Form N-SSATS 2014 abbre N-SSATS 2014 abbre N-SSATS 2014 abbreviated questionnaire

U.S. Department of Health and Human Services Attachment B2 (N-SSATS 2014 Abbreviated Questionnaire)

FORM APPROVED:

OMB No. 0930-xxxx

APPROVAL EXPIRES: xx/xx/xxxx

See OMB burden statement on last page

National Survey of

Substance Abuse Treatment Services

(N-SSATS)

March 31, 2014

Substance Abuse and Mental Health Services Administration (SAMHSA)

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

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 http://info.nssats.com.

• I

  Would you prefer to complete this questionnaire online? See the pink flyer enclosed in your questionnaire 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.

  f you have any questions or need additional blank forms, contact:

MATHEMATICA POLICY RESEARCH

1-888-324-8337

NSSATSWeb@mathematica-mpr.c om

IMPORTANT INFORMATION

_* Asterisked questions. Information from asterisked (_*) questions will be published in SAMHSA’s National Directory of Drug and Alcohol Abuse Treatment Programs and will be available online at http://findtreatment.samhsa.gov, SAMHSA’s Substance Abuse Treatment Facility Locator.

Mapping feature in Locator. Complete and accurate name and address information is needed for the online Treatment Facility Locator so it can correctly map the facility location.

Eligibility for Directory/Locator. Only facilities designated as eligible by their state substance abuse office will be listed in the National Directory and online Treatment Facility Locator. Your state N-SSATS representative can tell you if your facility is eligible to be listed in the Directory/Locator. For the name and telephone number of your state representative, call the N‑SSATS helpline at 1-888-324-8337.

1. Which of the following substance abuse services are offered by this facility at this location, that is, [fill LOCATION ADDRESS]?

MARK “YES” OR “NO” FOR EACH

YES NO

1. Intake, assessment, or referral 1  0 

2. Detoxification 1  0 

3. Substance abuse treatment

(services that focus on initiating and

maintaining an individual’s recovery

from substance abuse and on averting

relapse) 1  0 

4. Any other substance abuse

services 1  0 

1a. Does this facility, at this location, offer mental health treatment services (services focused on improving the mental well-being of individuals with mental disorders and on promoting their recovery)?

1  YES

0  NO

2. DID RESPONDENT ANSWER “YES” TO DETOXIFICATION IN OPTION 2 OF QUESTION 1 ABOVE?

1  YES SKIP TO Q.4 (BELOW)

0  NO

3. DID RESPONDENT ANSWER “YES” TO SUBSTANCE ABUSE TREATMENT IN OPTION 3 OF QUESTION 1?

1  YES

0  NO SKIP TO Q.34 (PAGE 5)

4. Is this facility operated by . . .

MARK ONE ONLY

1  A private for-profit organization

2  A private non-profit organization

3  State government

4  Local, county, or community

government

5  Tribal government

6  Federal Government

4a. Which Federal Government agency?

MARK ONE ONLY

1  Department of Veterans Affairs

2  Department of Defense

3  Indian Health Service

4  Other (Specify: )

7. 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.9 (BELOW)

7a. Just to confirm, this facility provides substance abuse treatment services only to incarcerated persons or juvenile detainees. Is that correct?

1  YES, THAT IS CORRECT SKIP TO Q.41

(PAGE 5)

0  NO, THAT IS NOT CORRECT

*9. What telephone number(s) should a potential client call to schedule an intake appointment?

1. (______) ________ - ____________ ext._____

2. (______) ________ - ____________ ext._____

10. Which of the following pharmacotherapies are provided by this facility at this location, that is, [fill LOCATION ADDRESS]?

MARK “YES” OR “NO” FOR EACH

YES NO

51. Methadone 1  0 

52. Buprenorphine with naloxone

(Suboxone^®) 1  0 

53. Buprenorphine without naloxone 1  0 

*11. Does this facility operate an Opioid Treatment Program (OTP) at this location?

• OTPs are certified by SAMHSA’s Center for Substance Abuse Treatment to use the opioid drugs methadone and buprenorphine in the treatment of opioid (narcotic) addiction.

• Some SAMHSA-certified OTPs use only buprenorphine in the treatment of opioid (narcotic) addiction.

• Physicians with a x-waiver may prescribe buprenorphine without being affiliated with an OTP. Therefore, not all facilities that prescribe buprenorphine are OTPs.

1  YES

0  NO SKIP TO Q.15 (NEXT PAGE)

*11a. Are ALL of the substance abuse clients at this facility currently in the Opioid Treatment Program?

1  YES

0  NO

*11b. Does the Opioid Treatment Program at this location provide maintenance services, detoxification services, or both?

MARK ONE ONLY

1  Maintenance services

2  Detoxification services

3  Both

*15. 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.16 (BELOW)

* 15a. Does this facility serve only DUI/DWI clients?

1  YES

0  NO

*16. Does this facility provide substance abuse treatment services in sign language at this location for the hearing impaired (for example, American Sign Language, Signed English, or Cued Speech)?

