A discharge assessment is completed when an admitted client will no longer be receiving any services from the provider. The discharge assessment documents the client’s problems and needs at admission, progress or lack of progress during treatment, and the circumstances of the discharge, including the client’s condition and living situation at discharge.
Although only a subgroup of the initial assessment questions must be answered for the discharge assessment, they are primarily questions that address the client’s current condition in the 30 days prior to discharge. It is the responsibility of the clinician to review all the assessment questions and enter any other important information about the client.
If the client is subject to GPRA reporting, then you will also need to complete a GPRA assessment in addition to the Initial SUD assessment upon Discharge.
The following instructions apply to both mental health and substance use Discharge Assessments. When variation exists for either service type, it is noted.
The questions and data fields that display in the CMBHS Discharge Assessment are determined according to the user’s location and program type (mental health or substance use).
The Discharge GPRA Assessment will only be visible/available for Treatment and Recovery Support Service locations with a Service Type of "Opioid". You will be able to initiate the Discharge GPRA Assessment only when the Initial GPRA Assessment is in the "Closed Complete" status.
You must have a CMBHS role that gives you access to the Discharge section. If it is within your job responsibilities, you may have access to edit Discharge GPRA Assessment data. For a list of Read-Only and Read-Write page rights according to roles, click here .
You must complete all the required fields in the Discharge Assessment before it can be placed in Closed Complete status.
On the Client Services Toolbar, left, select Discharge, and then Discharge Client. On the page that displays:
Enter the Discharge Date.
Enter the Discharge Time.
Enter the Discharge reason. Select the correct reason from the dropdown list. The reasons are:
Complete the Discharge Performed By from the dropdown listing agency staff.
Select the document status as Closed Complete. Do not save the document at this point. Assessment must be completed first.
Before you can document a Discharge Assessment, the client must have an Initial SUD Assessment in Closed Complete or Closed Incomplete status for the current Episode of Care. It is not required that an Update SUD Assessment be completed prior to documentation of a Discharge Assessment.
At the top of the Discharge Assessment page, you will see a row of nine labelled tabs.
The tabs are labelled: General, Education & Employment, Legal, Physical Health, Mental Health, Family & Social, Substance Use, Diagnosis, and Recommendation.
At the top of the Discharge GPRA Assessment page, you will see a row of 11 labelled tabs.
The tabs are labelled: Record Management, Behavioral Health Diagnoses, Drug & Alcohol Use, Family & Living Conditions, Education, Employment, & Income, Crime & Criminal Justice Status, Mental & Physical Health, Social Connectedness, Follow-Up Status, Discharge Status, and Services Received
The questions and data fields in this section pertains to the client’s discharge information and is only completed at discharge. A discharge assessment is completed when an admitted client will no longer be receiving any services from the provider. The discharge assessment documents the client’s problems and needs at admission, progress or lack of progress during treatment, and the circumstances of the discharge, including the client’s condition and living situation at discharge.
It is the responsibility of the clinician to review all the assessment questions and enter any other important information about the client.
Business Rules
Document the client’s experience in the past month. Presenting Problem will be pre-filled from an earlier Assessment. However, the text box can be edited if there is a change.
Primary, Secondary, and Tertiary substances are pre-filled from earlier interviews. However, you can change any of these fields, including Route of Administration of the drug, Frequency of Use, and Age of First Use, from the dropdown lists.
Record what substances the client has sought in the past 30 days in the text box. TYPE in how many days the client has used, and has not used. These numbers are required to add up to 30.
Select a Yes or No radio button as to whether the client has Literacy, Language, or Auditory challenges. Comments can be typed in the text box at the end of this section.
To document a New Service Provider, click on the button with that name in the next section. Choose the Provider Type from the dropdown list. Type the name of the provider and the phone number in the text boxes for those fields. Click Add to record the provider, or Cancel to close this part of the form without saving.
The next eight tabs on the Discharge Assessment screen are mostly prefilled with information from earlier assessments. However, there are open fields that require your input in each of these tabs. Review the contents of each tab carefully to see what information you need to add, and then save the Discharge information with the Save or Save and Continue buttons at the upper or lower right side of your screen.
Administrative Discharges are regularly scheduled to occur every Monday, Wednesday, Friday and Sunday at 1:30 a.m. An administrative discharge will be entered in client’s record if no activity is confirmed in a client’s record for 50 days or more. When client records remain open and no activity or services are occurring, this trend will negatively impact performance measures and is not a clinically sound practice.
Contractors cannot intentionally leave records open for more than 50 days for instance if a client was incarcerated and would be returning to treatment. Contractors need to take steps to discharge the client from services and in CMBHS.
Contractors can identify current records that have been inactive and stand to be administratively discharged by running the “Active Clients Not Receiving Services” report; located under the CMBHS Client Reports
*Instructions to identify active client records not receiving services.
The report may be run at the Provider/Parent location or at the Clinic/Child location. If the report is run at the Provider/Parent location the data will be displayed by clinic location. If the report is run at the Clinic/Child location it will only display data for that clinic.
