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pdfAttachment B1- N-SSATS 2019 questionnaire (Version A) (as of 2/25/2019)
OMB No. xxxx-xxxx
APPROVAL EXPIRES: xx/xx/xxxx
See OMB burden statement on last page
National Survey of
Substance Abuse Treatment Services
(N-SSATS)
March 29, 2019
Substance Abuse and Mental Health Services Administration (SAMHSA)
U.S. Department of Health and Human Services (HHS)
PLEASE REVIEW THE FACILITY INFORMATION PRINTED ABOVE.
CROSS OUT ERRORS AND ENTER CORRECT OR MISSING INFORMATION.
CHECK ONE
Information is complete and correct, no changes needed
All missing or incorrect information has been corrected
PLEASE READ THIS ENTIRE PAGE BEFORE
COMPLETING THE QUESTIONNAIRE
Would you prefer to complete this questionnaire online? See the pink flyer enclosed in your
survey packet for the Internet address and your unique user ID and password. You can log on and
off the website as often as needed to complete the questionnaire. When you log on again, the
program will take you to the next unanswered question. If you need more information, call the
N-SSATS helpline at 1-888-324-8337.
INSTRUCTIONS
Most of the questions in this survey ask about “this facility.” By “this facility” we mean the specific
treatment facility or program whose name and location are printed on the front cover. If you have any
questions about how the term “this facility” applies to your facility, please call 1-888-324-8337.
Please answer ONLY for the specific facility or program whose name and location are printed on the
front cover, unless otherwise specified in the questionnaire.
If the questionnaire has not been completed online, return the completed questionnaire in the envelope
provided. Please keep a copy for your records.
For additional information about this survey and definitions of some of the terms used, please visit our
website at https://info.nssats.com.
If you have any questions or need additional blank surveys, contact:
MATHEMATICA POLICY RESEARCH
1-888-324-8337
NSSATSWeb@mathematica-mpr.com
IMPORTANT INFORMATION
* Asterisked questions. Information from asterisked (*) questions may be published in SAMHSA’s online
Behavioral Health Treatment Services Locator (found at https://findtreatment.samhsa.gov), in
SAMHSA’s National Directory of Drug and Alcohol Abuse Treatment Programs, and other publicly-available
listings, unless you designate otherwise in question 35, page 15 of this questionnaire.
Mapping feature in online Locator. Complete and accurate name and address information is needed for
SAMHSA’s online Behavioral Health Treatment Services Locator so it can correctly map the facility location.
Eligibility for online Locator and Directory. Only facilities designated as eligible by their state substance
abuse office and that complete this questionnaire will be listed as substance abuse facilities in the online
Locator and Directory. Your state N-SSATS representative can tell you if your facility is eligible to be listed
in the online Locator and Directory. For the name and telephone number of your state representative, call
the N-SSATS helpline at 1-888-324-8337.
SECTION A: FACILITY
CHARACTERISTICS
*2b.
Section A asks about characteristics of
individual facilities and should be completed for
this facility only, that is, the treatment facility or
program at the location listed on the front cover.
*1.
Which of the following substance abuse services
are offered by this facility at this location, that is,
the location listed on the front cover?
3.
4.
MARK “YES” OR “NO” FOR EACH
YES
0
2. Detoxification .................................... 1
0
3. Substance use treatment ................. 1
0
5.
(services that focus on initiating and
maintaining an individual’s recovery
from substance abuse and on
averting relapse)
4. Any other substance abuse
1a.
*2a.
*6.
Yes
0
No
SKIP TO Q.4 (NEXT COLUMN)
1
Yes
0
No
SKIP TO Q.32 (PAGE 14)
Is this facility a jail, prison, or other organization
that provides treatment exclusively for
incarcerated persons or juvenile detainees?
1
Yes
0
No
SKIP TO Q.36 (PAGE 15)
Is this facility a solo practice, meaning, an office
with only one independent practitioner or
counselor?
1
Yes
0
No
Is this facility a Federally Qualified Health Center
(FQHC)?
To which of the following clients does this facility,
at this location, offer mental health treatment
services (interventions such as therapy or
psychotropic medication that treat a person’s
mental health problem or condition, reduce
symptoms, and improve behavioral functioning
and outcomes)?
FQHCs include: (1) all organizations that receive
grants under Section 330 of the Public Health
Service Act; and (2) other organizations that do
not receive grants, but have met the requirements
to receive grants under Section 330 according to
the U.S. Department of Health and Human
Services.
MARK ALL THAT APPLY
For a complete definition of a FQHC, go to:
1
Substance abuse clients
2
Clients other than substance abuse clients
3
2.
0
1
Did you answer “yes” to substance use treatment
in option 3 of question 1?
NO
1. Intake, assessment, or referral ........ 1
services .............................................. 1
Does this facility routinely use medications during
detoxification?
https://info.nssats.com
No clients are offered mental health treatment
services
Did you answer “yes” to detoxification in option 2
of question 1 above?
1
Yes
0
No
SKIP TO Q.3 (TOP OF NEXT COLUMN)
7.
