Mental Health and Substance Use Disorder Functional Screen Instructions: Module 5 - Risk Factors

Download the complete Mental Health and Substance Use Disorder Instruction Manual and Best Practices, P-00934 (PDF).

5.1 Self-injurious behaviors

The item includes cutting, burning, pica, polydipsia, and head banging. This does not include suicide attempts, unhealthy habits, or other high-risk activities.

• Pica is eating inedible objects such as metal or coins.
• Polydipsia is drinking excessive amounts of water, which can be fatal.

5.2 Substance use

Substance use does not include the use of tobacco or caffeine.

Outcomes of substance use information
The substance use questions are intended to ask about the outcomes or consequences of substance use. Hazardous drinking is defined as a quantity or pattern of alcohol consumption that places patients at risk for adverse health events, while harmful drinking is defined as alcohol consumption that results in adverse events (physical or psychological harm).

There are several categories of alcohol use:

• No use or low risk drinking.
• At-risk or hazardous drinking.
• Harmful or problem drinking (Possible alcohol use disorder).

No amount of alcohol consumption is safe or without risk. The federal government defines and recommends levels of alcohol consumption that have been found to generally carry only low to moderate risk for the general population. It is important to note that alcohol should not be consumed by people who are pregnant, people operating heavy equipment, people who are under the age of 21, people taking medication that interacts with alcohol, or people diagnosed with a medical or mental health condition. Within this screen, screeners are to evaluate risk by using the following federal guidelines to determine hazardous or harmful drinking.

A standard drink is equal to 14.0 grams (0.6 ounces) of pure alcohol.

• 12 ounces of beer (5% alcohol content)
• 8 ounces of malt liquor (7% alcohol content)
• 5 ounces of wine (12% alcohol content)
• 1.5 ounces or a shot of 80-proof (40% alcohol content) distilled spirits or liquor (gin, rum, vodka, whiskey)

Screening to identify outcomes of substance use is performed using the following questions. This section assists in determining the outcome and potential for negative consequences.

No use or low risk use evident in past 12 months (to include people in sustained remission—no symptoms, except for craving, for more than 12 months).

• Applicant is abstinent or uses substances in a way that is not currently associated with negative health consequences or other problems (alcohol consumption that does not exceed recommended levels or occasional cannabis use).
• Applicant does not drink alcohol or use drugs and uses prescription drugs only as prescribed.
• Applicant drinks less than recommended limits and has no health conditions or medications creating risks or problems even with low to moderate alcohol intake.
• Applicant has been abstinent for the past 12 months.

In the past 12 months, substance use has involved risks but it is not clear that negative consequences have occurred.

• Applicant is at risk for negative health, social consequences, or other problems.
• Applicant drinks more than recommended limits but has not had negative consequences.
• Applicant drinks less than recommended limits but has health conditions or medications. indicating that person should not drink at all or as much.
• Applicant has driven drunk but hasn’t been caught doing so.
• Applicant has engaged in unprotected sex.

In the past 12 months, the person has exhibited a problematic pattern of use leading to clinically significant impairment or distress.

• Applicant has a current diagnosis of a substance use disorder and continues to use.
• Applicant likely is experiencing a substance use disorder and/or substance-related health or other type of problem (alcohol use-related cirrhosis or consequences such as a separation from family or loss of employment) and engages in continued or escalating use despite negative consequences.
• Applicant has at least two signs of a substance use disorder, including:
  • Using substances in large amounts.
  • Spending a great deal of time obtaining, using, or recovering from substance use.
  • Experiencing cravings.
  • Recurring use resulting in failure to fulfill major role responsibilities at work, school, or home.
  • Continuing to use despite having recurrent social or interpersonal problems.
  • Giving up on or reducing involvement in social, occupational, or recreational activities.
  • Recurring use that hazardous (Drinking and driving).
  • Continuing to use despite knowledge of having recurrent physical or mental health problems.
  • Needing to use much more to achieve desired effect or the desired effect has weakened even with the same amount of substance.
  • Experiencing withdrawals.

Outcomes of substance use information - continued
The following questions have been added as screening items that will identify the additional need for further substance use screening, assessment, and treatment referral. With permission from Chestnut Health Services, the five questions from the Global Appraisal of Individual Needs (GAIN) Short Screener were adapted for this screen.

These questions are only screening questions to identify a potential issue and do not represent the information needed in a comprehensive substance use assessment.

The responses to the questions require that a timeframe be chosen.

• Past month: Any one single incident or more in the past 30 days.
• 2–12 months: Any one single incident or more that occurred 60 days to 12 months ago.
• 1 year or more ago: Any one single incident or more that occurred 12 months or longer ago, even if that incident was 20 years ago.

If there is a response to any question where there is a choice between two or more timeframes, record the timeframe that is the most recent. Ask the person the questions directly and record their answer. If one of their answers seems to be different from than the collateral information available, ask additional clarifying questions.

Used alcohol and drugs weekly or more often

• This question is designed to determine the frequency of substance use, not the quantity of weekly use or the seriousness or dangerousness of use.
• If the applicant drinks one alcoholic beverage or uses a drug daily, this item should be selected. If the applicant is using prescription medication as prescribed, then select not applicable. Smoking cigarettes daily is not to be accounted for in this section.

Spent a lot of time either getting alcohol or drugs, using alcohol or drugs, or feeling the effects of alcohol or drugs
This question is designed to receive a response that demonstrates the level of preoccupation the person experiences regarding their use of alcohol and drugs, including:

• Spending a lot of time thinking and planning about how they will get alcohol or drugs.
• Planning their day around when they can purchase alcohol or drugs or get drunk and/or high.
• Spending a lot of time using alcohol or drugs.
• Spending excessive time recovering from drug and/or alcohol use (hangovers).

Kept using alcohol or drugs even though it was causing social problems, leading to fights, or getting into trouble with other people
This question is designed to measure the negative social and physical aggressive consequences that people may experience when using drugs or alcohol, including incarcerations and justice involvement. This includes arguments with family members about substance use or losing important friendships because of continued use.

• Refer to section 4.9 for a definition of social or interpersonal skills.
• Refer to section 5.6 for definitions of physical aggression.
• Refer to section 5.7 for definitions of physical aggression that has resulted in the injured person being hospitalized.
• Refer to section 5.8 for definitions regarding involvement with the corrections system.

Use of alcohol or drugs caused applicant to give up, reduce, or have problems at important activities at work, school, home, or social events
This question is designed to measure the negative impacts of the person’s major life responsibilities solely related to the use of substances. This section should include financial issues due to their substance use, being demoted, losing a job, and/or being increasingly unable to perform job tasks, as well as estrangements from family and friends.

• Refer to section 4.9 for a definition of social and interpersonal skills.
• A comprehensive list of home issues can be found in the definitions from 4.7 to 4.16 under specific community living skills.

Had withdrawal problems for alcohol or drugs like shaking hands, throwing up, having trouble sitting still or sleeping or used any alcohol or drugs to stop being sick or avoid withdrawal problems
This question is designed to measure the negative physical effects caused by using too much of a substance such as blackouts and/or overdoses, hospitalizations due to substance use, symptoms of withdrawal listed above, and using substances to avoid withdrawal.

• Withdrawal is the body's response to the abrupt end of a drug once the body has developed a tolerance to it. The resulting cluster of symptoms is specific to each drug. Although withdrawal is very unpleasant, it does not usually require medical assistance. However, withdrawal from some drugs, such as alcohol, can be dangerous.
• If the patient is intoxicated or in withdrawal, it may be more appropriate to complete the screening once their condition has been stabilized. Consider immediate referral for medical evaluation or withdrawal management services.
• Withdrawal from cathinones (bath salts) or high dose prescription amphetamines can be associated with intense psychotic events needing a higher level of care.
• When assessing signs of intoxication, consider: Is the patient exhibiting any of the following? Disinhibition, sedation, decreased coordination, reddening of the skin or flushing of the face, slurred speech, trouble walking, vomiting, impairment in attention/memory, elevated heart rate, confusion, severe difficulty speaking, delusions, or hallucinations.

If the eligibility results indicate a yes, it is recommended that the applicant receive further substance use disorder assessment by a qualified substance use professional.

Substance use treatment

Have you received treatment, counseling, medication, case management or aftercare for your use of alcohol or any other drug? Please do not include any emergency room visits, withdrawal management, or support group meetings. 
This item is intended to collect instances of formal substance use treatment by a professional substance use disorder counselor(s). It can include individual and/or group therapy, case management, medication-assisted treatment, and other methods of professional substance use disorder treatment.

Have you attended one or more support group meetings or received recovery support services from a peer specialist or recovery coach for your alcohol or other drug use? (AA, NA, Celebrate Recovery, SMART Recovery, etc.).
This item is intended to collect participation in any in person or virtual peer support groups run by individuals with lived experience of substance use disorder. This does not include groups run by professional substance use disorder counselors as that is collected in the previous question.

5.3 Abuse information

We know that many people have experienced physical, emotional, or sexual abuse or neglect as an adult or in childhood. Would you say that you have?
Many people have experienced physical, emotional, or sexual abuse or neglect as an adult or in childhood. Trauma and its aftermath are under recognized realities in many people’s lives.

This question is optional. It can be answered unknown. This is a sensitive topic. Many people will not want to answer it. Be very clear that the individual does not have to answer it. The question, “Would you say that you have?” is purposefully equivocal so that it can be answered, “No, I have not experienced abuse” or “No, I would not say,” or “No, I will not divulge that information for the functional screen.”

Screeners should always preface this question with a statement (example below) that the applicant does not have to answer it.

“The Wisconsin Department of Health Services and advocates are concerned that trauma and abuse are overlooked. The functional screen includes a question on it. You do not have to answer it.”

5.4 Housing instability

Select yes or no. If the answer is yes, check all boxes that apply to indicate type of housing instability within the past 12 months:

• Currently homeless (on the street or no permanent address). This includes staying at homeless shelters, living in a car or tent, or temporarily staying at a friend’s or relative’s house for short periods (days or weeks).
• Homeless less than half the time in the past year.
• Homeless 50 percent of the time or more within the past year.
• Evicted two or more times in the past year (by landlords, family, friends, etc.).

If someone has housing but is at risk of losing housing or there are risks related to their housing not otherwise outlined above, document this concern in the notes section.

5.5 Intensity of treatment or functional severity

This item is intended to collect urgency in treatment for an individual who may be at risk to themselves or others and to address criteria for admission to a CSP.

The screener does not have to be screening an individual for CSP to answer this question.

The statement the screener is answering is:

There have been consistent and extensive efforts to treat this person for at least a year, or the person has had a serious sudden onset of dysfunction requiring services beyond basic outpatient services, and the person is dangerous to self or to others.

Wisconsin Admin. Code ch. DHS 63, the rule governing CSP, indicates that admission to a CSP is limited to an individual who (1) has serious and persistent mental illness in the psychotic spectrum (such as schizophrenia, bipolar disorder, schizoaffective, delusional disorder or recurrent major depression) which; (2) requires repeated acute treatment or prolonged periods of institutional care; and (3) who exhibits persistent disability or impairment in major roles of community living. Other diagnoses listed in the DSM can qualify if there have been consistent and extensive treatment efforts for over one-year or serious and sudden dysfunction that leads to the person exhibiting persistent dangerousness.

If the screener selects yes for this item, outline in the notes section evidence behind why this answer was selected. The information relating to this question will be critical for a behavioral health professional to know as they begin or continue working with the applicant.

5.6 Interdivisional agreement 1.67

This applies to individuals for whom a DHS Division of Quality Assurance nursing home surveyor has issued a 1.67 administrative order to refer the individual to the county for nursing home discharge and alternative living arrangement (or other needed services).

5.7 Current COP level 3 funding

COP level 3 funding is no longer used. Disregard this question as it is not required for submission of the screen.