READ IF NECESSARY: You should answer “yes” if either a staff counselor or an on‑call interpreter provides this service.

1  YES

0  NO

*17. Does this facility provide substance abuse treatment services in a language other than English at this location?

1  YES

0  NO SKIP TO Q.18 (PAGE 3)

17a. At this facility, who provides substance abuse treatment services in a language other than English?

MARK ONE ONLY

1  Staff counselor who speaks a language

other than English

2  On-call interpreter (in person or by phone)

brought in when needed SKIP TO Q.18

(PAGE 3)

3  BOTH staff counselor and on-call

Interpreter

*17a1. Do staff counselors provide substance abuse treatment in Spanish at this facility?

1  YES

0  NO SKIP TO Q.17b (BELOW)

17a2. Do staff counselors at this facility provide substance abuse treatment in any other languages?

1  YES

0  NO SKIP TO Q.18 (PAGE 3)

*17b. In what other languages do staff counselors provide substance abuse treatment at this facility?

READ IF NECESSARY: Do not count languages provided only by on-call interpreters.

MARK “YES” OR “NO” FOR EACH

American Indian or Alaska Native:

YES NO

Hopi 1  0 

Lakota 1  0 

Navajo 1  0 

Ojibwa 1  0 

Yupik 1  0 

Other American Indian or

Alaska Native language 1  0 

(Specify:__________________________________)

Other Languages:

Arabic 1  0 

Any Chinese language 1  0 

Creole 1  0 

French 1  0 

German 1  0 

Greek 1  0 

Hmong 1  0 

Italian 1  0 

Japanese 1  0 

Korean 1  0 

Polish 1  0 

Portuguese 1  0 

Russian 1  0 

Tagalog 1  0 

Vietnamese 1  0 

Any other language 1  0 

(Specify:__________________________________)

18. Individuals seeking substance abuse treatment can vary by age, gender or other characteristics. Which categories of individuals listed below are served by this facility, at this location?

• for each “yes” in column a: Please indicate in column b if this facility serves only that type of client.

• for each “no” in column b: Please indicate in *column c if this facility offers a substance abuse treatment program or group specifically tailored for those individuals.

	MARK YES OR NO FOR EACH CATEGORY		IF YES IN COLUMN A		IF NO IN COLUMN B
	Column A		Column B		*Column C
	Served by this Facility		This Facility Serves Only		Offers Specifically Tailored Programs or Groups
	YES	NO	YES	NO	YES	NO
1. Adolescents	1 	0 	1 	0 	1 	0 
2. Adult women	1 	0 	1 	0 	1 	0 
3. Adult men	1 	0 	1 	0 	1 	0 

18a. Many facilities have clients with one or more of the following characteristics. For which characteristic(s) does this facility offer a substance abuse treatment program or group specifically tailored for those individuals, at this location.

MARK ALL THAT APPLY

1  Pregnant/postpartum women

2  Seniors or older adults

3  Lesbian, gay, bisexual, transgender, or questioning (LGBTQ) clients

4  Veterans

5  Active duty military

6  Members of military families

7  Criminal justice clients (other than DUI/DWI)

8  Clients with co-occurring mental and substance abuse disorders

9  Persons with HIV or AIDS

10  Persons who have experienced sexual abuse

11  Persons who have experienced intimate partner violence or physical abuse

12  Persons who have experienced other types of trauma

13  Specifically tailored programs or groups for any other types of clients

(Specify below: ______________________________________________)

19. Does this facility offer HOSPITAL INPATIENT substance abuse services at this location, that is, [fill LOCATION ADDRESS]?

1  YES

0  NO SKIP TO Q.20 (PAGE 4)

*19a. Which of the following HOSPITAL INPATIENT services are offered at this facility?

MARK “YES” OR “NO” FOR EACH

YES NO

1. Hospital inpatient detoxification 1  0 

(Similar to ASAM Levels IV-D and III.7-D, medically managed or monitored inpatient detoxification)

2. Hospital inpatient treatment 1  0 

(Similar to ASAM Levels IV and III.7, medically managed or monitored intensive inpatient treatment)

NOTE: ASAM is the American Society of Addiction Medicine.

*20. Does this facility offer RESIDENTIAL (non‑hospital) substance abuse services at this location, that is, [fill LOCATION ADDRESS]?

1  YES

0  NO SKIP TO Q.21 (BELOW)

*20a. Which of the following RESIDENTIAL services are offered at this facility?

MARK “YES” OR “NO” FOR EACH

YES NO

1. Residential detoxification 1 ¨ 0 ¨

(Similar to ASAM Level III.2-D,

clinically managed residential

detoxification or social detoxification)

2. Residential short-term treatment 1 ¨ 0 ¨

(Similar to ASAM Level III.5, clinically

managed high-intensity residential

treatment, typically 30 days or less)

3. Residential long-term treatment 1 ¨ 0 ¨

(Similar to ASAM Levels III.3

and III.1, clinically managed

medium- or low-intensity residential

treatment, typically more than 30 days)

IF Qs. 20a.1, 20a.2, OR 20a.3 EQUALS “YES,” ASK:

*11.36 Does this facility provide residential beds for clients’ children?

