention:

46. Status at Discharge: If you enter “30-Left due to lack of child care”, you must answer question 47. Reason. Otherwise, skip to question 48.

NOTICE: This page contains a computer simulation which is not 508/ADA compliant. For additional training information please contact Stacey Chandler (Data Control Specialist) at the Maine Office of Substance Abuse – DHHS at the following telephone number: 207-287-6337 13.8. Chapter 13 –Discharge Data 2 (Screen 8/9)

48-50. Source of Payment: If ‘01-Office of Substance Abuse” is chosen, you must enter a contract number in Field F.

51. Total Number of Units and Cost per Unit: Enter numbers only – no dollar symbol.

NOTICE: This page contains a computer simulation which is not 508/ADA compliant. For additional training information please contact Stacey Chandler (Data Control Specialist) at the Maine Office of Substance Abuse – DHHS at the following telephone number: 207-287-6337 13.9. Chapter 13 – Saving Your Record (Screen 9/9)

Once you have finished entering all data, you’ll need to save your work by clicking on “Insert”. Like the other TDS form, if you have incomplete or inconsistent answers, you will get a list of errors that you will need to resolve before you can save the record. Continue to resolve the errors until the form is saved by the system.

14. Lesson 4: Chapter 14-Tips and Reference 14.1. Chapter 14 – What is TDS? (Screen 1/7)

TDS stands for Treatment Data System. TDS was designed specifically for the State of Maine to capture and report important treatment data, which allows decision makers to know about needs – like the one for a new treatment facility in Calais.

It also lets the State government, lawmakers, and the federal government, know how many people are getting treatment and how it’s working overall. 14.2. Chapter 14 – Getting to TDS (Screen 2/7)

Make sure your forms are filled out and ready for entry, because TDS does not allow you to save partial information. Remember that the accuracy of the information you input has a direct impact on services offered to people who need them.

Your attention to detail makes a difference in people’s lives!

Also, keep track of forms that need to be entered. The State of Maine and your agency lose credibility, and could lose funding, if your forms are not entered within in a timely fashion.

Completed forms must be electronically entered into the system no later than the 15th of the month following the treatment admission or discharge of the client. 14.3. Chapter 14 – TDS Rules of Entry (Screen 3/7)

Don’t forget the rules of TDS:

Use Numbers only.

Fill all number spaces. If a code on a form has 2 spaces, and the code someone entered has only 1 number, make sure you fill in the first space with a leading zero.

Don’t skip questions unless you’re specifically told to do so.

Finish all fields. You cannot save a partial record in TDS, so make sure you are prepared to enter every field at the same time. 14.4. Chapter 14 – TDS Location (Screen 4/7)

You can get to TDS using any internet enabled computer with a high-speed internet connection. Simply put http://www.maine.gov/dhhs/osa/data/tds/ into your browser.

Click on “Connect to the Treatment Data System” on the left hand menu.

Enter the username and password given to you by the Office of Substance Abuse.

Remember to keep your password in a safe place, so others cannot access your agency’s data. 14.5. Chapter 14 – Searching for and Entering the Client (Screen 5/7)

If you’re not sure whether the client has a current admission in your agency, or if your agency has several locations, it’s best to search for your client before adding a new one. Also, if you are entering a D-1 Discharge form, you must locate the client in the system.

A good way to search is to use the birth date and last four numbers of the Social Security Number. If the client does have a record in your agency, you’ll be able to find them.

Then simply click on the action you want to take, and enter all fields in order.

Click “Insert” to save your form. 14.6. Chapter 14 – Getting Help if You need it (Screen 6/7)

If you have any problems or questions, remember you can:

 Access the TDS user manual online

 E-mail the TDS office directly from the system

 Or call the TDS Help Desk at 287-6337.

Once you’re finished entering forms, make sure they are put back in the client’s chart. Your agency is required to keep the paper copy of all TDS forms. 14.7. Chapter 14 – A Final Word (Screen 7/7)

The following is a word of thanks from Susan:

“Thanks for taking the time to learn about data collection in Maine, and how it can impact people like me in a positive way. My family is doing great, and I’m learning to live drug free. It’s all because good data helped to pave the way for a new treatment center in my town. Your job has a lasting impact on people like me, and I’m grateful to you.”