1
Yes
0
No
d
Don’t know
What is the primary focus of this facility at this
location, that is, the location listed on the front
cover?
MARK ONE ONLY
1
Substance use treatment services
2
Mental health services
Does this facility detoxify clients from . . .
MARK “YES” OR “NO” FOR EACH
1.
2.
3.
4.
5.
6.
YES
Alcohol ............................................... 1
Benzodiazepines ............................... 1
Cocaine ............................................. 1
Methamphetamines ........................... 1
Opioids .............................................. 1
Other (Specify: ______________ ) .... 1
NO
0
0
0
0
0
0
3
Mix of mental health and substance use
treatment services (neither is primary)
4
General health care
5
Other (Specify: ___________________ )
1
*8.
Is this facility operated by . . .
*10a. Which of the following RESIDENTIAL services are
offered at this facility?
MARK ONE ONLY
1
A private for-profit organization
2
A private non-profit organization
3
State government
4
5
6
*8a.
MARK “YES” OR “NO” FOR EACH
SKIP TO
Q.9
(BELOW)
YES
1. Residential detoxification .................... 1
Local, county, or community
government
2. Residential short-term treatment ........ 1
Which Federal Government agency?
3. Residential long-term treatment ......... 1
MARK ONE ONLY
*9.
Department of Veterans Affairs
2
Department of Defense
3
Indian Health Service
4
Other (Specify: _____________ )
*9a.
Yes
0
No
*11.
SKIP TO Q.10 (BELOW)
YES
1. Hospital inpatient detoxification .......... 1
2. Hospital inpatient treatment ................ 1
NO
0
1
Yes
0
No
SKIP TO Q.12 (TOP OF NEXT PAGE)
YES
0
NOTE: ASAM is the American Society of Addiction Medicine.
For more information on ASAM please go to https://info.nssats.com.
2
Does this facility offer RESIDENTIAL (non-hospital)
substance abuse services at this location, that is,
the location listed on the front cover?
No
SKIP TO Q.10a (TOP OF NEXT COLUMN)
SKIP TO Q.11 (NEXT COLUMN)
1. Outpatient detoxification ..................... 1
NO
0
0
0
0
0
(similar to ASAM Levels I-D and II-D,
ambulatory detoxification)
2. Outpatient methadone/
(similar to ASAM Levels IV and III.7,
medically managed or monitored
intensive inpatient treatment)
0
MARK “YES” OR “NO” FOR EACH
(similar to ASAM Levels IV-D and
III.7-D, medically managed or
monitored inpatient detoxification)
Yes
0
*11a. Which of the following OUTPATIENT services are
offered at this facility?
Which of the following HOSPITAL INPATIENT
services are offered at this facility?
1
Does this facility offer OUTPATIENT substance
abuse services at this location, that is, the location
listed on the front cover?
MARK “YES” OR “NO” FOR EACH
*10.
0
(similar to ASAM Levels III.3 and III.1,
clinically managed medium- or lowintensity residential treatment,
typically more than 30 days)
SKIP TO
Q.10
(BELOW)
Does this facility offer HOSPITAL INPATIENT
substance abuse services at this location, that is,
the location listed on the front cover?
1
(similar to ASAM Level III.5, clinically
managed high-intensity residential
treatment, typically 30 days or less)
Federal Government
1
0
(similar to ASAM Level III.2-D,
clinically managed residential
detoxification or social detoxification)
SKIP TO
Q.10
(BELOW)
Tribal government
NO
buprenorphine maintenance or
naltrexone treatment .......................... 1
3. Outpatient day treatment
or partial hospitalization ..................... 1
(similar to ASAM Level II.5, 20 or
more hours per week)
4. Intensive outpatient treatment ............ 1
(similar to ASAM Level II.1, 9 or more
hours per week)
5. Regular outpatient treatment .............. 1
(similar to ASAM Level I, outpatient
treatment, non-intensive)
*12. Which of the following services are offered by this
facility at this location, that is, the location listed on
the front cover?
MARK ALL THAT APPLY
Assessment and Pre-Treatment Services
1
2
3
4
5
6
7
8
9
Screening for substance abuse
Screening for mental disorders
Comprehensive substance abuse assessment or
diagnosis
Comprehensive mental health assessment or
diagnosis (for example, psychological or
psychiatric evaluation and testing)
Screening for tobacco use
Outreach to persons in the community who may
need treatment
Interim services for clients when immediate
admission is not possible
Professional interventionist/educational consultant
We do not offer any of these assessment and
pre-treatment services
Testing (include tests performed at this location, even if
specimen is sent to an outside source for chemical
analysis.)
