STATE SUBSTANCE ABUSE TREATMENT STANDARDS FOR by liaoqinmei

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									May 20, 2007
Prepared by Children and Family Futures under CSAT Contract No. 270-03-7148


        STATE SUBSTANCE ABUSE TREATMENT STANDARDS FOR WOMEN:
                  A REVIEW OF THE CURRENT LANDSCAPE

         Prepared for Discussion at the NASADAD-WTC 2007 Annual Meeting
                          June 6, 2007, Burlington, Vermont

I. INTRODUCTION/OVERVIEW

The Substance Abuse and Mental Health Services Administration (SAMHSA), Center for
Substance Abuse Treatment (CSAT) and the National Association of State Alcohol and Drug
Abuse Directors (NASADAD) have entered into a collaborative venture to strengthen the State
Women’s Treatment Coordinators (WTC) network and develop guidance to States on creating
substance abuse treatment standards for women.

In 2005, Children and Family Futures (CFF), contractor to CSAT, did some initial work to learn
about State standards. CFF informally surveyed the WTCs to find out which States had
standards or protocols for women and/or pregnant women (beyond the SAPT Block Grant
requirements) and prepared a summary of key themes from the standards for discussion at the
WTC 2005 Annual Meeting. The WTCs found this preliminary discussion and information about
the standards very helpful.

The recent CSAT-NASADAD collaboration and 2007 WTC-NASADAD Annual Meeting set the
stage for revisiting this issue to update the knowledge base about existing State women’s
treatment standards. In March 2007, a brief questionnaire was sent to all State WTCs; for the 5
States that did not have a designated WTC at the time, the questionnaire was sent to the State
Director. The questionnaire sought information on whether the State had substance abuse
treatment standards or protocols for women and/or pregnant women (beyond the SAPT Block
Grant requirements); when such standards went into effect; whether they had ever been
revised; and key issues areas that NASADAD should address in developing guidance to the
States. CFF received responses from 49 States and the District of Columbia.

A total of 28 States (55 percent) indicated they had some kind of standards for women and/or
pregnant women beyond the SAPT Block Grant requirements; 20 States (39 percent) said they
did not have standards; and 3 (6 percent) said they were developing standards. Copies of
standards from the 28 States were collected and reviewed by CFF.1 Attachment 1 provides a
State-by-State list of these results and identifies the materials reviewed for the 28 States.

CFF’s review entailed a qualitative content analysis of the State standards, using the CSAT
Comprehensive Substance Abuse Treatment Model for Women and Their Children as an
organizing framework. The CSAT Comprehensive Model recommends that treatment providers
provide a range of clinical treatment and support services to women and to children, as well as
community support services to families, that cut across the continuum of care. In addition, CFF
also looked at the standards for other more general administrative issues such as staffing, and
outcomes and monitoring. This document presents the key themes regarding comprehensive

1
 The 28 States/jurisdictions reviewed were: Arizona, Arkansas, California, Colorado, Connecticut, District of
Columbia, Florida, Georgia, Hawaii, Idaho, Illinois, Maine, Massachusetts, Missouri, New Hampshire, New Jersey,
Nevada, Oklahoma, Oregon, Rhode Island, South Carolina, Tennessee, Texas, Vermont, Washington, Wisconsin
and Wyoming. Though Wyoming did not complete and submit the questionnaire, standards relating to women were
obtained and reviewed from an Internet search. The three States that indicated they are developing standards are
Alabama, Louisiana and Maryland. In addition, New Jersey, which has standards for women, indicated it is also in the
process of developing standards for pregnant women.


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services and select administrative issues, as well as a brief discussion of the issues WTCs said
they would like NASADAD to address in developing guidance to the States.

      In considering the information that follows, it is important to note that we only
      reviewed treatment standards specific to women; we did not review general
      treatment standards applicable to all providers, which also likely speak to some of
      the areas identified below. For instance, State standards may affirm that programs
      serving women need to meet women-specific standards in addition to the general
      and modality specific standards required for all substance abuse treatment
      programs.


II. HIGHLIGHTS OF THE REVIEW

The results of the review are organized into 13 areas below that include overall findings, as well
as specifics related to services and service delivery issues.

1. Lack of Uniformity in State “Standards”

Unlike many other health care issues, there is no “standard” that exists to ensure that
individuals receive high quality, evidence-based substance abuse treatment services. Instead,
the substance abuse treatment system is governed by a patchwork of mandated State policies.2
Indeed, this review indicated that, overall, treatment standards for women and pregnant women
vary greatly across the States. There is a substantial degree of variability when it comes to
breadth, depth, scope and emphasis placed on standards specific to women. It ranges, for
example, from a sentence, selected phrase or short paragraph pertaining to women (typically
pregnant women) mixed into the general substance abuse treatment standards, to more
detailed subsections specifically outlining women’s treatment standards, to lengthier, stand-
alone documents on women’s treatment requirements.

In addition, State standards may vary in which and how many treatment modalities are covered
(e.g., residential, outpatient, opioid treatment), and in some cases, may focus on a particular
subset of women, such as those involved in the criminal justice system (e.g., Maine) or the
TANF program (e.g., Georgia). For those that pertain to pregnant and postpartum women,
postpartum may be defined as up to 3, 6 or 12 months after delivery, depending on the State.

Moreover, the nature and type of the document in which standards may be found varies
significantly. As the table below shows, some States address women’s standards in their
administrative code or licensing regulations, while others speak to them in contractor
requirements. Still others have developed treatment guidelines that represent recommended
(but not required) practice. In Florida, for example, the Department of Children and Families
and the Department of Health signed a Memorandum of Agreement specifying protocols or
operating procedures for how the agencies will collaborate to serve pregnant and postpartum
women and their substance-exposed infants. For purposes of this summary we use the term
“standards” to encompass all of these types of documents.




2
  Chriqui, J.F. et al. (2004). State policy mandates for substance abuse outpatient treatment facilities: Are they
quality based? Abstract from presentation at the 132nd Annual APHA Meeting, November 10, 2004.

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Type of Standards Document                           State*
•   Licensing/Certification Standards;               Arkansas, Colorado, District of Columbia, Florida,
    Administrative Rules, Regulations or             Illinois, Missouri, New Hampshire, North Carolina,
    Statutes                                         Oklahoma, Oregon, Rhode Island, Tennessee, Texas,
                                                     Wisconsin, Wyoming
•   Contract Requirements                            South Carolina, Texas, Washington
•   Other Required State Agency                      Arizona, California, Georgia, Maine, Massachusetts,
    Standards of Care or Program                     Nevada, Vermont, Wisconsin
    Requirements
•   Guidelines                                       Connecticut, Florida, Hawaii, Idaho, Massachusetts,
                                                     Tennessee

•   Specifications in Request for                    Hawaii, Massachusetts
    Proposals or Request for Response
* A State may be listed in more than one category because it provided multiple documents.


2. “Gender-specific Treatment” – What Does it Mean? What Does it Look Like?

Though the majority of States indicate that treatment providers must provide “gender-specific
treatment,” many do not specify or define what gender-specific treatment means or
encompasses. Rather, States may simply assert the need for same gender clinical services or
that treatment occurs in the context of a family systems model. Arizona, Colorado, Connecticut,
Georgia, Idaho and Wisconsin, however, are examples of States that elaborate on the concept
and practice of gender-specific treatment.

For example, Arizona emphasizes the importance of a “relational/cultural approach that focuses
on the centrality of relationships in women’s lives,” and Colorado explicitly states, “Program
policies and procedures will reflect that women’s substance abuse differs from that of men both
in its etiology and the treatment of service required for remediation.” Georgia defines gender-
specific treatment as having: a) gender-specific staff; b) gender-specific services, including
prenatal services and child care; and, c) gender-specific therapies including all-female groups,
trauma counseling, sexual abuse counseling, non-aggressive/non-confrontational therapy
styles, therapeutic parenting skills classes and other recommended services. Wisconsin lays
out an overall philosophy—consisting of six core fundamental principles—of working with
women with substance use disorders. These core principles address concepts such as the
importance of women’s relationships in recovery, the provision of wraparound services through
inter-systems collaboration and involvement of informal supports, and work as a vital
therapeutic tool in recovery. Both Connecticut and Idaho draw on the work of nationally
recognized expert Stephanie Covington in outlining the principles or components of gender-
responsive treatment.

3. Treatment Services – General.

States vary greatly in the level of detail provided when prescribing what treatment services
women should receive. Some are very explicit about what services must be provided, while
others use more generic, open-ended language. Some go so far as to define expected or
maximum lengths of stay, required number of treatment hours per week, and minimum number
of beds for women with children. A number of States (e.g., Arizona, Georgia, Idaho, Maine,
South Carolina) provide an overview of the various ASAM Levels of Care and what they entail,

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and California describes various treatment modalities in their perinatal treatment guidelines. In
addition, States vary in the extent to which a service is required or recommended and must be
provided on-site or can be referred out.

Several States, such as Idaho and Maine, address the need to use best practices and evidence-
based treatment models. Idaho actually provides examples of best practices and effective
treatment models, while Maine specifies that treatment should be grounded in proven
Motivational and Cognitive-Behavioral practice models (e.g., Motivational
Interviewing/Motivational Enhancement Therapy, Cognitive Behavioral Therapy). Wisconsin
also indicates that all assessments shall be conducted through motivational interviewing.

4. Continuum of Care.

States also vary in the extent to which they address the full continuum of care – from outreach
to screening and assessment to treatment to aftercare, recovery maintenance and reentry into
the community. Georgia has comprehensive standards in this regard. Typically, though, States
will address only certain aspects of the care continuum, and to varying degrees of detail. When
it comes to treatment planning, several States explicitly state that clients must receive an
individualized treatment plan (Oklahoma and Massachusetts are at least two States that
mention treatment plans for both the woman and the child). Connecticut’s “recovery plan” is
reviewed and revised with the active participation of the client, at a minimum of every 90 days.
Nevada also emphasizes that the plan should be client-centered and responsive to the client’s
preferences. In the area of continuing care, those that do address this service do so to varying
degrees, touching on discharge plans, relapse prevention, and recovery community support
(see below for more detail on continuing care and recovery community support services).

5. Primary Treatment Services

In its Comprehensive Substance Abuse Treatment Model for Women and Their Children, CSAT
recommends that treatment providers provide a range of clinical treatment services to women.
Below are the primary treatment services that States with women’s standards most often
address. (Please see Attachment 2 for a more detailed matrix on the specific services outlined
in the CSAT Comprehensive Treatment Model that are addressed in the States’ standards.)

         Screening/Assessment. Nearly all (23) of the 28 States reviewed address screening
         and/or assessment – but to varying degrees of detail. While a State such as South
         Carolina may generally require “comprehensive biopsychosocial assessments,” others,
         such as Colorado, Connecticut, Idaho, Oklahoma, Oregon, Vermont, and Wyoming are
         more precise and outline women-specific areas that must be assessed (e.g., trauma,
         social isolation, domestic violence, parenting). A number of States require the use of the
         Addiction Severity Index (ASI) or recommend the Stages of Change/Readiness model.
         Idaho and Georgia also specify other types of screening and assessment instruments
         must be used. Arizona notes that assessments should be female-specific, while
         Connecticut says they must be conducted in manner that is sensitive to a history of
         possible sexual abuse or domestic violence, and possible re-traumatization. Florida has
         implemented an interagency agreement to ensure a coordinated, multi-agency
         assessment, and co-locates a Family Intervention Specialist (from treatment program)
         with Child Protective Services to assist with the substance abuse assessment.

         Medical Care/Primary Health Care. When it comes to actual clinical services covered in
         States’ standards, all but two address in some form or another, the need to provide or
         coordinate for medical care for women. Again, the degree of specificity and detail varies

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         greatly from State to State. Most often, standards will require providers to ensure that
         women receive appropriate prenatal and postnatal care, and HIV/AIDS, STDs and TB
         education, counseling and/or testing. Many other States also include family planning and
         reproductive health services. A handful of States specifically mention the provision of
         nutrition (e.g., Arkansas, Colorado, Connecticut, District of Columbia, Massachusetts,
         and Washington) and tobacco cessation services (e.g., Arizona, District of Columbia,
         Massachusetts, Oregon, Texas, and Wyoming). Arizona—citing the association between
         nicotine dependence and poorer birth outcomes—overtly states that “treatment for
         nicotine dependence should be a routine part of addiction treatment for pregnant
         women,” while Massachusetts requires its family shelters to have an on- or off-site
         tobacco cessation program. Arizona, Idaho, Massachusetts, and Washington specifically
         mention or require arrangement for dental services.

         Mental Health. Of States with standards, 19 include provision or coordination of mental
         health services for women. Typically this encompasses individual, group and/or family
         counseling. Wisconsin, however, has adopted more explicit instruction stating that
         women’s treatment providers must “demonstrate the ability to identify concurrent mental
         health disorders and develop a process to have the treatment for these disorders take
         place in an integrated fashion with substance abuse treatment and other health care.”
         Arizona calls for all new moms to be evaluated for postpartum depression and
         psychosis. A few States, such as Arizona, Idaho and Vermont, also specifically mention
         the need to assess for and address co-occurring eating disorders.

         Trauma/Violence. States are clearly beginning to recognize and respond to the need for
         trauma-informed and trauma-specific services for women. While 21 States say that
         treatment services shall address (either directly or by referral) issues such as past or
         current physical, sexual or emotional abuse and domestic violence, a few States offer
         more detailed guidance in this area. Wisconsin, for instance, specifically says that
         providers must develop a process to identify and address issues related to abuse,
         violence and trauma and that “services will be delivered in a trauma-informed setting.”
         South Carolina requires residential treatment providers to include “a best practice
         trauma curriculum” as part of the weekly menu of services provided; a trauma curriculum
         is also indicated as a major treatment component for intensive outpatient and day
         treatment. Colorado is one of the States that stands out in its emphasis on trauma,
         requiring treatment program policies, procedures and service delivery to understand,
         recognize and address the interplay between substance use and trauma symptoms.
         The standards also state that the emotional and physical safety of clients shall take
         precedence over all other considerations in the delivery of services. New Jersey requires
         that all services be trauma informed and trauma specific, while Massachusetts
         encourages the integration of trauma services into substance abuse treatment system
         and continuum of care, and provides a definition of trauma informed services.

         Substance Abuse Counseling and Education. While the majority of States (20) reviewed
         require some type of substance abuse education and counseling, the issues and topic
         areas covered vary. Oklahoma, for example, simply states that residential treatment
         services are to include educational groups. A number of States focus their education
         requirements on substance use during pregnancy. Texas, for example, requires
         providers to use “evidence-based curricula for education on substance use, abuse and
         effects of ATOD on the fetus,” while the District of Columbia requires that clients receive
         a minimum of 1 hour of educational per week on the effects during pregnancy. New
         Hampshire indicates pregnant women must be counseled, among other things, on the
         importance of informing medical practitioners of alcohol and other drug use during

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         pregnancy. California extends substance abuse education to the effects during
         breastfeeding, while Oregon’s opioid treatment programs must ensure a pregnant
         woman is fully informed concerning risks to herself and unborn child from use of the
         methadone, as well as other drugs and alcohol. Other States (e.g., Colorado, Georgia,
         Missouri, Washington) cast a broader net regarding substance abuse education,
         touching on issues such as impact on family, relationships, sexuality, self-esteem,
         gender roles, domestic violence, and other issues. Washington, for instance, requires 20
         hours of education and treatment per week that covers issues such as the biological,
         physiological, and social effects of ATOD; denial; relapse and relapse prevention;
         chemical dependency behaviors and co-dependency behaviors; symptom of disease;
         anger management; meditation and stress reduction; and the 12 steps.

         Continuing Care/Aftercare/Recovery Management. As stated above, the 20 States that
         do address this area do so to varying degrees. Wisconsin, for example, requires
         treatment providers to conduct an assessment prior to discharge, design a written
         discharge plan, make and document appropriate referrals and remain available to the
         client as a resource for support and encouragement for at least one year following
         discharge. In contrast, Texas states more broadly that services under the treatment plan
         will include follow-up services to prevent relapse, and that providers must coordinate
         with other services and resources to including continuing care for pregnant, postpartum
         and parenting women. And Georgia’s standards, which are targeted to TANF recipients,
         require that women receive an aftercare plan that includes random urine drug screens
         within the first three months after discharge. (See also “recovery community support
         services” below.) The duration of continuing care also varies by State. Massachusetts,
         for example, provides aftercare (which addresses family reunification, among other
         things, for certain clients) for up to 3 months after discharge. New Jersey, however,
         requires monthly face-to-face contacts for up to 12 months, while Arkansas calls for
         monthly follow-up contacts for a minimum of one year.

         Pharmacotherapy. Standards related to pharmacotherapy typically focus on pregnant
         women, often noting that pregnant women may be exempted from minimum admissions
         requirements and should undergo monthly pregnancy tests. State policies may also
         address withdrawal from maintenance therapy. For instance, Arizona and Colorado
         state that medically monitored maintenance therapy should be continued throughout
         pregnancy, and Wisconsin indicates that withdrawal should not be initiated before the
         14th week or after the 32nd week of pregnancy. In addition, State standards that cover
         pharmacotherapy often require that treatment programs must admit and accommodate
         clients on MM or other opioid pharmacotherapy, and such therapy may not be a basis for
         exclusion from a treatment program. Arkansas states that pregnant women cannot
         receive LAAM.

         Drug Monitoring. Only a few States address issue of drug monitoring or testing in their
         standards. Georgia states that ongoing services should include drug screens and 3 to 6
         (varies depending on level of care) random urine drug screens within the first 3 months
         after discharge. New Jersey requires a minimum of 4 to 6 random urine samples over
         course of treatment (again, varies depending on level of care). Other States are less
         prescriptive. Idaho, for example, indicates random urine testing should be used where
         clinically appropriate, and Florida’s guidelines merely state that women should consent
         to drug toxicology and be informed about possible uses of the test results.




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6. Support Services

The CSAT Comprehensive Treatment Model also outlines an array of clinical and community
support services for women and their children and families, much of which is designed to
strengthen family functioning and increase a woman’s self-sufficiency. Below are the support
services most often covered in the State standards reviewed. Attachment 2 provides additional
information on other support services – such as transportation, housing, life skills training and
education, and recreational services – that are addressed in the State standards.

         Parenting and Child Development Education. Not surprisingly, developing parenting
         skills, promoting parent-child bonding, and strengthening parent-child interaction are
         areas of emphasis for nearly all (86 percent) of the 28 States reviewed. Child
         development education may encompass coping skills, ways to redirect children’s
         misbehavior, effective and appropriate discipline, breastfeeding, child safety and other
         issues. The District of Columbia, for example, lays out very specific requirements that
         include preparing a detailed written plan and schedule of parent-child bonding activities
         that includes minimum hourly bonding, child development education and parenting skills
         training requirements. Similarly, Washington State requires providers to develop and
         document an individualized parenting education plan within 14 days of admission. And
         Wyoming notes that residential treatment for women with children must be integrated
         with a woman’s responsibilities to children, and mandates that treatment include at least
         30 hours a week of services that include parenting, family reunification and child
         development. Oklahoma’s requirement is slightly less – at least 24 hours a week of
         substance abuse, parenting and child development services. While States do not dictate
         what parenting curriculum is implemented, Massachusetts does require it to be
         evidence-based.

         Family Programs/Family Strengthening. Of the State standards reviewed, 86 percent (or
         24 States) also recognize and acknowledge that women function within a larger family
         system, that a woman’s substance abuse must be addressed in the context of her
         children and family, and that treatment services should involve a woman’s spouse,
         partner or other family members in a woman’s recovery (as appropriate) and provide
         services to the family as a whole. Typically, States will require services to include, at
         minimum, family counseling and basic substance abuse prevention education and
         support skills (e.g., crisis, anger and behavioral management, relapse prevention,
         communication, relationships). Some States (e.g., Florida, Wisconsin) broaden this
         notion, stating that providers must identify and address the needs of family members
         through direct service, referral and/or other processes. States may also define “family”
         differently. Both Massachusetts and Wisconsin define family broadly to include whoever
         the client identifies or chooses as family, while Hawaii says family may involve parents,
         children, partners or other significant others within the client’s home environment. A few
         States (e.g., Connecticut, Vermont) specifically address reunification plans, if
         appropriate, and the need to consider The Adoption and Safe Families Act (ASFA) or
         other mandates. Idaho even offers examples of recommended programs, including the
         Multi-family Group (part of the Matrix Model) and the Celebrating Families educational
         support group for parents in early recovery and their children.

         Among all States, however, Massachusetts is distinctive in its efforts to expand the
         concept of family-focused treatment and require programs to provide family-focused
         treatment and target more services for the children, as a means to promote recovery,
         increase family integration and reduce the intergenerational transmission of substance
         abuse related problems. The Bureau of Substance Abuse Services notes that “family-

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         focused treatment means programs recognize that most clients in our system are either
         connected with family when they begin the treatment process, will re-connect with family
         in the recovery process, or will form new family ties in recovery. Paying attention to this
         dimension and supporting clients as they are re-forming and re-defining these
         relationships in recovery is very important in relapse prevention.”

         Linkages with Child Welfare Systems, Courts/Criminal Justice and TANF. Twenty
         States address the need for treatment providers to coordinate and communicate with the
         courts and/or child welfare systems (where applicable), but again to varying degrees.
         South Carolina, for example, notes that providers should work with the Department of
         Social Services and encourage and provide every opportunity for parenting women to
         visit with their children. Others are more prescriptive in this area. Texas, for example,
         states that all efforts will be made to participate in the family reunification plan with the
         custodial agency. It further requires providers to work with the court and the client to
         meet court conditions and reunite the family. Washington requires treatment providers to
         develop agreements with Division of Children and Family Services (DCFS) social
         workers for parents whose children are involved with DCFS regarding on-site visits or
         conference calls, schedule of court dates, providing copies of the individual service plan
         prior to court dates, obtaining basic information about the child (e.g., behavior, medical
         status), and other related issues. Hawaii also addresses the need for working written
         agreements with child protective services (CPS) that delineates the responsibilities of
         the treatment program and CPS. New Jersey is specific in its provision that
         interdisciplinary meetings with child welfare services and/or the courts should start within
         30 days to incorporate a client’s case plan into the treatment plan, and continue at least
         once a month. Other States are less explicit, but still address the need for linkages:
         Idaho, for instance, indicates treatment programs should facilitate a team approach that
         integrates treatment with criminal justice system requirements and interventions. Idaho
         also indicates efforts should be made to obtain appropriate consents for information
         sharing from other systems the woman is involved in and to develop an effective team
         approach to her services. Though “linkages” are not specifically mentioned, Arizona’s
         protocol includes a special section on the unique needs of women with substance use
         disorders involved in the criminal justice system and discusses the importance of
         specialized addiction treatment for pregnant women offenders.

         A smaller number of States (7) address linkages with TANF. This concept is woven
         throughout Georgia’s standards, which are focused on women who are TANF
         participants. While Florida calls for substance abuse treatment providers to co-locate
         TANF outreach workers at TANF service sites to systematically screen TANF clients,
         other States very briefly and generally mention the need to partner or coordinate with
         welfare agencies.

         Educational/Vocational Support and Employment Readiness and Support. Nearly two-
         thirds (18) of the States reviewed require or recommend that treatment services include
         basic adult education/GED and literacy, vocational training, education and experience,
         and similar support services to help promote self-sufficiency. A somewhat smaller
         number of States (13) specifically address employment readiness and support, such as
         job skill assessment and training, or development of an employment plan. North
         Carolina, for instance, calls for interactive training for employment and indicates that a
         component of therapeutic communities may be business training schools (e.g., moving
         and storage, landscaping, construction, telemarketing, secretarial and clerical, retail
         sales). Connecticut notes that clients should be compensated for work provided within
         the organization, if available, while Nevada states that clients who are already employed

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         and in the process of recovery should receive any needed assistance with work-related
         problems.

         Recovery Community Support. Nineteen States address the need to provide recovery
         community support services. Georgia, for example, requires the provision of self-help
         groups during treatment and as part of a woman’s aftercare. South Carolina, in addition
         to requiring recovery community support in residential treatment, also notes that self-
         help group orientation is a major treatment component of intensive outpatient and day
         treatment, which allows women “the opportunity to test new coping strategies while in a
         supportive environment.” And Wisconsin states that the ultimate goal is to “weave the
         woman so well into the fabric of informal support systems that the role of formal services
         is very small or not needed at all.” Connecticut also emphasizes a recovery system of
         care and the extensive use of family and community systems for long-term recovery
         support. It indicates that peer supports within program should be clearly established
         (e.g., women in more advanced levels of treatment mentoring those beginning), while
         also connecting the woman to local family support, advocacy groups and, if requested,
         faith-based support, prior to discharge. In addition to integrated self-help and peer
         groups, Nevada also urges follow-up to re-engage clients who may have disengaged
         from support groups.

         Child Care. The majority of States (21) expressly require child care to be made
         available while women are in treatment and rehabilitative activities. In fact, Tennessee
         refers to this as an “essential aspect” of services to women, and indicates that child care
         should include as assessment of the child’s life functioning areas, and may include other
         services such as child counseling, play therapy and mother-child therapy. Typically
         standards related to child care apply to children up to age 12 or 13. While Georgia
         requires on-site therapeutic child care for children 13 and younger in residential
         treatment facilities, California requires on-site child care for children 0 – 36 months, and
         then gives providers the option of providing such care either on- or off-site for children 37
         months – 12 years. Idaho is unique in that it calls for creating a plan for respite care,
         which includes at least three sources the mother can call upon. Additional information
         on children’s services is provided below.

7. Mothers in Treatment with Children.

When it comes to the issue of children accompanying their mother in treatment, some States
(such as Washington, DC and Georgia) are quite explicit in their requirement that children
accompany their mothers in treatment, unless contraindicated for medical, legal or other
reasons. Idaho states “The key is that children are treated in the same setting as their mother.”
Others, however, use less directive language such as, “Admission of children shall depend on
program’s ability to provide the needed services,” (Oklahoma) or “Program shall endeavor to
provide services in facility that accommodates the presence of the children” (Wyoming) or
“Ideally, women will live with their children during residential treatment” (Arizona). Further, there
are differences among States when it comes to age limits of children admitted with their mom,
and the number of children per resident. Massachusetts is atypical in stating that all children up
to age 18 years are eligible to live with their parent (in family residential substance abuse
treatment programs). In contrast, other States may limit it to children up to age 3 or 5 years.
New Jersey allows women to enter treatment without their children for the first 30 days, after
which at least one child can join the mother, if space is available.




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8. Children’s Services.

In addition to clinical treatment and support services for women, CSAT’s Comprehensive Model
also identifies a range of services that children of women with substance use disorders should
receive. While no State standards explicitly covered the broad spectrum of children’s services
outlined in the model, many States did address the needs of children’s to some degree. This
information is broken down generally into a) screening and assessment and b) services, and
summarized below.

         Screening and Assessment. Sixteen of the States reviewed include requirements and/or
         recommendations – again, to varying degrees – regarding children’s screening and
         assessments. On one end of the spectrum, for example, are States that simply say
         infants and children 0 to 3 years of age will be referred for early childhood intervention
         screening. Others elaborate further. Arizona, the District of Columbia, Oklahoma and
         Washington State, for example, outline different areas (e.g., mental health,
         social/emotional/behavioral development, educational needs, parent-child relationships,
         sibling relationships) that children’s assessments should include. And while the District
         of Columbia requires a developmental assessment to be done within 3 days of a child
         being admitted, Washington State requires it to be completed within two weeks, Georgia
         gives providers 30 days, and Missouri states it must be done before the child receives
         any services beyond child care and community support. Georgia is one of the only
         States to list the various screening and assessment tools that may be used and for what
         ages they are appropriate (e.g., Achenbach Child Behavior Checklist, Denver II,
         BRIGANCE Diagnostic Inventory of Early Development). Most States address the need
         for a child’s health/medical screening. Idaho, however, specifically notes that this should
         include an evaluation of fetal alcohol and drug effects, as well as use of the Trauma
         Symptom Checklist for Children. And Florida’s interagency agreement is intended to
         ensure a coordinated, multi-agency assessment of the health, safety and other service
         needs of substance-exposed children.

         Services. Eighteen States address, in some fashion or another, what services should be
         provided to the children of women in treatment. In general, children’s services are less
         well-defined and vary more in focus and content. Most all require the provision or
         arrangement of primary pediatric care, including immunizations. Arizona also notes that
         babies exhibiting neonatal abstinence symptoms undergo safe and comfortable
         detoxification. Similarly, Texas requires that infants and children receive treatment for
         any perinatal effects of maternal substance abuse.

         The District of Columbia and Missouri both use the same language in calling for age-
         appropriate activities that will facilitate the parent’s recovery goals as well as help
         children achieve various goals, such as building self-esteem, learning to identify and
         express feelings, and developing decision-making skills. Along these lines,
         Massachusetts addresses the need for support, education and mentoring to children,
         while Idaho recommends the use of the Celebrating Families educational and support
         program. Several States stress the importance of early intervention services.
         Massachusetts, for example, necessitates the development of a prevention and early
         intervention system, which recognizes their special issues and needs of children to
         prevent them from developing their own substance abuse problems as they mature.
         New Jersey’s general statutes state that early intervention services provided to children
         under age 3 and their families may include early identification and screening,
         multidisciplinary evaluations, case management services, family training, counseling and


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         home visits, psychological services, speech pathology and audiology, and occupational
         and physical therapy.

         At least five States address the provision of therapeutic child care. Of these, Georgia
         includes a whole section on therapeutic child care requirements, including staffing
         patterns, ratios and outcomes. Further, all its residential programs must implement The
         Nurturing Program as the standard for their therapeutic child care. Washington State
         also provides specifics about therapeutic child care staff-to-child ratios, and indicates
         such care must be provided for a minimum of four hours a day, five days a week.
         Oklahoma requires its residential treatment centers to provide children aged 3-12 with a
         minimum of 12 hours of therapeutic services a week, with special attention to high risk of
         sexual abuse, sexual acting-out by children, and suicide risk and treatment.

         Other States may couple specific requirements with more open language. South
         Carolina, for example, requires its intensive outpatient programs to provide a
         “specialized children’s program that enhances healthy development and meets the
         physical, psychological, social and educational needs of each child.” Yet it also
         indicates that each child must receive a minimum of three hours a week of structured
         intervention and school-age children receive monthly therapeutic sessions that include
         parent-child interaction. And while Texas states broadly that children shall receive
         services to address their needs and support healthy development, it also explicitly
         requires that infants and children receive, either directly or by referral, counseling and
         other mental health services and referral to comprehensive services. And Wyoming,
         which says children shall receive age-appropriate therapy as needed, also states that
         children must be provided with access to a full range of services including transportation,
         educational services, well-child health care, emergency health care, health and
         speech/language screenings, dental care, and hearing and vision. Washington State is
         unique in that it requires its women and children residential programs to develop and
         maintain a Child Services Program Manual and spells out the various policies and
         procedures to be included, as well as services to be provided.

9. Pregnant Women

With regard to pregnant women specifically, most States have a common set of standard
regulations that typically reflect the SAPT Block Grant requirements, such as pregnant women
get priority treatment admission and must be admitted within 48 hours (or provided with interim
services if not able to admit). California provides the most comprehensive list of interim
services. Strong emphasis is also placed on ensuring that pregnant women receive prenatal
care and education on the effects of substance use during pregnancy. About a dozen States
include specific language regarding methadone or other opioid replacement treatment that
typically provide policies regarding admission, detoxification or withdrawal, pregnancy testing,
and education and counseling. Colorado and New Jersey both state that pregnant women may
not be discharged from substance abuse treatment solely for failure to maintain abstinence.
Illinois emphasizes the need for linkages with medical care and other providers serving
pregnant women and the development of special programs for case finding and service
coordination for pregnant women with substance use disorders. Georgia, too, underscores the
importance of a multidisciplinary, cross-systems collaborative approach in working with
pregnant women.




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10. Outcomes/Monitoring.

About a dozen State standards contained information regarding program outcomes and the
monitoring/tracking of clients. (Again, this may be an area that is more often covered in the
general standards applicable to all treatment providers.) Standards that did touch on this area
typically included general record-keeping requirements (e.g., a program shall document any
services provided) or other standard performance monitoring (e.g., submission of regular
progress reports). South Carolina, Georgia and Arizona were States that elaborated in this
area. South Carolina, in addition to semi-annual narrative reports that include outcome
evaluations, requires residential programs to conduct 6- and 12-month follow-up of clients to
determine program effectiveness. It also requires intensive outpatient programs to evaluate
their children’s services curriculum annually and submit any changes for approval. Arizona, too,
requires outcome categories to be measured at baseline, regular intervals (e.g., 30, 60, 90 days
of treatment, then every 1-2 months throughout treatment), discharge, and changes in treatment
level of service. Arizona’s standards also include an extensive section on desired outcomes that
outlines signs, symptoms and behaviors; targets; and measurements for addiction treatment
generally, as well as gender-specific treatment. Similarly, Georgia’s program requirements
include a section dedicated to expected outcomes and reporting requirements. Nevada’s
standards are structured around five categories, one of which is outcome measurement; further,
its standards encourage providers to fully implement the State Outcomes Measures (derived
from the Federal National Outcome Measures).

Georgia and Maine both require the collection of specific data using certain tools. For instance,
Georgia’s residential programs must implement the pre/post test of The Nurturing Program (the
standard for the therapeutic child care) and use the computerized version of the AAPI to
measure the effectiveness of their therapeutic child care’s parenting component. Maine requires
the use of six standardized instruments – Alcohol and Drug Refusal Self-Efficacy Questionnaire
(ADRSEQ), Drug Avoidance Self-Efficacy Scales (DASES), Coping Behaviors Inventory (CBI),
Commitment Scales (CS), Problem Solving Questionnaire (PSQ), and Perceived Modes of
Processing Inventory (PMPI) – as well as a Client Satisfaction Questionnaire. This battery of
assessments is used for ongoing assessment, as well as treatment planning and outcome
evaluation measures.

Other States list general areas for both performance and outcome measures. Hawaii, for
example, includes employment status, living arrangements, psychological distress, days or
work/school missed due to substance use, arrests, emergency room visits, and hospitalizations,
while Connecticut includes the appropriate utilization of gender responsive treatment services
and short- and long-term impact of interventions on program participants in 10 domains.
Massachusetts adds increased stability and preservation of the family system to outcomes
measures for its specialized pregnant and parenting women with children programs. New
Jersey’s programs must measure child welfare outcomes in the areas of safety, permanency
and well-being of children, while improved parenting is an expected outcome of residential
programs in North Carolina. In addition, Indiana conducts ongoing quality improvement activities
that include reviewing a sample of case management and other services provided to identify
opportunities to improve services.

11. Staff Training.

Sixteen of the States reviewed included some type of language about staff training and
development in their women’s treatment standards – but again, it varies greatly in breadth,
depth and specificity. For instance, a State may require quite generally that staff have training in
the area of gender-specific women’s substance abuse modalities and treatment skills or in

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therapeutic issues relevant to women and children. Other States expand upon this and actually
identify particular issues relevant to women, such as domestic violence, trauma, child abuse
and neglect, grief and loss, impact of substance abuse on parenting and family units, and
traditional and non-traditional community supports. (North Carolina requires staff training on
these and other issues within 60 days of employment.) And still others (North Carolina,
Oklahoma, Texas, Wyoming) take it a step further to include children’s issues – requiring, for
example, that treatment staff have specialized training in child development, early childhood
education, age-appropriate behaviors, effects of prenatal alcohol or drug exposure on child
development, recognition of sexual acting-out behavior and other issues, signs and symptoms
of pre-term labor and postpartum depression, dynamics and needs of children diagnosed with
ADD/ADHD, and infant feeding, including breastfeeding. Maine also specifically requires training
on Motivational Interviewing/Motivational Enhancement Therapy, and “extensive training in
program delivery and administration, scoring, and tracking of the applied psychometric
measures,” complete with quarterly booster training events.

12. Staff Qualifications.

In terms of staff qualifications (e.g., background and education), some States single out certain
service areas in which they discuss staff qualifications. For example, California outlines which
staff are eligible to conduct children’s assessments, while Washington indicates what staff may
provide on-site health care visits and consultation. Georgia and Washington provide specific
requirements for therapeutic child care staff (e.g., program director, program supervisor,
teachers/lead caregivers, and caregivers/aides), and Idaho’s Targeted Intensive Case
Management staff include an intensive case manager, early child development/parenting
specialist, and behavioral health specialist. Other States explicitly state the need for female
staff. Arizona, for example, says staff must include female role models, including women in
management positions, and counseling staff should be predominantly female, including women
in recovery. Connecticut also notes that the majority of staff members should be women. (Staff
education and professional requirements is also likely an area in which States provide more
information in the general standards applicable to all treatment providers.)

13. Miscellaneous/Other

In addition to the above themes that emerged, there are also some unique aspects to select
State standards that fall outside the above categories but deserve mention. For instance, the
Illinois Alcoholism and Other Drug Dependency Act established a Committee on Women’s
Alcohol and Substance Abuse Treatment to provide the State with input and recommendations
on how to best address the intervention, prevention and treatment needs of women and ensure
effective service delivery to women (among other duties). South Carolina requires residential
programs to have and use an Advisory Committee, the composition of which “should be
consistent with the population to be served and include consumers.” The District of Columbia
includes a related provision: it requires a program’s governing board to include “members with
special interest in expertise related to programs and services for parent(s) and children.” In
addition, Massachusetts is requiring bidders for residential family substance abuse treatment to
participate in regularly scheduled meetings to develop standards of care, including minimum
staffing and clinical treatment hours.

Florida’s guidelines represent a nice example of a collaborative model to address the needs of
pregnant and postpartum women with substance use disorders and substance-exposed
children. Florida also has a “last resort” involuntary commitment to substance abuse treatment
option for pregnant or postpartum women who are abusing alcohol or other drugs, which – if


                                                                                               13
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specific criteria are met – enables a caregiver to contact a law enforcement officer to implement
protective custody measures or petition the Circuit Court for court-ordered involuntary treatment.

There are two aspects to Nevada’s standards to mention. The first is a special emphasis on
client-centered care and client empowerment. The second is the requirement for all funded
programs to have national certifications, such as Joint Commission on Accreditation of
Healthcare Organizations (JCAHO), Commission on Accreditation of Rehabilitation Facilities
(CARF), or Council for Accreditation for Children and Family Services (COA), by 2009. A final
aspect to point out relates to funding. In New Jersey, contracting requirements state that
programs must develop a system for allocating, tracking and differentiating revenue, expenses,
services and capacity by payor to provide a comprehensive view of their service programs. And
in Massachusetts, the Bureau of Substance Abuse Services is working with its partners to
identify payor mechanisms to support programs that want to offer parenting as part of the
services and explore integrated systems for clients’ children to receive treatment, as needed.


III. KEY ISSUES/AREAS TO ADDRESS IN DEVELOPING GUIDANCE TO STATES ON WOMEN’S
TREATMENT STANDARDS

The treatment standards questionnaire also asked the WTCs to identify the key issues or areas
that NASADAD should address in developing guidance to the States on women’s treatment
standards. Below are the common themes that emerged from the open-ended comments
provided by 44 States.

•   Children’s Services/Family Services. Services for women in treatment and their children
    and families was one of the most frequently cited issue areas by the WTCs. Approximately
    25 comments from 19 States fell into this category. Comments ranged from the need for
    standards guidance to address generally the provision of child and family services (including
    women’s children who may be in foster care), to tackling more specialized treatment issues,
    such as family dynamics, children’s developmental services, trauma and attachment, family
    members’ co-occurring disorders, and FASD. Several WTCs also expressed the desire for
    standards to address licensing regulations and other standards regarding child care and
    therapeutic child care, as well as parenting skills. Other comments discussed the need for
    State, private and public collaboration to reinforce and address the needs of the family,
    including improved procedures and policies between State child welfare and substance
    abuse agencies.

•   Evidence-based Practices and Gender-Specific/Competent Treatment. The other major
    area that WTCs would like addressed in guidance around standards concerns evidence-
    based practices for women (including pregnant women) and gender-specific treatment
    approaches. More than 20 comments from 16 States touched on this subject area. Similar
    to the topic area of children and family services, comments were both general in nature
    (e.g., definition of gender-specific treatment) and quite specific (e.g., guidance related to
    number of treatment hours in specialized areas such as parenting, domestic violence,
    trauma, etc.; appropriate screening for pregnant women; and placement and length of stay
    as it relates to client need and treatment outcomes).

•   Access, Retention and Continuing Care/Aftercare. Comments from approximately 10 States
    could be categorized generally around continuum of care. Several identified the need to
    continue to address access to treatment (including wait times) and barriers to treatment
    retention. A couple of WTCs would like standards to incorporate length of stay requirements
    to enhance women’s success in treatment. Several States also highlighted the need for

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    standards to include continuing care and clearly defined aftercare plans to ensure a smooth
    transition back into the community.

•   Trauma and CODs. The provision of trauma-informed and trauma-specific services, and
    treatment for other co-occurring disorders, is another significant area that 14 of the States
    would like to see addressed in treatment standards. States expressed a need for guidance
    in education, assessment, and treatment protocols to adequately respond to a woman’s
    trauma and victimization.

•   Funding. Many of the States (15) provided comments related to treatment funding and
    payment. Several of these comments focused on the need for guidance regarding
    integrated, shared or coordinated funding with other sources, and how to leverage additional
    funds to support and sustain women-specific programming and any detailed changes in
    women’s treatment standards. Others centered specifically on Medicaid coverage for
    services. In addition, a couple of States indicated a need to address reimbursement rates
    for providers.

•   Other System Issues (Collaboration, Data, Staff Training/Workforce Development). About a
    dozen States provided comments on other types of service delivery systems issues.
    Several mentioned the need for standards guidance to cover data collection and information
    sharing, and collaboration with other service providers (generally and on specific issues
    such as detoxification). In addition, many (8) States identified the need to deal with staff
    qualifications, certifications and credentialing, and ongoing training and technical assistance
    on women’s treatment issues.

•   Methadone/Pharmacotherapy. Six States would like standards or guidance regarding
    standards to contain information on methadone maintenance and acceptable
    pharmacotherapy for women.

•   Other or General Services for Women. In the comments received, WTCs also touched on
    several other services they felt were important for women’s treatment standards to address:
    housing, physical health needs, vocational training and support, life skills, and access to and
    provision of community services.

•   Other Special Subpopulations. A number of States also highlighted specific subpopulations
    of women to consider in the development of treatment standards guidance, including women
    who use methamphetamine, women involved in the criminal justice system, and women
    across the lifespan (including teenagers and older women who are no longer parenting).

In addition to these specific treatment issues that States said they would like to see addressed,
many of the comments related to bigger-picture concerns, which speak to the future direction of
the overall development and implementation of women’s treatment standards. These included,
for example, the need for uniformity and consistency across the States; questions and concerns
about how to make standards a contractual or regulatory requirement for all providers (not just
those receiving SAPT Block Grant funding); how to incorporate any new standards into existing
State standards; ensuring the participation of other key systems, service providers and
consumers in the process; ensuring standards or guidelines are consistent with the National
Outcomes Measures (NOMS); and how to continue and increase national, State and local
support for women’s treatment.




                                                                                                 15
                                     ATTACHMENT 1:

   LISTING OF STATES AND STATUS OF TREATMENT STANDARDS FOR WOMEN
                AND/OR PREGNANT WOMEN (as of April 30, 2007)

STATES WITH STANDARDS (28)

  Arizona – Practice Improvement Protocol 5: Substance Use, Abuse, and/or Dependence in
  Pregnant and Postpartum Women. Developed by the Arizona Department of Health
  Services, Division of Behavioral Health Services. Effective July 9, 2001; Last Revised April
  3, 2003.

  Arkansas – Licensure Standards for Alcohol and/or Other Drug Abuse Treatment Programs.
  Arkansas Department of Human Services, Division of Behavioral Health Services, Alcohol
  and Drug Abuse Prevention. Revised January 1, 2004.

  California – Perinatal Network Services Guidelines 2004 (For Non Drug Medi-Cal Perinatal
  Programs), California Department of Alcohol and Drug Programs.

  Colorado – Substance Use Disorder Treatment Rules. Colorado Department of Human
  Services, Alcohol and Drug Abuse Division. 15.229 Gender-Specific Women’s Treatment
  and 15.230 Services to Child Welfare Clients. Working Copy, February 27, 2007.

  Connecticut – Treatment Guidelines – Gender Responsive Treatment of Women with
  Substance Use Disorders. Connecticut Department of Mental Health and Addiction
  Services, Women’s Services Practice Improvement Collaborative. Revised January 2007.

  District of Columbia – Department of Health, Chapter 23 Certification Standards for
  Substance Abuse Treatment Facilities and Programs. Section 2357 - Specialty Services −
  Additional Standards for Programs Serving Parents and Their Children; Section 2358 -
  Specialty Services − Standards for the Developmental Assessment of Children (2000).

  Florida – Florida Substance Abuse Licensure Rule 65D-30, Florida Administrative Code,
  Specific References in Rules to Females; and Guidance for Working With Pregnant and
  Postpartum Women Who Abuse Drugs or Alcohol, Children Prenatally Exposed to Drugs Or
  Alcohol, and Their Families, Florida Department of Health and Florida Department of
  Children and Families, October 2003.

  Georgia – Ready For Work: Community Substance Abuse Services for Pregnant and
  Postpartum Women and Women with Dependent Children. A Program of the Department of
  Human Resources to Assist Recipients who meet the Needy Family Definition. Program
  Requirements for Community Mental Health, Mental Retardation and Substance Abuse
  Providers Under Contract with Regional Boards and Required Linkages with Other
  Responsible DHR Programs. Georgia Department of Human Resources, Division of Mental
  Health, Mental Retardation and Substance Abuse. Issue Date: March 25, 1998; Revision
  Effective: July 1, 2007.

  Hawaii – Section 2 - Service Specifications. Specialized Substance Abuse Treatment and
  Therapeutic Living Program for Women, Pregnant Women and Parenting Women on Maui
  (RFP 440-1-8); Section 2 - Service Specifications. Specialized Substance Abuse Treatment
  Services for Pregnant and Parenting Women (RFP 440-1-7); Section 2 - Service
  Specifications. Baby SAFE - A Specialized Substance Abuse Outreach and Early
  Intervention Service for Pregnant Women on Kauai (RFP 440-1-9); and Substance Abuse
Treatment Guidelines, Best Practices/Evidence-Based Practices. Department of Health,
Alcohol and Drug Abuse Division. Effective July 1, 2002.

Idaho – Pregnant Women and Women with Children Treatment Service Continuum. State of
Idaho. Effective July 2006; Revised December 2006.

Illinois – Chapter 20, Executive Branch, Department of Alcoholism and Substance Abuse.
Act 301. Alcoholism and Other Drug Abuse and Dependency Act. Article 35 – Special
Services for Pregnant Women and Mothers. Effective July 13, 1993.

Maine – Differential Substance Abuse Treatment (DSAT) Model. Developed for the State of
Maine, Department of Health and Human Services, Office of Substance Abuse (OSA) and
Implemented in the State of Maine Department of Corrections (MDOC) Institutions and the
Statewide Adult Drug Treatment Court (ADTC) Programs. March 2005.

Massachusetts – Fiscal Year 2007 Request for Response, Terms and Conditions and
Standards of Care for the Alcohol and Other Drugs Service System. The Massachusetts
Department of Public Health, Bureau of Substance Abuse Services, Fall 2006; Request for
License Application and Renewal Form. Massachusetts Department of Public Health,
Bureau of Substance Abuse Services, September 13, 2001; Request for Response,
Residential Recovery Services &Family Residential Substance Abuse Treatment Services in
Boston; and Massachusetts Department of Public Health, Bureau of Substance Abuse
Services, Family Substance Abuse Shelter Guidelines.

Missouri – Rules of Department of Mental Health. Division 30 – Certification Standards.
Chapter 3 – Alcohol and Drug Abuse Programs. Title 9 CSR 30-3.190 Specialized Program
for Women and Children. (Also includes other excerpts that are related to women.) June 30,
2005.

Nevada – Substance Abuse Treatment Program Operating And Access Standards (POAS),
Department of Health and Human Services, Division of Mental Health and Developmental
Services (MHDS), The Substance Abuse Prevention and Treatment Agency (SAPTA),

New Hampshire (pregnant women only) – Chapter He-A 300 Certification and Operation of
Alcohol and Other Drug Disorder Treatment Programs. Part He-A 301 Certification of
Alcohol and Other Drug Abuse Disorder Treatment Providers. Statutory Authority: RSA
172:8-b. 5/23/01.

New Jersey – N.J.A.C. TITLE 8, Chapter 42A Manual of Standards for Licensure of
Residential Substance Abuse Treatment Facilities; Annex A – Contract Number: 08-ADA-0
(boilerplate); Annex A – Section III - Requirements for Specialized Women’s Services
Programs, March 2006; Annex A – Residential CWRP/DYFS/Women & Children’s Program,
September 8, 2006; Annex A -- Division Of Addiction Services (DAS)/CWRP, General
Funding Requirements March 1, 2007 - February 29, 2008; Annex A – Variable Level Of
Care, CWRP/DYFS/Women & Children’s Program, March 14, 2007; and Annex A, Section
III, Requirements For Women’s Set Aside Methadone Maintenance, September 11, 2006

North Carolina – Rules for Mental Health, Developmental Disabilities and Substance Abuse
Facilities and Services, 10A North Carolina Administrative Code 27G, Section .4100
Residential Recovery Programs for Individuals with Substance Abuse Disorders and their
Children, Department of Health and Human Services, Division of Mental Health,
Developmental Disabilities and Substance Abuse Services, April 1, 2006; Enhanced Benefit
Services for Mental Health and Substance Abuse, Effective March 20, 2006; and North



                                                                                         2
Carolina General Statutes, Chapter 122C. Mental Health, Developmental Disabilities, and
Substance Abuse Act of 1985, Sections 122C-211 (f) and (g).

Oklahoma – Oklahoma Department of Mental Health and Substance Abuse Services. Title
450, Chapter 18 – Standards and Criteria for Alcohol and Drug Treatment Programs. Part
13: Residential Treatment for Persons with Dependent Children; Part 21: Halfway House
Services for Persons with Dependent Children. July 1, 2006.

Oregon – Oregon Administrative Rules, Standards for Outpatient and Residential Alcohol
and Drug Treatment Programs, 415-051-0110 Women's Treatment Services & Division 20
Standards for Outpatient Synthetic Opiate Treatment Programs, 415-020-0025, August 16,
2004.

Rhode Island – Rules and Regulations for the Licensing of Behavioral Healthcare
Organizations, State of Rhode Island and Providence Plantations, Department of Mental
Health, Retardation and Hospitals, September 2004.

South Carolina – Policies regarding women’s treatment are reflected in the contracts
between the South Carolina Department of Alcohol and Other Drug Abuse and the local
providers. Definition, service activity and special conditions outlined for levels of care.

Tennessee – Administrative & Program Requirements and Scopes of Services, Tennessee
Bureau of Alcohol and Drug Abuse Services. Effective July 1, 2006; revised August 8, 2006;
Tennessee Alcohol and Drug Best Practice Guidelines, Tennessee Department of Health,
Bureau of Alcohol and Drug Abuse Services, September 2001.

Texas – Chapter 447 Contract Program Requirements, Subchapter A. Prevention and
Intervention, §447.116. Pregnant and Parenting Adult and Adolescent Female Prevention
Services. Subchapter F. Treatment for Pregnant and Postpartum Women with Dependent
Children. September 1, 2004; and Chapter 448 Substance Abuse Standards of Care Rules,
Subchapter C. Standards for Evidence-Based Prevention Programs, Subchapter I.
Treatment Program Services, §448.901 Requirements Applicable to all Treatment Services,
§448.903 Requirements Applicable to Residential Services, §448.904 Requirements
Applicable to Outpatient Treatment Programs, §448.910 Treatment Services for Women and
Children, September 1, 2004.

Vermont – Gender Responsive and Trauma Informed Services for Women and their
Children. March 2007.

Washington – Pregnant, Postpartum, Parenting Women – Residential Treatment Statement
of Work. March 2005.

Wisconsin – Wisconsin Department of Health and Family Services. Vision Statement and
Core Values. Philosophy of Working with Women with Substance Use Disorders. Treatment
Standards for AODA Services to Women; and Chapter HFS 75, Community Substance
Abuse Service Standards (primarily HFS 75.15 Narcotic treatment service for opiate
addiction).

Wyoming – Department of Health Substance Abuse Division, Rules and Regulations for
Substance Abuse Standards, Chapter 16, Section 17 – Special Population Designation(s):
(c) Women’s Treatment Services and d) Residential Treatment for Persons with Dependent
Children.




                                                                                              3
STATES THAT WERE DEVELOPING STANDARDS (3)

   Alabama
   Louisiana
   Maryland

* New Jersey, which has standards for women, is also in the process of developing standards
for pregnant women.

STATES THAT INDICATED THEY DID NOT HAVE STANDARDS (20)

   Alaska
   Delaware
   Indiana
   Iowa
   Kansas
   Kentucky
   Michigan
   Minnesota
   Mississippi
   Montana
   Nebraska
   New Mexico
   New York
   North Dakota
   Ohio
   Pennsylvania
   South Dakota
   Utah
   Virginia
   West Virginia




                                                                                              4
Revised 5-8-07; reflects information from standards collected & reviewed as of April 30, 2007

                                                      ATTACHMENT 2:
              CLINICAL TREATMENT AND SUPPORT SERVICES* FOR WOMEN ADDRESSED IN STATE STANDARDS
                    (*As recommended in the CSAT Comprehensive Treatment Model for Women and Their Children)

Note: A check mark in a given service category means that this service was in some way mentioned or identified in a State’s treatment
standards/protocols/guidelines for women and/or pregnant women. However, as we indicated in the summary of key themes, the degree to which
States address and elaborate on a particular service may vary greatly. It is important to note that a State also may address these service areas in
its general standards applicable to all treatment providers, regardless of population served. This review only focuses on women-specific
materials; it does not include information from general or universal standards that may address these areas.




                                                                                                                                                                 WA



                                                                                                                                                                           WY
                                                                                                     MO
                                                                                                MA
                                               CO




                                                                     GA




                                                                                          ME




                                                                                                                              OK

                                                                                                                                   OR
                                     AR

                                          CA




                                                          DC




                                                                                                               NH



                                                                                                                         NC
                                                                                                          NV




                                                                                                                                             SC
                               AZ




                                                     CT




                                                                                                                                                  TN
                                                                                                                    NJ




                                                                                                                                                       TX

                                                                                                                                                            VT
                                                               FL




                                                                                                                                                                      WI
            State




                                                                          HI

                                                                               ID




                                                                                                                                        RI
                                                                                    IL
CLINICAL TREATMENT SERVICES
Outreach

Screening

Assessment

Substance Abuse
Counseling/Education
Crisis Intervention

Treatment Planning

Case Management/
Care Coordination
Continuing Care/Aftercare/
Recovery Management
Pharmacotherapy

Drug Monitoring

Detoxification

Medical Care/
Primary Health Care
Mental Health




                                                                                                                                                                       1
Revised 5-8-07; reflects information from standards collected & reviewed as of April 30, 2007




                                                                                                                                                                 WA



                                                                                                                                                                           WY
                                                                                                     MO
                                                                                                MA
                                               CO




                                                                     GA




                                                                                          ME




                                                                                                                              OK

                                                                                                                                   OR
                                     AR

                                          CA




                                                          DC




                                                                                                               NH



                                                                                                                         NC
                                                                                                          NV




                                                                                                                                             SC
                               AZ




                                                     CT




                                                                                                                                                  TN
                                                                                                                    NJ




                                                                                                                                                       TX

                                                                                                                                                            VT
                                                               FL




                                                                                                                                                                      WI
              State




                                                                          HI

                                                                               ID




                                                                                                                                        RI
                                                                                    IL
Trauma/Violence

CLINICAL AND COMMUNITY SUPPORT SERVICES
Life Skills

Advocacy

Family Programs/
Family Strengthening
Parenting and Child
Development Education
Housing Supports &
Assistance
Educational/Vocational
Remediation and Support
Employment Readiness
and Support
Linkages with Child
Welfare, Legal/ Criminal
Justice Systems
TANF Linkages

Recovery Community
Support Services
(including Faith-Based
Organization Support)
Transportation

Child Care

Recreational Services




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