PURPOSE: This rule describes treatment principles and outcomes in Alcohol and Drug Abuse Treatment Programs, Comprehensive Substance Treatment and Rehabilitation Programs (CSTAR), Compulsive Gambling Treatment Programs, Community Psychiatric Rehabilitation Programs (CPRP), and Psychiatric Outpatient Programs. The performance indicators listed in this rule are examples of how a treatment principle can be met and do not constitute a list of specific requirements. The indicators include not only data that may be compiled by a program but also circumstances that a surveyor may observe or monitor, consumer satisfaction and feedback compiled by the department, and other data that the department may compile and distribute. A program may also use additional or other means to demonstrate achievement of these principles and outcomes.

1. (1) Applying the Treatment Principles. The organization’s service delivery shall apply the key principles listed in this rule in a manner that is:

   1. (A) Adapted to the needs of different populations served;
   2. (B) Understood and practiced by staff in providing services and supports; and
   3. (C) Consistent with clinical studies and practice guidelines for achieving positive outcomes.

2. (2) Outcome Domains. Services shall achieve positive outcomes in the emotional, behavioral, social and family functioning of individuals. Positive outcomes shall be expected to occur in the following domains:

   1. (A) Safety for the individual and others in his or her environment;
   2. (B) Improved management of daily activities, including the management of the symptoms associated with a psychiatric and/or substance use disorder and also the reduction of distress related to these symptoms;
   3. (C) Improved functioning related to occupational/educational status, legal situation, social and family relationships, living arrangements, and health and wellness; and
   4. (D) Consumer satisfaction with services.
3. (3) Outcome Measures and Instruments. An organization shall measure outcomes for the individuals it serves and shall collect data related to the domains listed in section (2) of this rule. In order to promote consistency and the wider applicability of outcome data, the department may require, at its option, the use of designated outcome measures and instruments. The required use of particular measures or instruments shall be applicable only to those services funded by the department or provided through a service network authorized by the department.

4. (4) Essential Treatment Principle— Therapeutic Alliance.

   1. (A) The organization shall promote initial attendance, engagement and development of an ongoing therapeutic alliance by—

      1. 1. Treating people with respect and dig-

nity;

1. 2. Enhancing motivation and self-direc-

tion through identification of meaningful goals that establish positive expectations;

1. 3. Working with other sources (such as

family, guardian or courts) to promote the individual’s participation;

1. 4. Addressing barriers to treatment;
2. 5. Providing consumer and family edu-

cation to promote understanding of services and supports in relationship to individual functioning or symptoms and to promote understanding of individual responsibilities in the process;

1. 6. Encouraging individuals to assume an

active role in developing and achieving productive goals; and

1. 7. Delivering services in a manner that

is responsive to each individual’s age, cultural background, gender, language and communication skills, and other factors, as indicated.

1. (B) Performance Indicators. The following are intended as examples of indicators that can be used by the department and the organization to demonstrate achievement of this essential treatment principle. Indicators of a therapeutic alliance can include, but are not limited to, the following:

   1. 1. Convenient hours of operation consis-

tent with the needs and schedules of persons served;

1. 2. Geographic accessibility including

transportation arrangements, as needed;

1. 3. Rate of attendance at scheduled ser-

vices;

1. 4. Individuals consistently reporting that

staff listen to and understand them;

1. 5. Treatment dropout rate;
2. 6. Rate of successfully completing treat-

ment goals and/or the treatment episode; and

1. 7. Consumer satisfaction and feedback. 9 CSR 10-7

1. (5) Essential Treatment Principle— Individualized Treatment.

   1. (A) Services and supports shall be individualized in accordance with the needs and situation of each individual served.

   2. (B) Performance Indicators. The following are intended as examples of indicators that can be used by the department and the organization to demonstrate achievement of this essential treatment principle. Indicators can include, but are not limited to, the following:

      1. 1. There is variability in the type and

amount of services that individuals receive, consistent with their needs, goals and progress;

1. 2. There is variability in the length of

stay for individuals to successfully complete a level of care or treatment episode, consistent with their severity of need and treatment progress;

1. 3. In structured and intensive levels of

care, group education/counseling sessions are available to deal with special therapeutic issues applicable to some, but not all, individuals;

1. 4. Services on a one-to-one basis

between an individual served and a staff member (such as individual counseling and community support) are routinely available and scheduled, as needed; and

1. 5. Individuals consistently report that

program staffs are helping them to achieve their personal goals.

1. (6) Essential Treatment Principle—Least Restrictive Environment.

   1. (A) Services and supports shall be provided in the most appropriate setting available, consistent with the individual’s safety, protection from harm, and other designated utilization criteria.

   2. (B) Performance Indicators. The following are intended as examples of indicators that can be used by the department and the organization to demonstrate achievement of this essential treatment principle. Indicators can include, but are not limited to the following:

      1. 1. Utilization rate of inpatient hospital-

ization and residential treatment;

1. 2. Length of stay for inpatient and resi-

dential treatment;

1. 3. Consistent use of admission/place-

ment criteria;

1. 4. Distribution of individuals served

among levels of care;

1. 5. Consumer satisfaction and feedback.

1. (7) Essential Treatment Principle—Array of Services.

   1. (A) A range of services shall be available to provide service options consistent with individual need. Emotional, mental, physical and spiritual needs shall be addressed whenever applicable.

      1. 1. The organization has a process that

determines appropriate services and ensures access to the level of care appropriate for the individual.

1. 2. Each individual shall be provided the

least intensive and restrictive set of services, consistent with the individual’s needs, progress, and other designated utilization criteria.

1. 3. To best ensure each individual’s

access to a range of services and supports within the community, the organization shall maintain effective working relationships with other community resources. Community resources include, but are not limited to, other organizations expected to make referrals to and receive referrals from the program.

1. 4. Assistance in accessing transporta-

tion, childcare and safe and appropriate housing shall be utilized as necessary for the individual to participate in treatment and rehabilitation services or otherwise meet recovery goals.

1. 5. Assistance in accessing employment,

vocational and educational resources in the community shall be offered, in accordance with the individual’s recovery goals.

1. (B) Performance Indicators. The following are intended as examples of indicators that can be used by the department and the organization to demonstrate achievement of this essential treatment principle. Indicators can include, but are not limited to, the following:

   1. 1. Percentages of individuals who com-

plete inpatient or residential treatment and receive continuing services on an outpatient basis;

1. 2. Readmission rates to inpatient or res-

idential treatment;

1. 3. Number of individuals receiving

detoxification who continue treatment;

1. 4. Number of individuals who have pro-

gressed from more intensive to less intensive levels of care;

1. 5. Feedback from referral sources and

other community resources; and

1. 6. Consumer satisfaction and feedback.

1. (8) Essential Treatment Principle—Recovery.

   1. (A) Services shall promote the independence, responsibility, and choices of individuals.

      1. 1. An individual shall be encouraged to

achieve positive social, family and occupational/educational functioning in the community to the fullest extent possible.

1. 2. Every effort shall be made to accom-

modate an individual’s schedule, daily activities and responsibilities when arranging services, unless otherwise warranted by factors related to safety or protection from harm.

1. 3. Individuals shall be encouraged to

accomplish tasks and goals in an independent manner without undue staff assistance.

1. (B) Reducing the frequency and severity of symptoms and functional limitations are important for continuing recovery.

2. (C) Performance Indicators. The following are intended as examples of indicators that can be used by the department and the organization to demonstrate achievement of this essential treatment principle. Indicators can include, but are not limited to, the following:

   1. 1. Measures of symptom frequency and

severity;

1. 2. Improved functioning related to—

   1. A. Occupational/educational status;
   2. B. Legal situation;
   3. C. Social and family relationships;
   4. D. Living arrangements; and
   5. E. Health and wellness;
2. 3. Tapering the intensity and frequency

of services, consistent with individual progress; and

1. 4. Consumer satisfaction and feedback.

1. (9) Essential Treatment Principle—Peer Support and Social Networks.

   1. (A) The organization shall mobilize peer support and social networks among those individuals it serves.

      1. 1. The organization shall encourage par-

ticipation in self-help groups.

1. 2. Opportunities and resources in the

community are used by individuals, to the fullest extent possible.

1. (B) Performance Indicators. The following are intended as examples of indicators that can be used by the department and the organization to demonstrate achievement of this essential treatment principle. Indicators can include, but are not limited to, the following:

   1. 1. Rate of participation in community-

based self help groups;

1. 2. Involvement with a wide range of

individuals in social activities and networks (such as church, clubs, sporting activities, etc.);

1. 3. Open discussion of therapeutic issues

in group counseling and education sessions with individuals giving constructive feedback to one another; and

1. 4. Consumer satisfaction and feedback.

1. (10) Essential Treatment Principle—Family Involvement.

   1. (A) Efforts shall be made to involve family members, whenever appropriate, in order to promote positive relationships.

      1. 1. Family ties and supports shall be

encouraged in order to enrich and support recovery goals.

1. 2. Family members shall be routinely

informed of available services, and the program shall demonstrate the ability to effectively engage family members in a recovery process.

1. 3. When the family situation has been

marked by circumstances that may jeopardize safety (such as domestic violence, child abuse and neglect, separation and divorce, or financial and legal difficulties), family members shall be encouraged to participate in education and counseling sessions to better understand these effects and to reduce the risk of further occurrences.

1. (B) Particular emphasis on family involvement shall be demonstrated by those programs serving adolescents and children.

2. (C) Performance Indicators. The following are intended as examples of indicators that can be used by the department and the organization to demonstrate achievement of this essential treatment principle. Indicators can include, but are not limited to, the following:

   1. 1. Rate of family participation in treat-

ment planning;

1. 2. Rate of family participation in direct

services, such as family therapy;

1. 3. Improved family relationships;
2. 4. Reduction of family conflict; and
3. 5. Satisfaction of family members with

services.

1. (11) Pharmacological Treatment. When clinically indicated for the person served, pharmacological treatment shall be provided or arranged to ameliorate psychiatric and substance abuse problems.

2. (12) Co-Occurring Disorders. For individuals with clearly established co-occurring disorders, coordinated services for these disorders shall be provided or arranged.

   1. (A) Each individual shall have access to a full range of services provided by qualified, trained staff.

   2. (B) Each individual shall receive services necessary to fully address his/her treatment needs. The program providing screening and assessment shall—

      1. 1. Directly provide all necessary ser-

vices in accordance with the program’s capabilities and certification;

1. 2. Make a referral to a program which

can provide all necessary services and maintain appropriate involvement until the individual is admitted to the other program; or

1. 3. Provide those services within its

capability and promptly arrange additional services from another program.

1. (C) Services shall be continuously coordinated between programs, where applicable. Programs shall—

   1. 1. Ensure that services are not redun-

dant or conflicting; and

1. 2. Maintain communication regarding

the individual’s treatment plan and progress.

AUTHORITY: sections 630.050 and 630.055, RSMo 2000.* Original rule filed Feb. 28, 2001, effective Oct. 30, 2001. *Original authority: 630.050, RSMo 1980, amended 1993, 1995 and 630.055, RSMo 1980.