11
12
13
14
15
16
17
18
19
10
Drug and alcohol oral fluid testing
Breathalyzer or other blood alcohol testing
Drug or alcohol urine screening
Testing for Hepatitis B (HBV)
Testing for Hepatitis C (HCV)
HIV testing
STD testing
TB screening
Testing for metabolic syndrome
We do not offer any of these testing services
Medical Services
20
21
22
Hepatitis A (HAV) vaccination
Hepatitis B (HBV) vaccination
We do not offer any of these medical services
Transitional Services
23
24
25
26
27
Discharge planning
Aftercare/continuing care
Naloxone and overdose education
Outcome follow-up after discharge
We do not offer any of these transitional services
Recovery Support Services
Mentoring/peer support
Self-help groups (for example, AA, NA, SMART
Recovery)
30 Assistance in locating housing for clients
31 Employment counseling or training for clients
32 Assistance with obtaining social services (for
example, Medicaid, WIC, SSI, SSDI)
33 Recovery coach
34 We do not offer any of these recovery support
services
Education and Counseling Services
35 HIV or AIDS education, counseling, or support
36 Hepatitis education, counseling, or support
37 Health education other than HIV/AIDS or Hepatitis
38 Substance abuse education
39 Smoking/tobacco cessation counseling
40 Individual counseling
41 Group counseling
42 Family counseling
43 Marital/couples counseling
44 Vocational training or educational support (for
example, high school coursework, GED
preparation, etc.)
45 We do not offer any of these education and
counseling services
28
29
Ancillary Services
46
47
48
49
50
51
52
53
54
55
Case management services
Social skills development
Child care for clients’ children
Domestic violence—family or partner violence
services (physical, sexual, and emotional abuse)
Early intervention for HIV
Transportation assistance to treatment
Mental health services
Acupuncture
Residential beds for clients’ children
We do not offer any of these ancillary services
Other Services
56
57
58
59
Treatment for gambling disorder
Treatment for Internet use disorder
Treatment for other addiction disorder
(non-substance abuse)
We do not offer any of these other services
3
Pharmacotherapies
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
4
Disulfiram (Antabuse®)
Naltrexone (oral)
Naltrexone (extended-release, injectable, for example, Vivitrol®)
Acamprosate (Campral®)
Nicotine replacement
Non-nicotine smoking/tobacco cessation medications (for example, bupropion, varenicline)
Medications for psychiatric disorders
Methadone
Buprenorphine with naloxone (for example, Suboxone®, Bunavail®, Zubsolv®)
Buprenorphine without naloxone
Buprenorphine sub-dermal implant (Probuphine®)
Buprenorphine (extended-release, injectable, for example, Sublocade®)
Medications for HIV treatment (for example, antiretroviral medications such as tenofovir, efavirenz, emtricitabine,
atazanavir, and lamivudine)
Medications for Hepatitis C (HCV) treatment (for example, sofosbuvir, ledipasvir, interferon, peginterferon, ribavirin)
Lofexidine
Clonidine
We do not offer any of these pharmacotherapy services
*13.
Facilities may treat a range of substance use disorders. The next series of questions focuses only on how this
facility treats opioid use disorder.
How does this facility treat opioid use disorder?
Medication assisted treatment (MAT) includes the use of methadone, buprenorphine and/or naltrexone for the
treatment of opioid use disorder. For this question, MAT refers to any or all of these medications unless specified.
MARK ALL THAT APPLY
1
2
3
4
5
6
7
This facility does not treat opioid use disorder.
This facility uses methadone or buprenorphine for pain management, emergency
cases, or research purposes. It is NOT a federally-certified Opioid Treatment
Program (OTP).
This facility treats opioid use disorder, but it does not use medication assisted
treatment (MAT), nor does it accept clients using MAT to treat opioid use disorder.
SKIP TO
Q.14
(TOP OF NEXT
PAGE)
This facility accepts clients using MAT, but the medications originate from or are
prescribed by another entity. (The medications may or may not be
stored/delivered/monitored onsite.)
This facility administers naltrexone to treat opioid use disorder. Naltrexone use is
authorized through any medical staff who have prescribing privileges.
This facility prescribes buprenorphine to treat opioid use disorder. Buprenorphine
use is authorized through a DATA 2000 waivered physician, physician assistant, or
nurse practitioner.
SKIP TO
Q.13b
(BELOW)
This facility is a federally-certified Opioid Treatment Program (OTP). (Most OTPs
administer/dispense methadone; some only use buprenorphine.)
*13a. From where do these clients obtain their medications?
MARK ALL THAT APPLY
1
The prescribing entity is in our network.
2
There is a business, contractual, or formal referral relationship with the prescribing entity.
3
The client obtains their prescription/medication from their personal physician/health care provider.
4
Other (Specify: ______________________________________________________ )
*13b. Does this facility serve only opioid use disorder clients?
1
Yes
0
No
*13c. Which of the following medication services does this program provide?
MARK ALL THAT APPLY
1
Maintenance services with methadone or buprenorphine
2
Maintenance services with medically-supervised withdrawal (or taper) after a period of stabilization
3
Detoxification from opioids of abuse with methadone or buprenorphine
4
Detoxification from opioids of abuse with lofexidine or clonidine
5
Relapse prevention with naltrexone
6
Other (Specify: ______________________________________________________ )
7
We do not offer any of these medication services
5
13d.
Approximately what percent of clients on MAT receive the following medication services for opioid use
disorder?