After a clinic number is in current location drop down location
1. Click on Data
2. Click on Reports
3. Click on CMBHS Report
4. Click on Active Clients Not Receiving Services
The Discharge Summary is an important document because it summarizes the client’s problems at admission, the assessment results, the treatment services delivered by the provider, and the client’s response. It also includes an overview of the discharge plan and referrals.
CMBHS has designed the Discharge Summary so that the user can select the information to be included and then create a draft through an automated process, edit the draft, and then produce a final document — an individualized Discharge Summary for the client’s episode of care.
To access the Discharge Summary page, you must be in the Client Workspace.
From the Clinician’s Workspace
From the Client’s Workspace
The Discharge Summary selection brings up the Episode of Care screen, and the first section is Service Components.
The user must first select the component type/s and then the corresponding date and quantity.
The Discharge Information page displays, showing the Individual Elements of the Service Types for the client. Click the Next button to view the Discharge Summary page pre-populated with the information CMBHS has compiled about the client.
When you select Discharge Summary from the Client Services Toolbar on the left side of the screen, CMBHS first displays the Episode of Care page. By making the selections on this page, you are customizing the Discharge Summary. CMBHS pulls information from the client’s record for the selected episode of care to populate data fields in the summary. CMBHS displays only the information you select for inclusion in the summary.
The Texas Administrative Code requires completion of a Discharge Follow-up for all clients leaving substance use disorder treatment. This documents how the client is doing after they’ve been discharged. Follow-up information is collected at various intervals depending on the treatment funding source, and the type of treatment the client received. These requirements are found in the provider’s HHSC Contract.
To assist with timely completion, CMBHS sends reminders to providers that the Discharge Follow-up is due. Discharge Follow-ups can still be completed for a client, however, even if the HHSC deadline is missed.
Business entities and CMBHS locations that provide treatment services will have access to the Discharge Follow-up Reminder List.
The user must be assigned a role that allows him/her to document a Discharge Follow-up in CMBHS.
Click here to view tables of all CMBHS pages and what roles have Read-Only or Read-Write access to the pages.
The client must have been discharged from your business entity (provider).
If a client’s Reason for Discharge on the Discharge Assessment was death; referred to another substance use treatment program; or change in provider status, a Discharge Follow-up Reminder will not be generated by CMBHS.
Discharge Follow-up Reminders are displayed on the Discharge Follow-up Reminder List, found on the Administrative Toolbar (at the top of each CMBHS page) under the menu item, Provider Tools > Administrative Action Lists.
For clients who received a substance use treatment service, Residential or Outpatient type, the reminder will be sent 60 days after the client’s discharge date from the provider. The provider must complete the Discharge Follow-up within 90 days of the date of discharge to receive credit from HHSC. This gives the provider 30 days to complete the Discharge Follow-up.
For clients who received Detoxification Services, the reminder will display on the Discharge Follow-up Reminder List nine (9) days after the discharge date. The Detox provider must complete the Discharge Follow-up within 30 days of the date of discharge to receive credit from HHSC. This gives the provider 20 days to complete the Discharge Follow-up. The message will also disappear from the Reminder List.
When the Discharge Follow-up for the client is marked as Closed Complete, the Discharge Follow-up reminder is automatically removed from the Discharge Follow-up Reminder List and no longer displays.
Even though there is no reminder in the list, a Discharge Follow-up can still be created from the Client Workspace, under the Discharge menu item on the Client Services Toolbar.
If a client’s Reason for Discharge on the Discharge Assessment was death; referred to another substance abuse treatment program; or change in provider status, a Discharge Follow-up Reminder will not be generated by CMBHS.
Discharge Follow-up Reminders are displayed on the Discharge Follow-up Reminder List found in the Administrative Toolbar (at the top of every CMBHS page) under Provider Tools > Administrative Action Lists > Discharge Follow-up Reminders.
The Discharge Follow-up Reminders List can be seen by many of the users at a location. The Business entity/location must develop a process to ensure that discharge follow-up contacts occur in a timely manner to meet the requirements of their contract with HHSC.
When the Discharge Follow-up for the client is marked as Closed Complete, the Discharge Follow-up reminder is automatically removed from the Discharge Follow-up Reminder List and no longer displays.
|
NOTE: Once the reminder has disappeared from the list, it cannot be brought back or the action reversed, but a Discharge Follow-up can still be created using the Discharge Menu on the Client Services Toolbar at the left side of the page. |
The Discharge Follow-up Reminder List will automatically display the following information about the client:
The options available to the user when viewing the Discharge Follow-up Reminder List are to:
For clients who have received substance use services, CMBHS will also send a Discharge Follow-up reminder to the Primary Clinician’s Workspace.
For clients who have received any substance use service type (except detoxification services), the reminder will be sent 60 days after the discharge date. For clients who received detoxification services, the reminder will be sent 10 days after discharge.
The reminder will display in the Message box on the Clinician’s Workspace used by the Primary Counselor and will include a link to the Client Workspace. The link allows the user to quickly access the client’s record for documentation of the Discharge Follow-up.
A reminder will not be sent for clients who receive mental health services only.
If a client’s Reason for Discharge on the Discharge Assessment was death; referred to another substance use treatment program; or change in provider status, a Discharge Follow-up Reminder will not be generated by CMBHS.