OPTIONS - How to document to create a referral
Maine EMS has developed a process by which EMS clinicians will be able to generate a referral for patients experiencing substance use issues to the Maine OPTIONS program. This document explains how the referral process works from the perspective of an EMS clinician documenting the patient encounter.
There are two starting points that will allow an EMS clinician to generate a referral, impressions, and medications.
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The first starting point is the narrative panel where the clinician must document one of the following as a primary or secondary impression
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Tox - Alcohol use (F10.9)
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Tox - Alcohol use - with intoxication (F10.92)
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Tox - Alcohol Use - withdrawal (F10.239)
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Tox - Cannabis use (F12.9)
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Tox - Cocaine Use/abuse (F14)
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Tox - Hallucinogen use (F16.9)
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Tox - Inhalant related disorders (F18)
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Tox - Opioid use - with Coma (F11.92)
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Tox - Opioid use - without Coma (F11.9)
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Tox - Overdose/Drug Ingestion (Non Opioid) (itICD.047)
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Tox - Psychoactive substance related disorders (F19)
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Tox - Psychoactive substance use (F19.9)
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Tox - Sedative or hypnotic use (F13.9)
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Tox - Sedative/hypnotic Use/Abuse (F13)
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Tox - Stimulant related disorder (F15)
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Tox - Tricyclic antidepressants Overdose (T43.014)
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The second starting point is by documenting the administration of naloxone as a medication given, regardless of whether it is given by EMS or prior to arrival.
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After documenting one of the two preceding alternatives a new section on the patient care report form will appear named Substance Use Programs and have a panel named OPTIONS Referral. The panel has a field requiring the documenting clinician to answer the question “Did you attempt to refer the patient to the OPTIONS program?” and chose from Yes, Patient accepts referral, Yes, Patient declined referral, or No. Selecting Yes, Patient accepts referral will require a signature.
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If the answer to the question “Did you attempt to refer the patient to the OPTIONS program?” is Yes, Patient accepts referral then the user will be required to have a signature with a signature type of OPTIONS Referral. If you are unable to obtain a signature directly into MEFIRS but have obtained a physical signature then you should also set the signature Status field to Physical Signature/Paper Copy Obtained.
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A new signature paragraph is added to the form when you add the OPTIONS Referral signature type
I authorize Maine EMS and the EMS agency providing care to me today to release my First name, Last name, date of birth, location information, and phone number to the Maine OPTIONS Program.
The purpose of this is to link individuals with substance use disorder (SUD) with community-based resources for SUD treatment options, reducing the likelihood of return to use and supporting the road toward recovery. The OPTIONS program will provide overdose response, assessment, behavioral health crisis de-escalation, referral to community treatment modules, system navigation, short-term counseling interventions, increase recovery capital, and aid in the completion of the State’s Medicaid program application for the uninsured population.
This consent is subject to revocation at any time except to the extent that Maine EMS or the EMS agency identified in this consent has already acted in reliance on it. Acting in reliance includes the provision of treatment services in reliance on valid consent to disclose information to a third-party payer.
If not revoked before, this consent will expire thirty days after the signature date.
I also understand that any disclosure made is bound by Part 2 of Title 42 of the Code of Federal Regulations governing the confidentiality of substance use disorder patient records.
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If you document consent for an OPTIONS Referral in error please ensure that you remove the OPTIONS Referral signature type.
IMPORTANT! OPTIONS referrals are based upon the county where the EMS activation occurred. To ensure success in the county’s OPTIONS liaison receiving the referral you must document the scene county.