MARK ONE BOX FOR EACH SERVICE
RECEIVED BY
SERVICE
NOT OFFERED
RECEIVED BY
33% OR LESS
RECEIVED BY
34% TO 67%
OF CLIENTS
OF CLIENTS
MORE THAN
67% OF
CLIENTS
1
2
3
4
1
2
3
4
3. Detoxification from opioids of abuse with methadone or buprenorphine
1
2
3
4
4. Detoxification from opioids of abuse with lofexidine or clonidine
1
2
3
4
5. Relapse prevention with naltrexone
1
2
3
4
6. Other (Specify: ________________________________________)
1
2
3
4
1. Maintenance services with methadone or buprenorphine
2. Maintenance services with medically-supervised withdrawal (or taper)
after a period of stabilization
6
*14.
Facilities may treat a range of substance use disorders. The next series of questions focuses only on how this
facility treats alcohol use disorder.
How does this facility treat alcohol use disorder?
These medications have been approved by FDA to treat alcohol use disorder: Naltrexone, acamprosate, and
disulfiram. For this question, MAT refers to any or all of these three medications.
MARK ALL THAT APPLY
1
2
3
4
This facility does not treat alcohol use disorder.
SKIP TO Q.15 (TOP OF NEXT PAGE)
This facility treats alcohol use disorder, but it does not use medication assisted
treatment (MAT) for alcohol use disorder, nor does it accept clients using MAT to
treat alcohol use disorder.
SKIP TO Q.14b (BELOW)
This facility accepts clients using MAT for alcohol use disorder, but the medications
originate from or are prescribed by another entity.
This facility administers/prescribes at least one of Disulfiram (Antabuse®), naltrexone, and/or
acamprosate (Campral®) for alcohol use disorder.
SKIP TO Q.14b (BELOW)
*14a. From where do these clients obtain their medications?
MARK ALL THAT APPLY
1
The prescribing entity is in our network.
2
There is a business, contractual, or formal referral relationship with the prescribing entity.
3
The client obtains their prescription/medication from their personal physician/health care provider.
4
Other (Specify: ______________________________________________________ )
*14b. Does this facility serve only alcohol use disorder clients?
1
Yes
0
No
7
*15. Which of the following clinical/therapeutic approaches listed below are used frequently at this facility?
MARK ALL THAT APPLY
3
4
5
6
7
8
9
10
11
12
13
14
15
16
1
2
8
Substance abuse counseling
12-step facilitation
Brief intervention
Cognitive behavioral therapy
Dialectical behavior therapy
Contingency management/motivational incentives
Motivational interviewing
Trauma-related counseling
Anger management
Matrix Model
Community reinforcement plus vouchers
Rational emotive behavioral therapy (REBT)
Relapse prevention
Telemedicine/telehealth (including Internet, Web, mobile, and desktop programs)
Other treatment approach (Specify: _________________________________________________ )
We do not use any of these clinical/therapeutic approaches
*16.
Does this facility, at this location, offer a specially
designed program or group intended exclusively
for DUI/DWI or other drunk driver offenders?
1
Yes
0
No
SKIP TO Q.17 (BELOW)
*16a. Does this facility serve only DUI/DWI clients?
*17.
*18b. In what other languages do staff counselors
provide substance use treatment at this facility?
Do not count languages provided only by on-call
interpreters.
MARK ALL THAT APPLY
American Indian or Alaska Native:
Yes
1
Hopi
1
No
2
Lakota
0
3
Navajo
4
Ojibwa
5
Yupik
Does this facility provide substance use
treatment services in sign language at this
location for the deaf and hard of hearing (for
example, American Sign Language, Signed
English, or Cued Speech)?
6
Mark “yes” if either a staff counselor or an on-call
interpreter provides this service.
*18.
Other American Indian or Alaska Native
language
(Specify: ___________________________ )
1
Yes
Other Languages:
0
No
7
Arabic
8
Any Chinese language
9
Creole
Does this facility provide substance use
treatment services in a language other than
English at this location?
1
Yes
0
No
SKIP TO Q.19 (TOP OF NEXT PAGE)
18a. At this facility, who provides substance use
treatment services in a language other than
English?
MARK ONE ONLY
1
2
Staff counselor who speaks a language other
than English
On-call interpreter (in person or by phone)
brought in when needed
SKIP TO Q.19
(TOP OF NEXT
PAGE)
3
BOTH staff counselor and on-call interpreter
*18a1. Do staff counselors provide substance use
treatment in Spanish at this facility?
1
Yes
0
No
SKIP TO Q.18b (TOP OF NEXT COLUMN)
18a2. Do staff counselors at this facility provide
substance use treatment in any other
languages?
1
Yes
GO TO Q.18b (TOP OF NEXT COLUMN)
0
No
SKIP TO Q.19 (TOP OF NEXT PAGE)
10
Farsi
11
French
12
German
13
Greek
14
Hebrew
15
Hindi
16
Hmong
17
Italian
18
Japanese
19
Korean
20
Polish
21
Portuguese
22
Russian
23
Tagalog
24
Vietnamese
25
Any other language
(Specify: ___________________________ )
9
*19. Individuals seeking substance use treatment can vary by age, gender or other characteristics. Which
categories of individuals listed below are served by this facility, at this location?
