Adult System of Care Policy & Procedure

Santa Clara Valley Health & Hospital System

Substance Use Treatment Services (SUTS)

Adult System of Care


The Policy and Procedure Manual for the Substance Use Treatment Services' (SUTS) Adult System of Care (ASOC) is a “work-in-progress”, changing and expanding as Treatment System evolves. As needed, representatives from the Provider network and SUTS Administration work together to create or improve System processes and develop policy. The SUTS Quality Improvement (QI) Division formally records the processes in the form of policies and procedures and distributes them System-wide to be retained in this Manual.

Following is a description of the organizational layout of the Manual to assist you in finding the information you need. The Manual consists of a Table of Contents, the Policies and Procedures, and the Appendices. Each Policy and Procedure is assigned a number (top right, each page) and grouped into sections marked by colored tabs numbered one through ten. At the end of the sectional tabs, the four appendices are separated and labeled “A” through “D”. Appendix “D” is subdivided into six colored tabs, “D-1” through “D-6”.

Table of Contents

Section 1: Client Entry Into the System
Policies and Procedures related to a client’s entry into SUTS Adult System of Care: DADS Referral for Services through Gateway, and client placement.

Section 2: Client Movement Through The System
Policies and Procedures related to a client’s movement through the System: transferring or increasing a client's level of care and making referrals to other services in the System.

Section 3: Clinical
Policies and Procedures related to clinical issues: clinical standards, special clinical issues and populations, medical issues, and chart documentation.

Section 4: Communication
Policies and Procedures related to all types of communication: client confidentiality and “reporting” client and/or System information both inside and outside the System.

Section 5: Client Exit from the System
Policies and Procedures related to a client’s exit from the System: voluntary and involuntary discharges; client rights, and grievance and appeals process.

Section 6: Quality Improvement/Assurance
Policies and Procedures related to quality improvement: client outcomes and Provider performance, Unicare User Name Request and Unicare Data Entry information

Section 7: Continuous Recovery Monitoring (CRM)
Policies and Procedures related to Continuous Recovery Monitoring

Section 8: Drug Medi-Cal
Policies and Procedures related to Drug Medi-Cal.

Sections 9 - 10:

Included for future expansion.

Appendix A: Performance Measures
The Performance Measures for the current Fiscal Year are still being developed.

Appendix B: Counselor Resource Materials
Other resource materials for counselors, such as Best Practices Guide and The Clinician’s Guide.

Appendix C: THU Standards
The Transitional Housing Unit (THU) Standards.

Appendix D: Client Tx Forms
All the standardized forms used throughout the System. Note: any form that is referenced or discussed in the policies and procedures in the Manual will be found in Appendix D. These forms are useful as visual aids when orienting or training new staff. Appendix D is subdivided as follows: Appendix D is subdivided as follows:

Tab D-1:

Forms: The Capacity Report

Tab D-2:

Forms used primarily for client movement: entry, referrals, and transfers

Tab D-3:

Forms used primarily during client treatment, i.e., related to clinical tasks

Tab D-4:

Forms used primarily for “reporting” purposes, i.e., client status or System feedback

Tab D-5:

Forms used in the client outcome measurement process

Tab D-6:

Forms used in Continuous Recovery Monitoring (CRM)

If you have questions or suggestions concerning this Manual, please contact Pauline Casper, SUTS QI Coordinator at 1-408-792-5218 or email [email protected]

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