Standards for public agencies

2020 Edition

Opioid Treatment (PA-OTP) 16: Case Closing and Aftercare

The agency 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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Individuals who participate in Opioid Treatment Programs improve social, emotional, and vocational functioning, achieve optimal productivity, and attain the recovery they seek.
Full Implementation, Outstanding Performance
A rating of (1) indicates that the agency's practices fully meet the standard and reflect a high level of capacity.  
  • All elements or requirements outlined in the standard are evident in practice, with rare or no exceptions: exceptions do not impact service quality or agency performance. 
Substantial Implementation, Good Performance
A rating of (2) indicates that an agency's infrastructure and practices are basically sound but there is room for improvement.
  • The majority of the standards requirements have been met and the basic framework required by the standard has been implemented. 
  • Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality or agency performance.

Partial Implementation, Concerning Performance
A rating of (3) indicates that the agency's observed infrastructure and/or practices require significant improvement.  

  • The agency has not implemented the basic framework of the standard but instead has in place only part of this framework.  
  • Omissions or exceptions to the practices outlined in the standard occur regularly, or practices are implemented in a cursory or haphazard manner.  
  • Service quality or agency functioning may be compromised.  
  • Capacity is at a basic level.
Unsatisfactory Implementation or Performance
A rating of (4) indicates that implementation of the standard is minimal or there is no evidence of implementation at all.  
  • The agency’s observed service delivery infrastructure and practices are weak or non-existent; or show signs of neglect, stagnation, or deterioration.
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

PA-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.

PA-OTP 16.02

Upon case closing, the agency notifies any collaborating service providers, including the courts, as appropriate.

PA-OTP 16.03

When appropriate, the agency 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.


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.

PA-OTP 16.04

The agency 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.