Indicate only the highest or lowest age the facility would accept. Do not indicate the highest or lowest age
currently receiving services in the facility.
MARK “YES” OR “NO” FOR
EACH CATEGORY
TYPE OF CLIENT
1. Female
1
1
2. Male
IF SERVED, WHAT IS
THE LOWEST AGE SERVED
SERVED BY THIS FACILITY
Yes
Yes
0
0
No
| | |
YEARS
No
| | |
YEARS
*19a. Many facilities have clients in one or more of the
following categories. For which client categories
does this facility at this location offer a substance
use treatment program or group specifically
tailored for clients in that category? If this facility
treats clients in any of these categories but does
not have a specifically tailored program or group
for them, do not mark the box for that category.
MARK ALL THAT APPLY
1
Adolescents
2
Young adults
3
Adult women
4
Pregnant/postpartum women
5
Adult men
6
Seniors or older adults
7
Veterans
9
Active duty military
10
Members of military families
11
Criminal justice clients (other than DUI/DWI)
13
Clients with co-occurring pain and substance
use
Clients with HIV or AIDS
15
Clients who have experienced sexual abuse
17
18
19
10
Clients with co-occurring mental and substance
abuse disorders
14
16
0
*20.
Clients who have experienced intimate partner
violence, domestic violence
Clients who have experienced trauma
Specifically tailored programs or groups for any
other types of clients
No minimum age
| | |
YEARS
0
No maximum age
No minimum age
| | |
YEARS
0
No maximum age
Does this facility use a sliding fee scale?
Sliding fee scales are based on income and other
factors.
1
Yes
0
No
SKIP TO Q.21 (BELOW)
20a. Do you want the availability of a sliding fee scale
published in SAMHSA’s online Locator and
Directory?
The online Locator and Directory will explain that
potential clients should call the facility for
information on eligibility.
*21.
Lesbian, gay, bisexual, transgender (LGBT)
clients
8
12
0
IF SERVED, WHAT IS
THE HIGHEST AGE SERVED
1
Yes
0
No
Does this facility offer treatment at no charge or
minimal payment (for example, $1) to clients who
cannot afford to pay?
1
Yes
0
No
SKIP TO Q.22 (BELOW)
21a. Do you want the availability of treatment at no
charge or minimal payment (for example, $1) for
eligible clients published in SAMHSA’s online
Locator and Directory?
The online Locator and Directory will explain that
potential clients should call the facility for
information on eligibility.
*22.
1
Yes
0
No
Does this facility receive any funding or grants
from the Federal Government, or state, county or
local governments, to support its substance use
treatment programs?
Do not include Medicare, Medicaid, or federal
military insurance. These forms of client
payments are included in Q.23.
(Specify: ___________________________)
1
Yes
No specifically tailored programs or groups are
offered
0
No
d
Don’t know
*23.
Which of the following types of client payments or insurance are accepted by this facility for substance use
treatment?
MARK “YES,” “NO,” OR “DON’T KNOW” FOR EACH
YES
NO
DON’T
KNOW
1. No payment accepted (free treatment for ALL clients) ............................................................... 1
0
d
2. Cash or self-payment .................................................................................................................. 1
0
d
3. Medicare ..................................................................................................................................... 1
0
d
4. Medicaid ...................................................................................................................................... 1
0
d
5. State-financed health insurance plan other than Medicaid......................................................... 1
0
d
6. Federal military insurance (e.g., TRICARE) ............................................................................... 1
0
d
7. Private health insurance ............................................................................................................. 1
0
d
8. IHS/Tribal/Urban (ITU) funds ...................................................................................................... 1
0
d
9. Other ........................................................................................................................................... 1
0
d
(Specify: ______________________________)
11
SECTION B:
REPORTING CLIENT COUNTS
24.
Questions 25 through 30 ask about the number
of clients in treatment. If possible, report
clients for this facility only. However, we realize
that is not always possible. Please indicate
whether the clients you report will be for . . .
MARK ONE ONLY
1
Only this facility
2
This facility plus others
3
SKIP TO Q.25
(TOP OF NEXT COLUMN)
HOSPITAL INPATIENT CLIENT COUNTS
25.
On March 29, 2019, did any patients receive
HOSPITAL INPATIENT substance abuse services at
this facility?
1 Yes
0 No
SKIP TO Q.26 (TOP OF NEXT PAGE)
25a. On March 29, 2019, how many patients received the
following HOSPITAL INPATIENT substance abuse
services at this facility?
COUNT a patient in one service only, even if the
patient received both services.
DO NOT count family members, friends, or other
non-treatment patients.
ENTER A NUMBER FOR EACH
(IF NONE, ENTER “0”)
Another facility will report this facility’s
client counts
SKIP TO Q.31 (PAGE 14)
1. Hospital inpatient detoxification _____________
(Similar to ASAM Levels IV-D
and III.7-D, medically managed or
monitored inpatient detoxification)
2. Hospital inpatient treatment
_____________
(Similar to ASAM Levels IV
and III.7, medically managed or
monitored intensive inpatient treatment)
24a. How many facilities will be included in your
client counts?
