Guidelines for the Establishment of Pilot Recovery Clinics for Persons Who Use Drugs

May 15, 2019

DOH ADMINISTRATIVE ORDER NO. 2019-0005

 

I. BACKGROUND

The Dangerous Drugs Board in consultation with the Department of Health issued Board Regulation #4 series of 2016: Guidelines on the Assessment of Individuals Who Voluntary Surrender and Determination of Appropriate Intervention to address the increased number of drug users who surrendered to authorities. The aforementioned Board Regulation provides an algorithm for an evaluation and referral system where Low Risk Persons Who Use Drugs (PWUDs) are initially screened and referred to the Anti-Drug Abuse Council (ADAC) for supportive General Interventions, while Moderate to High risks cases are assessed and referred by a DOH-Accredited Physician. Patients with Mild drug dependency will be referred to Community-Based Rehabilitation Program managed by the ADAC, while patients assessed with Moderate and Severe drug dependency may be referred to either outpatient treatment, or inpatient treatment in a Drug Abuse Treatment and Rehabilitation Center (DATRC). cDCEIA

DOH-Dangerous Drugs Abuse Prevention and Treatment Program (DDAPTP) piloted six (6) model outpatient Substance Use Disorder (SUD) clinics called Recovery Clinics for Moderate to High risk PWUDs who do not meet the severity criteria for compulsory confinement in DATRCs. DDB issued Board Resolution No. 4 series of 2018: Establishment and Operation of Pilot Community-Based Treatment Drug Abuse Recovery Facilities (Recovery Clinics and Homes) as basis to establish and operate Pilot Recovery Facilities in the following areas:

1. Lagawe, Ifugao

2. Tarlac City, Tarlac

3. Pasay City, Metro Manila

4. Calapan City, Oriental Mindoro

5. Mandaue City, Cebu, and

6. Nabunturan, Compostela Valley

This guideline is aligned with the strategic framework of FOURmula One Plus for Health (F1+) and was developed for Local Government Units (LGUs) and private entities that aim to establish sustainable and accessible free standing Recovery Clinics. ISHaCD

II. OBJECTIVES

A. This Order aims to prescribe guidelines for the effective implementation of pilot Recovery Clinics. Specifically, it aims to set standard services, staffing pattern, architectural layout, and structured training modules for capacity building activities.

B. This shall prescribe a human rights based and a full voluntary treatment pathway of care program premised on the principles and values of accessibility, appropriateness, affordability, acceptability, effectiveness, efficiency, equity and quality.

III. SCOPE OF APPLICATION

A. This Order shall apply to all LGUs that aim to establish and operate pilot Recovery Clinics and prescribe its minimum components covering critical phases of interventions to PWUDs with full involvement of patients and their families in treatment planning, management and rehabilitation at the LGU setting.

B. This shall also apply to individuals, institutions, and private organizations involved in the provision of outpatient services for PWUDs.

IV. DEFINITION OF TERMS

A. Drug Dependency Examination (DDE) — a medical examination conducted by a DOH-Accredited Physician, whether private or government, to assess the extent of drug dependency, medical complications, and presence of co-morbidities, and recommend appropriate intervention. DHESca

B. Matrix Intensive Outpatient Program — provides an intensive outpatient treatment model for substance abuse clients and their families, incorporating elements of relapse prevention, cognitive-behavioral, psychoeducation, and family approaches.

C. Recovery Clinic — a non-residential treatment facility where specialized consultations, evaluations and treatment may be provided. Health professionals shall make decisions about treatment options, maintain confidential medical records and observe patients' rights and privacy.

D. Rehabilitation — a life-long dynamic process or intervention emphasizing aftercare and follow-up treatment, directed towards attaining those changes in physical, psychological, vocational, social, and spiritual state necessary to live a life without drug use.

E. Relapse — the recurrence of drug use while undergoing and/or after apparent recovery.

F. Social Reintegration — any social intervention with the aim of integrating former or recurrent drug users in to the community.

G. Substance Use Disorder (SUD) — occurs when the recurrent use of alcohol and/or drugs causes clinically and functionally significant impairment such as health problems, disability, and failure to meet major responsibilities at work school and, home. cDTACE

H. Voluntary Care Model — a new pathway that adds to, but does not replace the existing DATRC pathway where admission is on a voluntary basis where patients are as free to enroll in treatment as they are to quit treatment. There are no consequences or punishments, and no reports to police or civil authorities for premature departures from care or for positive urine tests.

