Specifications Manual for Joint Commission National Quality Measures (v2021B2)
Posted: 9/29/2021
Home » Referral for Addictions Treatment

Release Notes:
Data Element
Version 2021B2

Name:Referral for Addictions Treatment
Collected For: SUB-3
Definition:Documentation that a referral was made at discharge for addictions treatment by a physician or non-physician (such as nurse, psychologist, or counselor). A referral is defined as an appointment made by the provider either through telephone contact, fax or e-mail. The referral may be to an addictions treatment program, to a mental health program or mental health specialist for follow-up for substance use or addiction treatment, or to a medical or health professional for follow-up for substance use or addiction.
Question:Was a referral for addictions treatment made for the patient prior to discharge?
Allowable Values:

1    The referral to addictions treatment was made by the healthcare provider or health care organization at any time prior to discharge.

2    Referral information was given to the patient at discharge, but the appointment was not made by the provider or health care organization prior to discharge.

3    The patient refused the referral for addictions treatment and the referral was not made.

4    The patient:
- is being discharged to a residence outside the USA
- is released to a court hearing and does not return
- is being discharged to jail/law enforcement

5    A referral for addictions treatment was not offered anytime prior to discharge or Unable to Determine (UTD) from the medical record documentation

Notes for Abstraction:
  • If a patient is referred to an addictions treatment provider that does not schedule appointments and the patient was given a specific date and time to present for addictions treatment, select Value “1.”
  • Value "4" should be selected if the patient:
    • is being discharged to a residence outside the USA
    • is released to a court hearing and does not return
    • is being discharged to jail/law enforcement
  • A referral to Alcoholics Anonymous (AA) or similar mutual support groups does not meet the intent of the measure. Select Value “5.”
  • Select Value “5” if:
    • it cannot be determined that a referral for addictions treatment was made or;
    • it is unclear that the absence of the referral was due to a patient refusal or because the referral was not offered.
Suggested Data Sources:
  • Discharge summary
  • Transfer sheet
  • Discharge Instruction Sheet
  • Nursing Discharge Notes
  • Physician Order Sheet
Additional Notes:
Guidelines for Abstraction:
Inclusion Exclusion
  • Group counseling
  • Individual counseling
    • Addictions counselor
    • Personal physician
    • Psychiatrist
    • Psychologist

  • Self help interventions in the form of printed/electronic/digital media
  • Support groups that are not considered treatment such as Alcoholics Anonymous (AA)

Referral for Addictions Treatment
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Specifications Manual for Joint Commission National Quality Measures (v2021B2)
Discharges 10-1-21 through 12-31-21 (4Q21)


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