THIS FACILITY
1
HOSPITAL INPATIENT
TOTAL BOX
+ ADDITIONAL FACILITIES
TOTAL FACILITIESα
α
For Section B, please include all of these
facilities in the client counts that you report
in questions 25 through 30.
NOTE: ASAM is the American Society of Addiction Medicine.
For more information on ASAM please go to https://info.nssats.com.
25b. How many of the patients from the HOSPITAL
INPATIENT TOTAL BOX were under the age of 18?
ENTER A NUMBER
(IF NONE, ENTER “0”)
Number under age 18
24b. To avoid double-counting clients, we need to know
which facilities are included in your counts. How
will you report this information to us?
MARK ONE ONLY
1
2
By listing the names and location addresses of
these additional facilities in the “Additional
Facilities Included in Client Counts” section on
page 16 of this questionnaire or attaching a sheet
of paper to this questionnaire
Please call me for a list of the additional facilities
included in these counts
25c.
How many of the patients from the HOSPITAL
INPATIENT TOTAL BOX received:
Include patients who received these drugs for
detoxification, maintenance, or relapse prevention
for opioid use disorder.
ENTER A NUMBER FOR EACH
(IF NONE, ENTER “0”)
1.
2.
3.
12
_______________
Methadone dispensed at this
facility for opioid use disorder _______________
Buprenorphine dispensed or
prescribed at this facility
for opioid use disorder
_______________
Naltrexone administered
at this facility for
opioid use disorder
_______________
25d. How many of the patients from the HOSPITAL
INPATIENT TOTAL BOX received:
Include clients who received these medications for
alcohol use disorder.
26b. How many of the clients from the RESIDENTIAL
TOTAL BOX were under the age of 18?
ENTER A NUMBER
(IF NONE, ENTER “0”)
ENTER A NUMBER FOR EACH
(IF NONE, ENTER “0”)
Disulfiram (Antabuse®) dispensed
or prescribed at this facility
for alcohol use disorder
_______________
2. Naltrexone dispensed
or prescribed at this facility
for alcohol use disorder
_______________
3. Acamprosate (Campral®) dispensed
or prescribed at this facility
for alcohol use disorder
_______________
25e. On March 29, 2019, how many hospital inpatient
beds were specifically designated for substance
use treatment?
1.
Number under age 18
26c. How many of the clients from the RESIDENTIAL
TOTAL BOX received:
Include clients who received these drugs for detoxification,
maintenance, or relapse prevention for opioid use disorder.
ENTER A NUMBER FOR EACH
(IF NONE, ENTER “0”)
1. Methadone dispensed at this
facility for opioid use disorder _______________
2. Buprenorphine dispensed or
prescribed at this facility
for opioid use disorder
26.
at this facility for
opioid use disorder
_______________
RESIDENTIAL (NON-HOSPITAL)
CLIENT COUNTS
26d.
On March 29, 2019, did any clients receive
RESIDENTIAL (non-hospital) substance abuse
services at this facility?
1 Yes
0 No
SKIP TO Q.27 (NEXT COLUMN)
1. Residential detoxification
___________
(Similar to ASAM Level III.2-D,
clinically managed residential
detoxification or social detoxification)
2. Residential short-term treatment
How many of the clients from the RESIDENTIAL
TOTAL BOX received:
Include clients who received these medications for
alcohol use disorder.
1.
2.
3.
Disulfiram (Antabuse®) dispensed
or prescribed at this facility
for alcohol use disorder
_______________
Naltrexone dispensed
or prescribed at this facility
for alcohol use disorder
_______________
Acamprosate (Campral®) dispensed
or prescribed at this facility
for alcohol use disorder
_______________
26e. On March 29, 2019, how many residential beds were
specifically designated for substance use
treatment?
ENTER A NUMBER
(IF NONE, ENTER “0”)
Number of beds
_______________
___________
(Similar to ASAM Level III.5,
clinically managed high-intensity
residential treatment, typically
30 days or less)
3. Residential long-term treatment
_______________
ENTER A NUMBER FOR EACH
(IF NONE, ENTER “0”)
26a. On March 29, 2019, how many clients received the
following RESIDENTIAL substance abuse services
at this facility?
COUNT a client in one service only, even if the
client received multiple services.
DO NOT count family members, friends, or other
non-treatment clients.
ENTER A NUMBER FOR EACH
(IF NONE, ENTER “0”)
_______________
3. Naltrexone administered
ENTER A NUMBER
(IF NONE, ENTER “0”)
Number of beds
_______________
___________
(Similar to ASAM Levels III.3 and
III.1, clinically managed medium- or
low-intensity residential treatment,
typically more than 30 days)
OUTPATIENT CLIENT COUNTS
27.
During the month of March 2019, did any clients
receive OUTPATIENT substance abuse services at
this facility?
1
Yes
SKIP TO Q.27a (TOP OF NEXT PAGE)
0
No
SKIP TO Q.28 (TOP OF PAGE 14)
RESIDENTIAL
TOTAL BOX
13
27a. As of March 29, 2019, how many active clients were
receiving each of the following OUTPATIENT
substance abuse services at this facility?
