West Virginia Code of State Rules
Agency 69 - Health And Human Resources
Title 69 - LEGISLATIVE RULE DEPARTMENT OF HEALTH AND HUMAN RESOURCES
Series 69-12 - Medication-Assisted Treatment - Office-Based Medication-Assisted Treatment
Section 69-12-25 - Individualized Plan of Care or Treatment Strategy

Universal Citation: 69 WV Code of State Rules 69-12-25

Current through Register Vol. XLI, No. 38, September 20, 2024

25.1. Delivery of patient care and treatment interventions shall be based on the needs identified in the individualized plan of care or treatment strategy.

25.2. Within 30 days after admission of a patient, the OBMAT program shall develop an individualized plan of care or treatment strategy and attach it to the patient's chart. The individualized plan of care or treatment strategy shall be developed pursuant to the guidelines and protocols established by the American Society of Addiction Medicine (ASAM), the Center for Substance Abuse Treatment (CSAT) and the National Institute on Drug Abuse (NIDA), the American Association for the Treatment of Opioid Dependence (AATOD), or such other nationally recognized authority approved by the Secretary. The individualized plan of care or treatment strategy shall include a recovery model based upon the generally approved guidelines and protocols.

25.3. The individualized plan of care or treatment strategy shall be reviewed by the program physician, primary counselor, and patient at least every 90 days and documented in the patient record. A revised plan of care or treatment strategy may be implemented with each review. After one year of successful treatment, the individualized plan of care or treatment strategy shall be reviewed annually, or more often based on the program physician and primary counselor's discretion and updated as appropriate.

25.4. The individualized plans of care or treatment strategies shall be developed by the patient, the program physician or physician extender and primary counselor, with input as appropriate from other health care providers.

25.5. All individualized plans of care or treatment strategies may include, but are not limited to:

25.5.1. Documentation of the patient's diagnoses; the proposed medical treatment and counseling; medication dosages and administration;

25.5.2. A requirement that the patient regularly attend and participate in the OBMAT program, both medical and counseling aspects, as determined necessary by the staff and patient;

25.5.3. The identification of triggers for misuse of substances;

25.5.4. The development and use of coping strategies for each trigger;

25.5.5. The development of a detailed relapse prevention plan;

25.5.6. Meaningful follow-up on any identified behavioral health issues;

25.5.7. Follow-up medical or physical issues as necessary;

25.5.8. Referral for a vocational evaluation, formal or informal, as appropriate;

25.5.9. A plan to achieve financial stability and independence, where appropriate;

25.5.10. A requirement that the patient abstain from use of illicit substances, abuse of prescription substances, or other substances of abuse;

25.5.11. Documentation of other patient or familial issues as relevant and appropriate and the proposed means of addressing such issues;

25.5.12. The success of the patient's treatment, initiatives and goals;

25.5.13. A description of services and their frequency to be provided for the patient and primarily directed to achieve the expected goals and outcomes;

25.5.14. The results from drug tests; and

25.5.15. Such other information as recommended by the guidelines and recovery model utilized for the patient.

25.6. With the patient's permission, the OBMAT program shall request complete medical records from other providers and maintain the records in the patient's medical record.

25.7. Coordination of Care Agreement.

25.7.1. If a coordination of care agreement is required, it shall be signed by the patient, program physician and primary counselor. If a change of program physician or primary counselor takes place, a new agreement must be signed.

25.7.2. The coordination of care agreement shall be reviewed and updated at least annually. If the coordination of care agreement is reviewed, but not updated, the review shall be documented in the patient's record.

25.7.3. The coordination of care agreement shall include the following:
25.7.3.a. An authorization allowing communication between the program physician and primary counselor so that the patient may receive comprehensive and quality medication-assisted treatment;

25.7.3.b. The name and contact information for the program physician and primary counselor;

25.7.3.c. The categories of records which may be shared;

25.7.3.d. A summary of treatment and goals, diagnoses, and services to be received onsite or by referral;

25.7.3.e. Current medications being prescribed, including dosage, frequency, and delivery; and

25.7.3.f. Date and prescription history for medication-assisted treatment medications.

Disclaimer: These regulations may not be the most recent version. West Virginia may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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