V. GENERAL GUIDELINES

A. Recovery Clinics shall provide sustained and accessible facility-based non-residential treatment and support services as an essential part of a continuum of care for PWUDs, with an individual treatment care plan developed jointly with the PWUD.

B. All Recovery Clinics shall implement the voluntary care model where admission shall be on a voluntary basis not requiring court order. Health professionals shall provide decision-making about treatment options, maintain confidential medical records, and observe patient's rights and privacy. PWUDs shall have the option to withdraw from the program without interference with voluntary discharges and terminations of care.

C. Recovery Clinics shall be managed by an LGU, which may be a municipality, city, or province. The Recovery Clinic shall be located within the premises, or near an LGU hospital or health center in order that specialized consultations or evaluations for medical and psychiatric symptoms may be facilitated. TEHIaD

D. There shall be no consequences or punishments, and no reports to police or civil authorities for premature departure from care. Drug dependency is a chronic relapsing medical disorder requiring tolerance of slips and relapses, and repeated episodes of care.

E. All Recovery Clinics shall institute policies that adhere to human rights and dignity of PWUD and highest possible professional and ethical standards in the performance of their functions, and show sensitivity to culture, ethnicity, religion, age, gender and sexuality in dealing or relating, treating and managing PWUD. Services shall be provided in a non-stigmatizing and respectful manner, with no punishment systems such as verbal humiliation and the likes.

VI. SPECIFIC GUIDELINES

All Recovery Clinics shall comply with the following:

A. Informed Consent

An informed consent form from the PWUD or a legal representative shall be obtained prior to initiating any service. (See Annex A. Informed Consent Template)

B. Recovery Clinic Core Services:

1. Clinical Assessment and Screening:

a. Initial assessment of patients regarding drug use and its severity:

i. Assess patient's needs and personal background

ii. Assess and identify the drug history of the patient

iii. Substance use patterns

iv. Dependence Syndrome

v. Assess life functioning problems and functioning analysis

vi. Determine biomedical and neuropsychological effects to patients

2. Medical and Mental Health Assessment:

a. Assess patient's specific health needs

b. Evaluate the medical treatment given to the patients

c. Psychological assessment through administration of test and evaluation of patient

d. No Drug Dependency Examination (DDE) shall be performed. Confidential medical recommendation to transfer to a secure treatment facility may occasionally be received by patients, but it should not be coerced or enforced. DETACa

3. Matrix Intensive Out-Patient Treatment Program:

a. Provides a structured treatment experience for patients and their families with stimulant use disorders particularly methamphetamine.

b. The patient shall attend intensive phase outpatient treatment sessions for 16 weeks such as:

i. Individual/Conjoint Family Sessions

ii. Early Recovery Skills Group Sessions

iii. Relapse Prevention Group Sessions

iv. Family Education Group Sessions

v. Social Support Group Sessions

c. The remaining eight (8) weeks after the 16 weeks intensive phase outpatient treatment session shall be utilized for community support and social reintegration programs. CScaDH

C. Recovery Clinic Support Services

1. Support Services

a. Aftercare Program

b. Skills and Vocational Trainings

c. Spiritual Enhancement

d. Individual Coaching

e. Recreational Program

f. Social and Psychological Services

g. Family Support Program

h. Referral Services

i. Outreach Program

2. Other Services (Optional)

a. Drug Testing Laboratory

b. Psychiatric Services

c. HIV Prevention Education

d. Community Reinforcement Approach

e. Multi-dimensional family therapy and/or Social Networking

D. All Recovery Clinics shall follow the algorithm of "Client Flow for Wellness and Recovery from Substance Related Issues" (Annex B) of DDB Regulation No. 4, series of 2016 and this guideline. PWUDs categorized as mild to moderate drug dependent who do not meet the severity criteria for admission to a DATRC, shall be referred to a Recovery Clinic in line with the abovementioned algorithm. TaDCEc

E. Patient Exclusion Criteria:

1. Patients who are petitioned for treatment in Drug Abuse and Treatment Rehabilitation Centers as well as patients with existing court order shall not be allowed to enroll in the clinic program.

2. Patients diagnosed with major Mental Health conditions (i.e., Psychosis, Bipolar Disorder, Schizophrenia) and emergencies shall not be allowed to enroll in the clinic program, but may be referred to a higher level of treatment and care.