27c. How many of the clients from the OUTPATIENT
TOTAL BOX received:
Include clients who received these drugs for
detoxification, maintenance, or relapse prevention for
opioid use disorder.
An active client is a client who received treatment in
March AND is still enrolled in treatment on March 29,
2019.
ENTER A NUMBER FOR EACH
(IF NONE, ENTER “0”)
COUNT a client in one service only, even if the
client received multiple services.
DO NOT count family members, friends, or other
non-treatment clients.
ENTER A NUMBER FOR EACH
(IF NONE, ENTER “0”)
1. Outpatient detoxification
2. Outpatient methadone/
2.
Buprenorphine dispensed or
prescribed at this facility
for opioid use disorder
_______________
3.
Naltrexone administered
at this facility for
opioid use disorder
_______________
_________
buprenorphine maintenance
or naltrexone treatment
(Count methadone/buprenorphine/
naltrexone clients on this line only)
3. Outpatient day treatment
27d.
How many of the clients from the OUTPATIENT
TOTAL BOX received:
Include clients who received these medications for
alcohol use disorder.
_________
or partial hospitalization
(Similar to ASAM Level II.5,
20 or more hours per week)
ENTER A NUMBER FOR EACH
(IF NONE, ENTER “0”)
1.
4. Intensive outpatient treatment
_________
(Similar to ASAM Level II.1,
9 or more hours per week)
5. Regular outpatient treatment
_________
(Similar to ASAM Level I,
outpatient treatment,
non-intensive)
OUTPATIENT
TOTAL BOX
27b. How many of the clients from the OUTPATIENT
TOTAL BOX were under the age of 18?
ENTER A NUMBER
(IF NONE, ENTER “0”)
14
Methadone dispensed at this
facility for opioid use disorder _______________
_________
(Similar to ASAM
Levels I-D and II-D,
ambulatory detoxification)
Number under age 18
1.
_______________
2.
3.
Disulfiram (Antabuse®) dispensed
or prescribed at this facility
for alcohol use disorder
_______________
Naltrexone dispensed
or prescribed at this facility
for alcohol use disorder
_______________
Acamprosate (Campral®) dispensed
or prescribed at this facility
for alcohol use disorder
_______________
ALL SUBSTANCE ABUSE
TREATMENT SETTINGS
SECTION C:
GENERAL INFORMATION
Including Hospital Inpatient,
Residential (non-hospital) and/or Outpatient
28.
This question asks you to categorize the substance
use treatment clients at this facility into three
groups: clients in treatment for (1) abuse of both
alcohol and substances other than alcohol; (2)
abuse only of alcohol; or (3) abuse only of
substances other than alcohol.
Enter the percent of clients on March 29, 2019, who
were in each of these three groups:
Clients in treatment for abuse of:
*31.
Yes
0
No
SKIP TO Q.32 (BELOW)
MARK ONE ONLY
___________%
2. ONLY alcohol
1
*31a. What type of hospital?
1. BOTH alcohol and substances
other than alcohol
Is this facility a hospital or located in or operated
by a hospital?
1
General hospital (including VA hospital)
2
Psychiatric hospital
3
___________%
Other specialty hospital, for example,
alcoholism, maternity, etc.
(Specify: ___________________________ )
3. ONLY substances other than
alcohol
___________%
TOTAL
29.
100
*32.
%
Approximately what percent of the substance use
treatment clients enrolled at this facility on March
29, 2019, had a diagnosed co-occurring mental and
substance abuse disorder?
*33.
Does this facility operate transitional housing, a
halfway house, or a sober home for substance
abuse clients at this location, that is, the location
listed on the front cover?
1
Yes
0
No
Which of the following statements BEST describes
this facility’s smoking policy for clients?
MARK ONE ONLY
PERCENT OF CLIENTS
(IF NONE, ENTER “0”)
30.
%
Using the most recent 12-month period for which
you have data, approximately how many substance
use treatment ADMISSIONS did this facility have?
OUTPATIENT CLIENTS: Count admissions into
treatment, not individual treatment visits. Consider
an admission to be the initiation of a treatment
program or course of treatment. Count any
re-admission as an admission.
1
Not permitted to smoke anywhere outside or
within any building
2
Permitted in designated outdoor area(s)
3
Permitted anywhere outside
4
Permitted in designated indoor area(s)
5
Permitted anywhere inside
6
Permitted anywhere without restriction
IF THIS IS A MENTAL HEALTH FACILITY: Count
all admissions in which clients received substance
use treatment, even if substance abuse was
their secondary diagnosis.
NUMBER OF SUBSTANCE
ABUSE ADMISSIONS IN A
12-MONTH PERIOD
15
*34.
Is this facility or program licensed, certified, or accredited to provide substance abuse services by any of the
following organizations?
Do not include personal-level credentials or general business licenses such as a food service license.
