Substance Use Case Management Assessments

To successfully document in a Case Management Assessment, complete all the required data fields under each tab and save the document in Closed Complete status.

Closed Incomplete status is intended for use only when the client is no longer in services and not available to participate in the remainder of the Initial or Update Case Management Assessment process. Placing the document in Closed Incomplete allows the information you documented to be there for others if the client returns. This status also allows you to move forward with documenting the Close Case.

Closed Complete and Closed Incomplete are final document statuses. Ready for Review and Draft statuses are not considered final statuses and the Assessment is not considered complete if in Ready for Review or Draft.

Required data fields are indicated on each screen with a red * asterisk.
Some required fields will auto-fill in the Update Assessment and these fields can also be edited if the client’s situation has changed.
The items in the assessment are designed to be answered for adults and youth. There are items added to the employment section and Family & Social tab of the assessment that will only display when the Client Profile indicates the person is 18 years old or older. All other items will display for all ages.
The Initial and Update Case Management Assessments are available for Substance Use Intervention services, and can be found under the left side Client Services Toolbar > Assessment menu, when an Open Case is in Closed Complete status.
There is not a Discharge, Service End Assessment, or Discharge Follow-up for Case Management services.

Case Management Assessment – Initial

The headings that follow are links to more information about aspects of assessments.

General Tab

The user gathers information about why the client is presenting for case management services and documents that information in the General section. The data fields and questions under the General tab are the same for all clients receiving all service types and of any age.

— Age at First Use (Required)

What was the client’s age when they first used this drug?

For drugs other than alcohol, these fields identify the age at which the client first used the respective substance.

For alcohol, these fields record the age of first intoxication.

Enter the client’s age when substances other than alcohol were first used.

Assessment Information

Assessment Type

How to Document an Assessment

Education & Employment

Legal Tab

Physical Health Tab

The user documents answers to medical questions specifically related to Substance Use Disorder symptoms. These symptoms have co-occuring medical conditions that may increase the severity of the consequences of substance use.

The Clinical Opiate Withdrawal Scale (COWS) and Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-AR) display when the client is receiving services in a Detoxification setting. The COWS will display only for clients with Opioid withdrawal diagnoses. The CIWA-AR will display only for clients with Alcohol Withdrawal diagnoses. The COWS and CIWA are available in the Blank Forms section of CMBHS separate from the Detoxification Assessment for use by contractors during detoxification services.

Mental Health Tab

Case managers document information about the client's mental health in this section.

During the interview, case managers need to make sure the client understands that the symptoms describe experiences that happen when the client is not directly under the influence of mind altering substances. If the client indicates they have experienced certain symptoms while not taking drugs, but possibly while withdrawing from them, add this information in the Comment section. The information gathered is historical and current information.

Family & Social Tab

Users document information about the client's family, social, and living environment in this section.

Substance Use Tab

Users document information about the client's substance use in this section.

Outcome Measures Tab

Pregnancy and Postpartum Intervention Services (PPI) Close Case Intervention Outcome Measures

When Pregnancy and Postpartum Intervention Services PPI is selected as the Service Type when Completing a Close Case, Outcome Measure questions will display. Responses to the questions are required before saving status as Closed Complete, Closed Incomplete, Draft, or Ready for Review. An error message will display prompting the user to answer the questions when a status save is attempted before the Outcome Measure questions are answered.

The questions, along with response choices, are listed below.

Did the client receive all recommended reproductive health visits? Yes No NA
Did the client’s children receive all recommended well child visits? Yes No Unknown
Client reports abstinence at close case for PPI program? Yes No Unknown

Close Case Outcome Measures Tab

Are you currently in school? Yes, No, Unknown, Not Applicable
Are you currently employed? Yes, No, Unknown, Not Applicable
Is the client currently in stable housing? Yes, No, Unknown
Is the client currently incarcerated, detained, or in detention? Yes, No, Unknown
Is the client currently receiving substance use disorder services? Yes, No, Unknown
In the past 30 days, how many times have you been arrested?
Have you/Has participant reduced substance use amount and/or frequency? Yes, No, Unknown
Did the participants child/children receive well child visits (recommended medical check-ups) during the time case was open? Yes, No, Unknown

Parenting Awareness and Drug Risk Education Services (PADRE) Open Close Case Outcome Measures

When Parenting Awareness and Drug Risk Education Services (PADRE) is selected as the Service Type and Completing an Open Case, an additional tab will display with the heading Open Case Outcome Measures. Responses to the questions displayed on this tab are required before saving status as Closed Complete, Closed Incomplete, Draft, or Ready for Review. An error message will display prompting the user to answer the questions when a status save is attempted before the Outcome Measures are answered.

When PADRE is selected as the Service Type and Completing a Close Case, an additional tab will display with the heading Close Case Outcome Measures. Responses to the questions displayed on this tab are required before saving status as Closed Complete, Closed Incomplete, Draft, or Ready for Review. An error message will display prompting the user to answer the questions when a status save is attempted before the Outcome Measures are answered.

Outcome Measure questions are the same for PADRE open case and PADRE close case. The questions are displayed with radio buttons for responses.

The questions, along with response choices, are listed below.

Are you currently in school? Yes No Unknown NA
Are you currently employed? Yes No Unknown NA
Is the client currently in stable housing? Yes No Unknown
Is the client currently incarcerated, detained, or in detention? Yes No Unknown
In the past 30 days, how many times have you been arrested? [text box]
Is the client currently receiving substance use disorder treatment services? Yes No Unknown
Frequency of substance use? [responses displayed in dropdown menu]

No use in the past month.
1-3 times in the past month.
1-2 times in the last week.
3-6 times in the last week.
Daily

Diagnosis Tab

Recommendations

Case Management Update Assessment

The SUD Case Management Update Assessment has the same items displayed as the Initial Case Management Assessment.

CMBHS will carry forward answers — that do not require updated responses from the Initial Case Management Assessment — to questions in the Update Assessment.

The clinician may edit any response carried forward from the Initial Case Management Assessment. These fields should be edited if the client's information or condition has changed.

There are other fields that must always be answered with new information from the client. These will be blank.

The required items display with a red * asterisk.