3. Patients who are minors, especially girls, shall not be admitted to a Recovery Clinic and will be referred to DSWD for proper interventions. The program is designed for adults who have different level of cognitive ability.

4. Patients unwilling to agree to basic program rules about attendance and behavior shall not be admitted to the clinic program.

F. All Recovery Clinics shall be part of a network with the Anti-Drug Abuse Councils (ADACs) resource mapping to ensure that PWUDs receive holistic and integrated care. aHSTID

G. Confidentiality of Medical Records:

1. Recovery Clinics shall protect the rights to privacy and confidentiality of the PWUD according to the provisions of Republic Act 10173 known as the "Data Privacy Act of 2012" and existing DOH privacy policies. No release of medical records unless fully informed Release of Information (ROI) forms have been understood and signed, or if there are compelling legal court orders.

2. Data Protection Officers (DPO) or Compliance Officer for Privacy (COP) shall provide assistance in ensuring compliance to existing laws and issuances.

3. Periodic reports may be prepared on aggregated data based on large cohorts. All record entries need to be verified, dated, and signed by the originator.

H. Human Resources for Health Requirements:

1. Human Resources for Health:

 To provide a comprehensive package of services for PWUDs, Human Resources profile of pilot Recovery Clinics shall consist of medical and social work professionals which includes, but is not limited to: Physicians, Registered Nurses, Licensed Social Workers, and Certified Security Personnel, on full duty time (Annex C). Staff allocation shall be based on the projected population of drug dependents and availability of resources. cDEHIC

2. Mandatory structured modules for capacity building activities adopted from global evidence-based principles that is socially acceptable and culturally adaptable shall include, but is not limited to:

a. Matrix Intensive-Outpatient Program (U.S. SAMHSA Module)

b. Mental Health Gap Action Programme (mhGAP) Intervention Guide, Version 2.0

c. Basic Training Course for Rehabilitation Practitioners on the Assessment Management of Drug Dependency

d. Basic Training Course for Physicians on the Assessment and Management of Drug Dependency

I. Establishment of Physical Facility:

1. Establishment of a physical facility shall follow the procedural guidelines for the Permit to Construct Application set by the Health Facilities and Services Regulatory Bureau (HFSRB) of DOH. For details on architectural designs, specifications, and procedural guidelines, refer to Administrative Order No. 2016-0042: Guidelines in the Application for Department of Health Permit to Construct and its amendments. CDHaET

2. Adequate facility shall be in place for the safe and efficient operation of the recovery clinic. For details, refer to Administrative Order No. 2016-0042: Guidelines in the Application for Department of Health Permit to Construct and its amendments, and Models for Small and Large Recovery Clinics (Annex D and Annex E) respectively.

J. Monitoring and Evaluation

Pilot Recovery Clinics shall ensure that no monitoring reports on individual patients will be submitted to civil or police authorities. Aggregated anonymized data for large cohorts of patients may be shared with other agencies to support planning.

Monthly Accomplishment Reports shall be submitted to their respective Centers for Health Development and DOH-DDAPTP using a template provided in Annex F. Performance indicators for monitoring and evaluation of the Program shall be developed in coordination with other DOH Offices, Local Government Units, National Government Agencies, and other development partners.

VII. Roles and Responsibilities

A. National Government Agencies:

1. Department of the Interior and Local Government (DILG) shall advocate to LGUs the establishment of Recovery Clinics and assist DOH in coordinating with them.

2. Department of Health (DOH):

a. DDAPTP shall oversee LGU's implementation and management of pilot Recovery Clinics. It shall assist in capability building, policy formulation, advocacy, technical assistance and financial support subject to availability of funds, networking, coordination, monitoring and evaluation. It shall monitor and evaluate government and private Recovery Clinics based on specific indicators.

b. Health Facilities and Services Regulatory Bureau (HFSRB) shall provide assistance in the eventual accreditation and licensure of Recovery Clinics, and shall inspect and monitor the Recovery Clinics using the Assessment tool for non-residential DATRC for their compliance to the guidelines.

c. Centers for Health Development through the Regulation, Licensing and Enforcement Division (RLED) shall provide assistance in the mapping of health workers trained in SUD management, and initial inspection, assessment, and monitoring of Recovery Clinics regarding infrastructure compliance to existing laws and guidelines. TaCEHA

3. Dangerous Drugs Board (DDB) shall issue policies and strategies in coordination with DOH and may provide financial support for its operations, subject to availability of funds.

