Standards for private organizations

2020 Edition

Opioid Treatment (OTP) 16: Case Closing and Aftercare

The organization works with persons served and family members, when appropriate, to plan for case closing and, when possible, to develop aftercare plans.
2020 Edition

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Purpose

Individuals who participate in Opioid Treatment Programs improve social, emotional, and vocational functioning, achieve optimal productivity, and attain the recovery they seek.
1
All elements or requirements outlined in the standard are evident in practice, as indicated by full implementation of the practices outlined in the Practice Standards.
2
Practices are basically sound but there is room for improvement, as noted in the ratings for the Practice Standards; e.g.,   
  • Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality; or
  • Procedures need strengthening; or
  • With few exceptions, procedures are understood by staff and are being used; or
  • Proper documentation is the norm and any issues with individual staff members are being addressed through performance evaluations and training; or
  • In a few instances, the organization terminated services inappropriately; or  
  • Active client participation occurs to a considerable extent; or
  • A formal case closing evaluation is not consistently provided to the public authority per the requirements of the standard.
3
Practice requires significant improvement, as noted in the ratings for the Practice Standards. Service quality or program functioning may be compromised; e.g.,
  • Procedures and/or case record documentation need significant strengthening; or
  • Procedures are not well-understood or used appropriately; or
  • Services are frequently terminated inappropriately; or  
  • Aftercare planning is not initiated early enough to ensure orderly transitions; or
  • A formal case closing summary and assessment is seldom provided to the public authority per the requirements of the standard; or  
  • Several client records are missing important information; or
  • Client participation is inconsistent. 
4
Implementation of the standard is minimal or there is no evidence of implementation at all, as noted in the ratings for the Practice Standards; e.g.,
  • No written procedures, or procedures are clearly inadequate or not being used; or 
  • Documentation is routinely incomplete and/or missing. 
Self-Study EvidenceOn-Site EvidenceOn-Site Activities
  • Case closing procedures
  • Aftercare planning and follow-up procedures
No On-Site Evidence
  • Interviews may include:
    1. Program director
    2. Relevant personnel
    3. Persons served
  • Review case records

OTP 16.01

Planning for case closing:
  1. is a clearly defined process that includes assignment of staff responsibility;
  2. begins at intake; and
  3. involves the worker, persons served and others, as appropriate to the needs and wishes of the individual.

OTP 16.02

Upon case closing, the organization notifies any collaborating service providers, as appropriate.

OTP 16.03

When appropriate, the organization works with persons served and their family to develop an aftercare plan, sufficiently in advance of case closing, that: 
  1. identifies short- and long-term needs and goals; and 
  2. facilitates the initiation or continuation of needed supports and services.

Interpretation

The aftercare plan must include relapse prevention. The plan should also address re-entry into maintenance treatment in the event of relapse. Plans for meeting the individual’s physical and mental health needs following medically supervised withdrawal should also be indicated, as appropriate.

OTP 16.04

The organization follows up on the aftercare plan, as appropriate, when possible, and with the permission of the service recipient.
Examples: Reasons why follow-up may not be appropriate include, but are not limited to, cases where the person’s participation is involuntary, or where there may be a risk to the service recipient such as in cases of domestic violence.