A quick snapshot: who you are and why you're here

• Tell me in one sentence who you are bringing to treatment and what made you start this conversation today
• How long has this person been using substances at the current level of severity Options: Less than 1 month, 1 to 6 months, 6 to 12 months, More than 1 year, Unknown
• When did the last medical or safety event related to use occur, for example an overdose, seizure, or ER visit Options: Within 48 hours, Within 7 days, Within 30 days, More than 30 days, No known events
• Describe the last time you tried treatment or a major change, what helped briefly and what derailed progress
• Which family or legal stakeholders must be involved in admission decisions or can block placement Options: Primary caregiver or spouse, Parent or guardian, Court or probation officer, Employer or EAP, No stakeholder blocks, Other
• Are there immediate safety or suicide risks we should know before we proceed Options: Yes, imminent risk, Yes, recent but not imminent, No known risk, Unsure

Where the clinical risk is highest right now

• If nothing changes in the next 30 days, what specific clinical emergency are you most worried will happen Options: Emergency overdose requiring naloxone, Severe withdrawal needing medical detox, Suicidal crisis or self harm, Violent behavior or harm to others, Legal incarceration, Other
• List the substances used in the last 30 days and approximate frequency of use for each
• How severe are withdrawal symptoms historically and have they required medical detoxification Options: None or minor, Moderate managed outpatient, Severe, required inpatient detox previously, Unknown
• What medications including medication assisted treatment like buprenorphine or methadone are in use now or have been stopped recently Options: None, Buprenorphine or Suboxone, Methadone, Naltrexone, Benzodiazepines, Other prescribed meds, Unknown
• If the person refuses a recommended level of care who makes the call next and what usually changes the outcome

Triggers and lived patterns: what the day-to-day looks like

• Which recent behavior or pattern most surprised you and convinced you that help is now necessary
• Walk me through a typical 24 hour period at the worst point in the last month from waking to sleep
• And how long has the current pattern been escalating Options: Days, Weeks, Months, Years, Variable
• Is there a clear trigger, people, places, times, or emotions that reliably precede relapse episodes Options: Specific people, Certain locations, Weekends or evenings, Stress or mood swings, No clear trigger, Other
• On a scale from 1 to 10 how ready is the person to accept structured residential care right now Options: 1, 2, 3, 4, 5, 6, 7, 8, 9, 10

Co-occurring conditions that change the plan

• Name the untreated mental health symptom that creates the biggest barrier to sustained recovery here Options: Unmanaged depression, Severe anxiety or panic, Active psychosis, Trauma driven symptoms, Personality disorder traits, None primary
• Describe any past psychiatric diagnoses hospitalizations or current therapy engagement
• Have medications for mental health been effective missed or stopped and why Options: Effective and continued, Partially effective, Stopped due to side effects, Not tried, Unknown
• Who provides ongoing psychiatric care and are they willing to coordinate with an inpatient team Options: Primary care physician, Community psychiatrist, No current provider, I do not know, Other
• What would need to change before admission if untreated anxiety or depression would make residential therapy ineffective

Family dynamics legal orders and payer complexity

• Who controls payment and approval for treatment and how quickly can they make a decision
• Select the insurance benefit that if absent would prevent admission Options: Detox coverage, Residential behavioral health days, Medication coverage, Prior authorization already approved, No insurance or self pay, Other
• In the past how often have payment or authorization issues shortened clinically recommended stays Options: Never, Rarely, Occasionally, Often, Always, Unknown
• Are there active legal orders employer mandates or court dates that affect timing or placement Options: Yes court ordered, Yes employer mandated, No legal constraints, Unsure
• Name an alternate funding or placement you would accept if authorization is delayed beyond one week Options: Self pay with payment plan, Short stay residential, Outpatient plus intensive case management, Court sanctioned program, Other

Consent capacity and information sharing

• When consent or capacity is unclear what evidence causes you to pause admission
• List any guardianship power of attorney or designated decision maker legal documents we need to see
• Have all involved adults given verbal or written consent to share clinical information with our team Options: Yes written consent provided, Yes verbal consent only, No consent yet, Consent pending legal review
• Please name the day one point of contact for clinical updates and family involvement
• Please list any religious or cultural practices that must be accommodated during residential stays

Measuring success, short term wins and deal breakers

• Ten months from now which single measurable outcome would prove this treatment worked Options: Sustained abstinence from primary substance, Return to work or school, No medical emergencies, Stable psychiatric symptoms, Improved family relationships, Other
• Provide three short term goals for the first 30 days that would signal progress
• Tell the top three signs family or referrers will use to judge progress
• Does any potential outcome make continuing treatment unacceptable to you Options: Yes critical safety concern, Yes unacceptable treatment approach, No deal breaker identified, Unsure
• Within what time frame would you expect the first reliable sign of improvement after admission for example 72 hours 2 weeks 1 month Options: 48 to 72 hours, 1 week, 2 weeks, 1 month, Longer than 1 month