4. Department of Education (DepED) and Commission on Higher Education (CHED) shall provide relevant educational assessment and services (e.g., Alternative Learning Services).

5. Department of Social Welfare and Development (DSWD) shall provide Aftercare Services jointly with DOH.

6. Technical Education and Skills Development Authority (TESDA) shall provide relevant training and appropriate certification for recovering patients.

B. Local Government Units (LGUs) and private institutions shall constitute an enabling act (Provincial Ordinance, Board Resolution) that will ensure the provision of funds for personnel services, maintenance and other operating expenses. Capital outlays for LGU managed pilot Recovery Clinics may be sourced from local funds, DOH, DDB, or other development partners.

C. Development Partners shall provide technical assistance and financial support subject to availability of funds.

VIII. TRANSITORY CLAUSE

These Guidelines for the Establishment of Pilot Community-Based Recovery Clinics for Persons Who Use Drugs shall be an interim guideline towards a long-term measure to include other Substance Use Disorders. The pilot program shall be evaluated after three (3) years for necessary amendments of the guidelines.

IX. REPEALING CLAUSE

All issuances inconsistent with this order are hereby repealed.

X. EFFECTIVITY

This Order shall take effect immediately.

(SGD.) FRANCISCO T. DUQUE III, MD, MScSecretary of Health

ANNEX AConsent Template

Consent to Perform Services

ANNEX B

Client Flow for Wellness and Recovery from Substance-Related Issue

 

ANNEX C

Human Resources Profile for Pilot Recovery Clinics

 

HR Categories	Number	Duty Time	Core Competencies
Clinic Director	1	Full time	Demonstrates the ability to engage in advocacy, communication and negotiations with LGU and DOH
DOH Accredited Physician	1-(2)	Full time	Ability to provide assessment and management of drug dependence
Registered Psychologist	(1)	Part time/on-call	Performs and manages individual, group, and family counseling activities
Registered Psychometrician	(1)	Part time/on-call	Performs standardized appropriate psychological tests and manages individual, group, and family sessions
Registered Nurse	1	Full time	Performs patient intake procedures and manages individual, group, and family sessions
Licensed Social Worker	1-(3)	Full time	Manages individual, group and family sessions and conducts home visitations
Senior Secretary/Administrative Staff	1	Full time	Facilitates reception, scheduling, management of patient flow data, and outreach to patients
Administrative Assistant	1	Full time	Demonstrates good IT skills in data entry, reception, and scheduling
Security Guard	1-(2)	Full time	Ensure security and safety of patients and staff in the facility

 

ANNEX D

Model for Small Recovery Clinics

 

ANNEX E

Model for Large Recovery Clinics

 

ANNEX F

Monthly Accomplishment Report

Health Facilities and Infrastructure Development Team

DANGEROUS DRUGS ABUSE PREVENTION AND TREATMENT PROGRAM

Monthly Accomplishment Report Community-Based Recovery Clinic

MONTH of: __________________

Name of Facility: _____________________________________________________

Address: ___________________ Contact No.: ______________________________

I. SERVICE PROVISION

 

New Admission: ___________	Relapse: __________
Moved-up/Completed: ________	Re-admission: __________
On-going Treatment:________	Referred: _____________
Drop-out: _________

 

CORE SERVICES	TARGET	ACTUAL	%
Clinical Assessment and Screening
Medical and Mental Health Assessment
Matrix Intensive Outpatient Program
SUPPORT SERVICES
Aftercare Program
Skills and Vocational Training
Spiritual Enhancement
Individual Coaching
Recreational Program
Social and Psychological Program
Family Support Program
Outreach Program
Drug Tests
Psychiatric Services
Harm Reduction Program
CAPABILITY BUILDING
Advocacy and Community Mobilization (Outreach)
SOCIAL SERVICES
Social Case Study
Home Visitation
Family Psychotherapy
REFERRAL SERVICE
Medical
Psychiatric
Livelihood Service

 

II. PROGRAM COMPLETION

 

	TARGET	ACTUAL	%
Completed/Moved-up (Primary Program)
Completed (Aftercare Program)
Premature Departure from Care/Drop-out
Referred (Medical/Psychiatric)

 

Prepared by:	Noted by:
_____________________ Print Name and Signature	_____________________ Print Name and Signature
Date:_________________	Date: ________________