MARK “YES,” “NO,” OR “DON’T KNOW” FOR EACH
YES
NO
DON’T
KNOW
1. State substance abuse agency ..................................................................................................... 1
0
d
2. State mental health department .................................................................................................... 1
0
d
3. State department of health ............................................................................................................ 1
0
d
4. Hospital licensing authority ............................................................................................................ 1
0
d
5. The Joint Commission ................................................................................................................... 1
0
d
6. Commission on Accreditation of Rehabilitation Facilities (CARF) ................................................ 1
0
d
7. National Committee for Quality Assurance (NCQA) ..................................................................... 1
0
d
8. Council on Accreditation (COA) .................................................................................................... 1
0
d
9. Healthcare Facilities Accreditation Program (HFAP) .................................................................... 1
0
d
10. Other national organization or federal, state, or local agency ....................................................... 1
0
d
(Specify: ___________________________________________________________ )
35.
If eligible, does this facility want to be listed in the Directory and the online Locator? (See inside front cover
for eligibility information)
The Directory will be available at https://www.samhsa.gov/data/substance-abuse-facilities-data-nssats
The Locator can be found at: https://findtreatment.samhsa.gov
1
Yes
0
No
SKIP TO Q.36 (BELOW)
35a. To increase public awareness of behavioral health services, SAMHSA may be sharing facility contact
information with large commercially available Internet search engines, such as Google, Bing, Yahoo!, etc. Do
you want your facility information shared on these Internet search engines?
Information to be shared would be: facility name, location address, telephone number, and website address.
36.
1
Yes
0
No
Who was primarily responsible for completing this form? This information will only be used if we need to
contact you about your responses. It will not be published.
MARK ONE ONLY
1
Ms
2
Mrs
3
Mr
4
Dr
5
Other (Specify: ___________________________________ )
Name: ____________________________________________________________________________________
Title: ______________________________________________________________________________________
Phone Number:
(_____) _______ - _________
Fax Number:
(_____) _______ - _________
Ext. ________
Email Address: _____________________________________________________________________________
Facility Email Address: _______________________________________________________________________
16
ADDITIONAL FACILITIES INCLUDED IN CLIENT COUNTS
Complete this section if you reported clients for this facility plus other facilities, as indicated in Question 24.
For each additional facility, please mark if that facility offers hospital inpatient, residential and/or outpatient
substance abuse services at that location.
FACILITY NAME:
FACILITY NAME:
ADDRESS:
ADDRESS:
CITY:
CITY:
STATE:
ZIP:
STATE:
PHONE:
PHONE:
FACILITY EMAIL
ADDRESS:
FACILITY EMAIL
ADDRESS:
HOSPITAL INPATIENT
RESIDENTIAL
OUTPATIENT
HOSPITAL INPATIENT
FACILITY NAME:
FACILITY NAME:
ADDRESS:
ADDRESS:
CITY:
CITY:
STATE:
ZIP:
PHONE:
FACILITY EMAIL
ADDRESS:
FACILITY EMAIL
ADDRESS:
RESIDENTIAL
OUTPATIENT
HOSPITAL INPATIENT
FACILITY NAME:
FACILITY NAME:
ADDRESS:
ADDRESS:
CITY:
CITY:
STATE:
ZIP:
PHONE:
FACILITY EMAIL
ADDRESS:
FACILITY EMAIL
ADDRESS:
RESIDENTIAL
OUTPATIENT
HOSPITAL INPATIENT
OUTPATIENT
ZIP:
RESIDENTIAL
STATE:
PHONE:
HOSPITAL INPATIENT
RESIDENTIAL
STATE:
PHONE:
HOSPITAL INPATIENT
ZIP:
OUTPATIENT
ZIP:
RESIDENTIAL
If you require additional space, please continue on the next page.
OUTPATIENT
ANY ADDITIONAL COMMENTS
PLEDGE TO RESPONDENTS: The information you provide will be protected to the fullest extent allowable under the Public Health Service Act (42 USC
290aa(p)). This law permits the public release of identifiable information about an establishment only with the consent of that establishment and limits the
use of the information to the purposes for which it was supplied. With the explicit consent of treatment facilities, information provided in response to survey
questions marked with an asterisk may be published in SAMHSA’s online Behavioral Health Treatment Services Locator, the National Directory of Drug
and Alcohol Abuse Treatment Programs, and other publicly-available listings. Responses to non-asterisked questions will be published with no direct link
to individual treatment facilities.
Thank you for your participation. Please return this questionnaire in the envelope provided.
If you no longer have the envelope, please mail this questionnaire to:
MATHEMATICA POLICY RESEARCH
ATTN: RECEIPT CONTROL - Project 50345
P.O. Box 2393
Princeton, NJ 08543-2393
Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it
displays a currently valid OMB control number. The OMB control number for this project is xxxx-xxxx. Public reporting burden for this collection of
information is estimated to average xx minutes per respondent, per year, including the time for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate
or any other aspect of this collection of information, including suggestions for reducing this burden, to SAMHSA Reports Clearance Officer, 5600
Fishers Lane, Room 15E57-B, Rockville, Maryland 20857.
18
| File Type | application/pdf |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |