The Joint Commission recently released new requirements for Behavioral Health and Human Services organizations treating Opioid Use Disorder.  Opioid use and its associated consequences, such as overdose, represent a significant health care issue in the United States. In 2022, the rate of overdose deaths from opioids was 28.7 per 100,000 residents across 30 U.S. jurisdictions. Barriers like access to care and societal stigma often prevent individuals with substance use disorders from seeking the help they need.

Medications for opioid use disorder (MOUD) are scientifically proven to improve treatment outcomes, with methadone, buprenorphine, and naltrexone being the primary evidence-based medications. Research shows these medications increase treatment engagement and reduce opioid use outside prescribed treatments.

To enhance the quality and safety of care, The Joint Commission is introducing four new requirements for behavioral health care and human services organizations treating opioid use disorder. Effective August 1, 2024, these requirements mandate education on medications for opioid use disorder and ensure that organizations either provide MOUD or have referral processes in place. These changes aim to ensure that individuals seeking treatment have access to these critical medications. The new standards are available on The Joint Commission’s website and will be included in the summer interim update of the Comprehensive Accreditation Manual for Behavioral Health and Human Services (CAMBHC).

Requirement Summary: Standard CTS.04.02.33

Organizations treating individuals with addictions must provide evidence-based treatment for opioid use disorder (OUD), including medications for opioid use disorder (MOUD).

Key Elements of Performance (EP)

• EP 1: Organizations must offer MOUD to individuals with OUD as part of their agreed-upon treatment plan. MOUD can be provided directly, through contractual agreements, or via referral. The organization must document if the individual declines MOUD.
• EP 2: If MOUD is provided via referral, the organization must coordinate care and confirm the initiation and continuation of the medication.
• EP 3: At the start of MOUD, the organization must inform individuals about the risks of abruptly discontinuing treatment, especially if they leave the organization. If an individual requires a different level of care or transfers, the organization must ensure continuous treatment without interruption.
• EP 4: Staff involved in assessing, planning, and delivering services to individuals with OUD must demonstrate an understanding of evidence-based treatment, which includes MOUD, psychosocial therapies, and harm-reduction strategies.

Rationale for Change

The Joint Commission approached the development and implementation of these four requirements with great care and diligence. The Joint Commission has reviewed relevant literature and engaged experts who treat opioid use disorder. In fact, the new requirements are a result of this development process.

Based on their findings, the Joint Commission determined it was time for change. Increasing access to medications for opioid use disorder and removing barriers to treatment can significantly improve the lives of individuals with opioid use disorder (OUD) and reduce opioid-related deaths. MOUD is the established standard of care for managing OUD, leading to better outcomes such as reduced illicit drug use, fewer overdoses, lower rates of infectious disease transmission, and less crime. It supports sustained recovery and lowers both opioid-related and all-cause mortality by reducing cravings and alleviating withdrawal symptoms.

Coordinated care ensures individuals receive the appropriate level of treatment without interruption, preventing risks associated with abrupt cessation of opioids, such as cravings, acute withdrawal syndrome, relapse, and overdose. It is crucial to inform individuals of the dangers of discontinuing MOUD, especially the increased risk of overdose if they return to opioid use.

Addressing stigma and negative perceptions about OUD and MOUD, even among healthcare professionals, is essential. Providing staff education on MOUD and harm-reduction approaches can enhance the initiation of evidence-based treatments, leading to better care for individuals with OUD.

Tips for Compliance

• Include the use of MOUD in client assessments.
• Discuss the current evidence for the use of MOUD in client admission and seek feedback from client.
• Encompass the need for direct provision, or referral for MOUD in the plan for care, treatment and services.
• Include client education regarding the risks of abruptly discontinuing MOUD treatment upon initiation of the plan for care, treatment, and services, periodically thereafter, and upon discharge from services.  
• Include a warm hand-off to the MOUD provider if a referral is indicated or the individual is transferred to a different level of care.  
• Ensure treatment is not interrupted during the transfer process.
• Communicate with referral organization upon initiation of treatment and periodically thereafter to confirm the initiation and continuation of the medication according to organization policy.
• Gather data regarding client compliance with initiation and continuation of the medication. 
• Collect, aggregate, and analyze the data to improve care coordination processes and client compliance.
• Educate and competency validate staff involved in assessing, planning, and delivering OUD services during orientation and periodically thereafter as required in organization policy. Education should address evidence based treatments, MOUD, harm reduction, and psychosocial therapies.

Documentation Tips

1. Incorporate MOUD Usage: Ensure the use of medications for opioid use disorder (MOUD) is included in the assessment documentation forms.
2. Education Section: Add a section in the assessment documents to record that education about the efficacy of MOUD was provided to the client and that the client has verbally acknowledged their understanding.
3. Acceptance or Declination: Document whether the client accepts or declines MOUD. Specify if the organization will directly provide MOUD, refer externally for MOUD, or transfer the individual to a higher level of care.
4. Referral Form Enhancement: Develop a new referral form or update an existing one to include fields that document a warm hand-off to the referral organization. Ensure it includes the referral organization’s commitment to coordinate care, confirm the initiation of treatment, and provide periodic updates on the client’s ongoing treatment.
5. Transfer Form Enhancement: Create or update a transfer form to include detailed communication with the receiving entity, ensuring uninterrupted treatment until the transfer is fully completed.
6. Staff Education Documentation: Document staff education and competence validation regarding MOUD during orientation and periodically as part of the ongoing training process.

Survey Process Tips

• Accessible MOUD Policies: Ensure that policies and procedures regarding MOUD are readily available during the survey.
• Staff Preparedness: Train staff to accurately discuss MOUD policies and processes with surveyors, including the education and competency validation they received upon hire and periodically, as per organizational policy.
• Chart Audits: Regularly audit charts to ensure that MOUD policies and processes are clearly documented according to organizational requirements.
• Data Management: Collect, aggregate, and analyze data. Implement performance improvement processes to ensure organizational expectations are consistently met, both in preparation for surveys and on an ongoing basis.
• Chart Navigation Practice: Practice navigating the chart for a surveyor, demonstrating compliance with organizational policies and processes for MOUD within the clinical record.
• Referral and Transfer Partner Coordination: Notify referral and transfer partners of upcoming Joint Commission surveys and ensure they can clearly articulate their role in the coordination and continuation of care, treatment, and services with your organization.
• Audit Compliance Files: Audit orientation, education, and competency files regularly to ensure compliance with organizational policies.

Helpful Resources

In addition, these resources can assist behavioral health care and human services organizations with the compliance process.

• Department of Standards and Survey Methods
• TJC R3 Report
• Prepublication Standards

Barrins and Associates

Barrins stays up to date with current accreditor changes.  By conducting mock surveys, we enable your organization to remain in continuous compliance with accreditation and regulatory requirements. We will include compliance with TJC standard CTS.04.02.33 in all future SUD mock surveys.  Contact us today to schedule a 2024 Mock Survey.

Barrins & Associates – “Your Compliance Needs, Our Expertise: Whenever You Need It, We Deliver!”

TJC References

• See TJC R3 report