1  YES

0  NO

*21. Does this facility offer OUTPATIENT substance abuse services at this location, that is, [fill LOCATION ADDRESS]?

1  YES SKIP TO Q.21a (TOP OF NEXT COLUMN)

0  NO SKIP TO Q.22 (NEXT COLUMN)

*21a. Which of the following OUTPATIENT services are offered at this facility?

MARK “YES” OR “NO” FOR EACH

YES NO

1. Outpatient detoxification 1 ¨ 0 ¨

(Similar to ASAM Levels I-D and II-D,

ambulatory detoxification)

2. Outpatient methadone/

buprenorphine maintenance 1 ¨ 0 ¨

3. Outpatient day treatment or

partial hospitalization 1 ¨ 0 ¨

(Similar to ASAM Level II.5,

20 or more hours per week)

4. Intensive outpatient treatment 1 ¨ 0 ¨

(Similar to ASAM Level II.1,

9 or more hours per week)

5. Regular outpatient treatment 1 ¨ 0 ¨

(Similar to ASAM Level I,

outpatient treatment, non-intensive)

*22. Does this facility use a sliding fee scale?

1  YES

0  NO SKIP TO Q.23 (BELOW)

22a. Do you want the availability of a sliding fee scale published in SAMHSA’s online Treatment Facility Locator?

READ IF NECESSARY: The Locator will explain that sliding fee scales are based on income and other factors.

1  YES

0  NO

*23. Does this facility offer treatment at no charge to clients who cannot afford to pay?

1  YES

0  NO SKIP TO Q.25 (PAGE 5)

23a. Do you want the availability of free care for eligible clients published in SAMHSA’s Directory/Locator?

READ IF NECESSARY: The Directory/Locator will explain that potential clients should call the facility for information on eligibility.

1  YES

0  NO

*25. Which of the following types of client payments or insurance are accepted by this facility for substance abuse treatment?

MARK “YES,” “NO,” OR “DON’T KNOW” FOR EACH

DON’T

YES NO 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. Access To Recovery (ATR)

vouchers 1 ¨ 0 ¨ d ¨

9. IHS/638 contract care funds 1 ¨ 0 ¨ d ¨

10. IF OTHER TYPES OF PAYMENTS

ARE VOLUNTEERED, RECORD

HERE.

1 ¨ 0 ¨ d ¨

*34. Does this facility operate transitional housing or a halfway house for substance abuse clients at this location, that is, [fill LOCATION ADDRESS]?

1 ¨ YES

0 ¨ NO

*38. Does this facility have a website or web page with information about the facility’s substance abuse treatment programs?

1 ¨ YES

0 ¨ NO SKIP TO Q.39 (TOP OF NEXT COLUMN)

3 8x. The website address for this facility will appear in the Locator. Please give me the address exactly as it should be entered in order to reach your site.

Web Address:

39. If eligible, does this facility want to be listed in the National Directory and online Treatment Facility Locator? (See inside front cover for eligibility information.)

1 ¨ YES

0 ¨ NO

M1. Is this facility part of an organization with multiple facilities or sites that provide substance abuse treatment?

1 ¨ YES

0 ¨ NO SKIP TO uloc2 (BELOW)

M2. What is the name, address, and phone number of the facility that is the parent, or master site, of the organization?

Name:

Address:

Phone Number: (_____) - ______ -

uloc2. INTERVIEWER: VERIFY THE NAME, ADDRESS, PHONE NUMBER, AND FAX NUMBER ON THE CONTACT SHEET. MAKE ANY CORRECTIONS ON THE CONTACT SHEET AND GIVE THE SHEET TO YOUR SUPERVISOR.

41. INTERVIEWER: ENTER RESPONDENT’S NAME. IF NOT KNOWN, ASK.

Name:

INTERVIEWER: WAS THIS A . . .

1  CATI CALLOUT

2  WEB INTERVIEW

3  HARD COPY INTERVIEW?

PLEDGE TO RESPONDENTS: The information you provide will be protected to the fullest extent allowable under Section 501(n) of the Public Health Service Act (42 USC 290aa(n)). 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 eligible treatment facilities, information provided in response to survey questions marked with an asterisk will be published in SAMHSA’s National Directory of Drug and Alcohol Abuse Treatment Programs and the Substance Abuse Treatment Facility Locator. Responses to non-asterisked questions will be published only in statistical summaries so that individual treatment facilities cannot be identified.

P ublic 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 0930-xxxx. Public reporting burden for this collection of information is estimated to average 25 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, 1 Choke Cherry Road, Room 2-1057, Rockville, Maryland 20857.

PREPARED BY MATHEMATICA POLICY RESEARCH