The alternatives you are weighing

• Of the other options you are considering which feels most likely to be chosen and why
• Select which alternatives you have evaluated so far Options: Residential program with 30 day minimum, Short term medically supervised detox only, Outpatient or IOP, Medication management only, Court mandated local program, In-home family support plan, No outside help planned, Other
• To remain with your current approach name the outcomes it must deliver
• Has anyone on your side proposed solving this without an outside provider Options: Yes family led plan, Yes employer EAP approach, No one has proposed that, Unsure
• Identify the single change that would keep you from switching to an outside provider

Operational readiness and constraints

• Identify the operational constraint that if unresolved would prevent admission next week Options: No verified insurance, Active legal hold, No transportation arranged, Unsafe medical condition needing stabilization, Lack of consent, Other
• Provide the third-party systems that must be integrated for continuity of care for example medication records insurance portals or court databases
• State the owner of API access or login credentials for each system and whether they are prepared to share them
• Could you list any regulatory approvals data use agreements or consent forms that must be signed before sharing clinical notes
• State the names of technical staff who would be assigned for integration or coordination and the earliest available start date

Next steps and a clear yes or no

• Assuming the intake is clinically appropriate what barrier would most likely delay admission beyond 48 hours Options: Insurance authorization delay, Transportation or logistics, Legal or court scheduling, Medical stabilization needed, Family or payer decision delay, Other
• Point to the single answer in this intake that would cause you to stop the referral now
• Within how many business days can you provide verified insurance details and prior authorization paperwork for example 1 3 or 7 Options: Same day, 1 business day, 3 business days, 7 business days, More than 7 days
• Do you have a preferred admission date and how flexible is that window Options: Preferred date fixed, Preferred week with +/- 3 days, Flexible within 2 weeks, No preferred date
• Given a guaranteed medically supervised detox and placement within your preferred window are you ready to proceed with admission today Options: Yes ready to proceed, Need to check with payer or family, Not ready today, Unsure

• Continuum Walkthrough — Solution Experience

• Confirm the current state and what it is costing you
• You confirm that the proposed continuum directly addresses the specific transition failures and relapse risk described in Discovery.
• Deliver a patient-specific continuum plan with milestone dates, relapse-prevention interventions, and named owners for each transition within 48 hours.
• Provide verified insurance benefits, any legal mandates, and current medication lists for this patient before the authorization window closes.
• Walk the proposed continuum in this patient's clinical context
• You validate the milestone timing and the relapse-prevention supports as clinically appropriate for the patient's context.
• Prove the milestones and relapse-prevention supports
• You agree on what remaining authorization or documentation is required to secure the recommended length of stay and next steps to obtain it.
• Confirm the decision timeline and who must sign off on the care plan so authorization and admission steps can be scheduled.
• Demonstrate family engagement and operational ownership at each transition
• Address insurance and authorization constraints in the plan
• Validate the plan against what you described

• Continuum Walkthrough — Solution Experience
• Continuum Walkthrough Deck
• Solution Brief — Continuum of Care

• meeting
• slides
• document

• Medically Supervised Detoxification
• Medication-Assisted Treatment Initiation and Stabilization
• Medication-Assisted Treatment Maintenance
• Residential Inpatient Treatment Program
• Intensive Outpatient Program (IOP) Sessions
• Outpatient Counseling and Individual Therapy
• Cognitive Behavioral Therapy Sessions
• Group Counseling and Peer Support Groups
• Family Counseling and Education Sessions
• Integrated Co-Occurring Disorder Psychiatric Care
• Aftercare Case Management and Alumni Support
• Insurance Benefits Advocacy and Prior Authorization Assistance
• Rapid Readmission and Relapse Crisis Stabilization

Medically Supervised Detoxification

• Do you require medically supervised detoxification based on a recent withdrawal risk assessment such as CIWA-Ar or a documented benzodiazepine/ alcohol withdrawal score? Options: Yes, No, Unsure - need assessment
• Which substances requiring detox were documented on intake (select all that apply)? Options: Alcohol, Benzodiazepines, Short-acting opioids, Long-acting opioids, Stimulants, Polysubstance
• How many inpatient detox days do you anticipate based on ASAM withdrawal risk level and prior withdrawal history? Options: 24-72 hours, 3-7 days, 8-14 days, More than 14 days
• What medical monitoring and lab protocols must be followed during detox (for example LFTs, CBC, EKG, CIWA-Ar charting frequency)?
• Who will serve as the authorized prescriber for detox medications and do they hold required privileges or waivers? Options: Addiction medicine specialist, Hospitalist/attending, Waivered primary care prescriber, Not assigned yet
• What objective criteria will confirm successful detox and safe transfer to the next level of care (for example CIWA-Ar <8 for 24 hours, stable vitals without PRN benzodiazepines or naloxone use)?

Medication-Assisted Treatment Initiation and Stabilization

• Which FDA-approved medications do you plan to initiate during induction? Options: Buprenorphine (sublingual), Methadone (opioid treatment program), Naltrexone (oral or extended-release), Combination approach, Not yet decided
• Which induction protocol should be used given last-use timing and urine drug screen (for example standard buprenorphine induction, microdosing/bridging, methadone OTP referral)? Options: Standard buprenorphine induction, Microdosing (low-dose buprenorphine), Methadone clinic referral, Naltrexone induction after confirmed abstinence, Undecided - need clinical review
• Do you have a current supervised urine drug screen and documented timing of last opioid use to guide safe MAT induction? Options: Yes - recent UDS available, No - UDS needed prior to induction, Last use documented but no UDS
• Who will hold prescribing authority during induction and stabilization (for example waivered physician, nurse practitioner, OTP clinic)? Options: Waivered physician, Waivered nurse practitioner/PA, OTP clinic prescriber, Community prescriber with consult, Not assigned
• What measurable stabilization criteria will you accept before moving the patient to maintenance (for example stable buprenorphine dose for 7 days, absence of withdrawal symptoms, supervised UDS without illicit opioids)?
• How frequently should clinical monitoring occur during induction (daily, every other day, weekly) and which specific checks are required (vitals, sedation scale, UDS)? Options: Daily monitoring, Every other day, Weekly monitoring, Other - specify

Medication-Assisted Treatment Maintenance

• Which maintenance medication and target dosing range do you expect for ongoing therapy (please include examples such as buprenorphine 8-24 mg/day or individualized methadone dosing)?
• How often should medication follow-ups and urine drug screens occur during maintenance? Options: Weekly, Biweekly, Monthly, Quarterly
• Do you require take-home dosing or pharmacy dispensation and what documentation supports take-home privileges (stability documentation, urine history)? Options: Clinic dosing only, Pharmacy dispensation with monitoring, Partial take-home permitted, Not required
• Who will manage long-term prescriptions and controlled substance agreements (program prescriber, community prescriber, collaborated care)? Options: Program prescriber, Community prescriber, Shared care agreement, Not assigned
• Which relapse-detection triggers should prompt escalation or readmission (for example positive supervised UDS for illicit opioid, three missed medication visits, overdose event)? Options: Positive supervised UDS for illicit opioid, Missed 3 consecutive appointments, Emergency department visit/overdose, Self-reported relapse, Other
• Do you require integration of medication records with a specific EHR or pharmacy system and if so name the system for connector planning?

Residential Inpatient Treatment Program

• How long do you anticipate the residential stay should be for clinical benefit (select typical options)? Options: 30 days, 60 days, 90 days, More than 90 days
• Which daily treatment modalities must be included in residential programming (for example individual therapy, group CBT, medication management, psychoeducation)? Options: Individual therapy, Group therapy (CBT-focused), Medication management rounds, Psychoeducation/skill-building, Peer support/alumni sessions
• What rooming and medical observation needs must the facility meet (private room, medical observation bed, telemetry capability)? Options: Private room available, Shared room acceptable, Medical observation bed required, Telemetry/step-down capability required
• Which family engagement expectations should be offered during residential stay (weekly family therapy, family education sessions, limited visiting hours)? Options: Weekly family therapy, Family education sessions, Structured family weekend, Limited visiting only
• What clinical indicators do you expect the team to document when recommending step-down from residential (consistent attendance, progress on individualized treatment goals, medication stability)?
• What staffing credentials and ratios are required onsite during residential care (for example 24/7 RN coverage, addiction counselor LPCC/LCSW, on-call physician)? Options: 24/7 RN coverage, Licensed addiction counselors (LPCC/LCSW), On-call physician, Addiction medicine specialist onsite

Intensive Outpatient Program (IOP) Sessions

• How many hours per week of IOP programming should be provided during the core phase? Options: 9 hours/week, 12-15 hours/week, 16-20 hours/week, Custom schedule
• Which therapy components must be part of IOP (group CBT, relapse prevention, medication check-ins, family nights)? Options: Group CBT, Relapse prevention groups, Medication check-ins, Family education nights, Peer recovery support
• What minimum attendance requirement should define acceptable IOP participation (for example 75% attendance, mandatory make-ups)? Options: 75% attendance, 90% attendance, Make-up sessions required, Flexible attendance with case review
• Do you require telehealth capability for IOP sessions and do you need integration with a particular telehealth platform? Options: Yes - telehealth allowed, No - in-person only
• What written documentation must IOP provide at transition points (weekly progress notes, updated treatment plan, discharge summary)? Options: Weekly progress notes, Updated treatment plan, Formal discharge summary, All of the above
• Who will coordinate scheduling the first IOP session after step-down from residential or detox? Options: Residential case manager, Outpatient coordinator, Patient/family to schedule, Other

Outpatient Counseling and Individual Therapy

• How many individual therapy hours per month do you expect in the outpatient phase? Options: 1-2 hours/month, 4-8 hours/month, 8+ hours/month, Custom
• Which therapeutic approaches are required for individual sessions (CBT, motivational interviewing, trauma-informed therapy)? Options: Cognitive Behavioral Therapy (CBT), Motivational Interviewing, Trauma-informed therapy, Dialectical Behavior Therapy (DBT)
• Do you require sessions to be delivered by licensed clinicians for co-occurring psychiatric diagnoses? Options: Yes - licensed clinicians required, No - supervised trainees acceptable, Hybrid model
• What measurable progress indicators should be captured in therapy notes (treatment goal milestones, PHQ-9/GAD-7 score changes, behavioral targets)?
• Should outpatient therapy include formal coordination and written releases to external providers such as PCPs or psychiatrists? Options: Yes - written release required, No - keep within program, Case-by-case
• What scheduling flexibility is required for outpatient therapy (evening hours, weekend availability, telehealth options)? Options: Evening availability, Weekend sessions, Telehealth options, Standard weekday hours only

Cognitive Behavioral Therapy Sessions

• How many CBT sessions per week should be included during the active treatment phase? Options: 1 session/week, 2 sessions/week, 3+ sessions/week, Custom cadence
• Should CBT be delivered using a manualized curriculum (for example a relapse prevention workbook) or a flexible CBT model? Options: Manualized curriculum required, Flexible CBT model, Combination
• Do you require CBT fidelity monitoring such as session recordings, checklist scoring, or supervisor reviews? Options: Yes - session recordings, Yes - fidelity checklist, No fidelity monitoring required
• Who is expected to deliver CBT sessions (licensed therapist, certified CBT practitioner, peer specialist)? Options: Licensed therapist (LPC/LCSW), Certified CBT practitioner, Peer specialist with supervision, Other
• What CBT outcome measures will you track (homework completion rate, coping skill competency, reduction in trigger reactivity)?
• Should CBT homework assignments be documented in the clinical record and how should completion be evidenced? Options: Documented in chart with patient signature, Self-report only, Not required

Group Counseling and Peer Support Groups

• What frequency and group size do you require for group counseling sessions (for example 3x/week, 6-12 participants)? Options: Daily groups, 3x/week, Weekly groups, Other - specify
• Should groups be organized by primary substance, gender, age cohort, or stage of recovery? Options: By primary substance, By gender, By age cohort, By stage of recovery, Combination
• Do you require peer recovery specialist presence in groups and should their credentials be documented? Options: Yes - peer specialist required, Optional, No
• What confidentiality and attendance verification practices must be enforced for groups (signed agreements, roll calls, group ground rules)?
• Would you prefer structured curriculum-based groups (for example 12-step or matrix model) or open process groups? Options: Structured curriculum, Open process, Combination
• What metrics should be used to measure group effectiveness (retention rate, module completion, self-reported coping improvements)?

Family Counseling and Education Sessions

• How many family sessions should be scheduled during treatment and in aftercare? Options: Weekly during early treatment, Biweekly, Monthly, On demand
• Which family therapy models are preferred (for example CRAFT, systemic family therapy, behavioral family therapy)? Options: Community Reinforcement and Family Training (CRAFT), Systemic family therapy, Behavioral family therapy, General family education
• Are there legal family involvement requirements to document such as court orders, guardianship, or power of attorney? Options: Yes - court order/guardianship present, No legal requirements, Pending documentation
• What type of consent or release must be obtained to share clinical updates with family members (signed HIPAA release, court order)? Options: Signed HIPAA release, Court order, Power of attorney document, Other
• Should family sessions produce a written family recovery plan with roles and responsibilities documented? Options: Yes - written family recovery plan required, Optional, No
• Who will own scheduling family sessions and communicating notes to family (care coordinator, family liaison, patient/family)? Options: Care coordinator, Family liaison, Patient/family schedule, Other

Integrated Co-Occurring Disorder Psychiatric Care

• Do you require on-site psychiatric evaluation for co-occurring mental health disorders at admission? Options: Yes - psychiatric eval at admission, No - outpatient referral acceptable, Conditional based on screening
• Which standardized screening or diagnostic tools should be used for psychiatric comorbidity (for example PHQ-9, GAD-7, MINI)? Options: PHQ-9, GAD-7, MINI, AUDIT/DAST, Other
• What psychotropic medication management capabilities must be available (initiation, adjustment, long-term monitoring of antidepressants, antipsychotics, mood stabilizers)? Options: Initiation and adjustment onsite, Consult-only psychiatric support, Referral to community psychiatry
• Should a formal psychiatric treatment plan and medication reconciliation be completed at admission and discharge? Options: Yes - both admission and discharge, Only at admission, Only at discharge, No
• How should psychiatric care be coordinated with addiction treatment (shared treatment plan, weekly interdisciplinary case conferences, electronic chart access)? Options: Shared treatment plan, Weekly interdisciplinary case conference, Ad hoc communication, Electronic chart access required
• What clinical stabilization targets for psychiatric symptoms must be met to allow step-down or discharge (for example PHQ-9 reduction, no active suicidality, medication adherence documented)?

• Informed Consent to Treatment
• Financial Responsibility Agreement
• Insurance Authorization & Assignment
• Release of Information & Family Communication Authorization
• Legal or Employer Mandate Acknowledgement
• Readmission & Aftercare Commitment
• Emergency Medical & Transport Authorization
• HIPAA Notice of Privacy Practices & PHI Authorization
• HIPAA Business Associate Addendum (BAA) — conditional

• Go-live Health Check (weeks 1-4)
• First Outcome Measurement (weeks 4-10)
• Acceptance Review, 90-day Outcome Gate
• Quarterly Recovery & Aftercare Review

• Update aftercare and alumni program materials based on lessons learned and publish the revised materials to the shared workspace.
• Compile insurance authorization exception list and initiate appeals or alternative funding pathways for affected patients.
• Restate acceptance criteria and numeric targets
• Produce a documented acceptance decision for the 90-day outcomes, tied to the targets recorded in the Treatment Scope stage.
• For any unmet criteria, have a time-bound remediation plan that will be tracked in the shared aftercare channel.
• Publish the acceptance decision and outcome dataset to the shared workspace for audit and future reference.
• If any acceptance criteria failed, create a remediation plan with measurable milestones and dates for re-check at the next quarterly review.
• Update the shared aftercare channel with escalation steps for relapse events and a summary of lessons learned from cases that did not meet targets.
• Review trend lines for key recovery metrics
• Confirm whether quarterly recovery metrics remain on track versus Treatment Scope targets and capture any metric regressions needing action.
• Produce a prioritized list of enhancements or remediations drawn from the shared channel, with dates to demonstrate impact.
• Create a prioritized backlog of enhancement requests from the shared aftercare channel and schedule implementation windows.
• Schedule targeted follow-up interventions for patients flagged at elevated readmission risk, including timelines for reassessment.
• Re-confirm agreed success criteria and owners
• All critical admission and initial-care tasks are verified complete or have documented remediation plans.
• Early adoption signals for aftercare and family engagement are captured and a baseline list of blockers is agreed.
• Publish a consolidated status log of admission tasks and outstanding exceptions for the shared aftercare channel.
• Collect and document sources used to verify early adoption signals, including attendance logs and aftercare enrollment lists.
• Submit requests to resolve any pending insurance authorization issues and track resolution dates.
• Present first outcomes data
• Establish whether each named metric is trending toward the Treatment Scope targets and document root causes for any shortfalls.
• Agree a short list of corrective actions with completion dates to be validated at the acceptance gate.
• Publish the metric definitions and data sources used to calculate the 30-day abstinence rate, aftercare attendance rate, and 30-day readmission rate.
• Create targeted outreach tasks for patients who missed aftercare sessions, with follow-up windows and success criteria.
• Surface persistent issues and enhancement requests
• Validate clinical and operational go-live items
• Diagnose gaps and root causes
• Present outcome data against each criterion
• Case review and lessons learned
• Document pass or fail per criterion and capture the acceptance decision
• Review early adoption signals
• Agree corrective actions and timeline to acceptance gate
• Confirm data and reporting cadence
• Open issues and blockers
• Agree remediation plan for any failed criteria
• Prioritize actions and update roadmap for aftercare operations
• Agree immediate remediation actions