Treatment Improvement Protocols (TIP) 13 |
In implementing any patient placement criteria (PPC) on a statewide or systemwide basis, a number of issues must be considered. What criteria will be used, and what modifications must be made to these criteria to take into account local resource distribution and special populations? How will the criteria be implemented (for example, as part of a payment system or through program licensing requirements)? Will the criteria necessitate changes in laws or administrative rules? Which agencies will have primary responsibility for making placement decisions? Who will need training? How will it be provided? Who will pay for it? What kind of ongoing technical assistance will be provided, and by whom? What are the funding sources for treatment? Will they impede the use of placement criteria? If so, can their limitations be changed?
In the States that have adopted patient placement criteria, the decision to implement was made by the single State agency (SSA). Stakeholder input was sought for the balance of the issues, although the responsibility for final decisions remained with the SSA.
This chapter addresses some of the considerations necessary for making implementation decisions.
Licensure requirements can be established by statute or rule and can include a requirement that a program adopt uniform patient placement criteria (UPPC) in order to obtain or retain a license. Montana has already implemented this procedure by describing levels of care in a statute. Treatment providers are then required, through licensing regulations, to identify the level or levels they provide and to adopt a system of PPC for appropriate placement. Licensure is also linked to eligibility for county and Federal block grant funds. Many hours of staff training have focused on learning the process of compliance with the regulations, which is supervised by onsite visits of State regulators. While still in the early stages of implementation and evaluation, the Montana model has largely achieved appropriate referrals and has been positively received. Oversight and staff training are seen as critical elements of this program, which have contributed to its success.
Other States have approached PPC and licensure differently. Massachusetts, for example, found that licensure and patient placement criteria initially conflicted and worked to align them, eventually making the conflicting requirements compatible. In another case, Minnesota wrote PPC in separate regulations but revised their licensing requirements at the same time, ensuring compatibility of requirements from the outset.
The primary funding sources for AOD treatment are:
Other less common sources include foundation grants, asset forfeiture, specific tax levies, and fines. Government sources can include Federal block grants and funds from the Indian Health Service, the Centers for Disease Control and Prevention (CDC), the Department of Veterans Affairs, and the Department of Justice, among others. One of the strongest arguments in favor of UPPC is the current reality that each funding source may dictate separate criteria for eligibility, admission, and continued stay.
There are several ways to successfully link funding requirements to UPPC, ensuring uniform implementation. Massachusetts linked placement criteria to the procurement process, so that vendors agreed to participate in the development and implementation of PPC in their agencies as a condition for funding. Another method is to require programs to have PPC in place to obtain Medicaid funding.
Private payers have their own PPC that may conflict with those of the SSA. This situation can be avoided by including the private payers in the planning process. In Montana, conflicts over duration and intensity of care issues between treatment providers and insurers were part of the impetus for developing the State's PPC. Blue Cross and Blue Shield of Montana collaborated with providers and the SSA on the development of PPC and now provides some of the compliance monitoring.
Minnesota's Consolidated Chemical Dependency Treatment Fund (CCDTF) is another method of linking PPC to the funding source. Before implementing the CCDTF, Minnesota used a combination of Medical Assistance, State-funded general assistance medical care, available Federal block grant funds, State hospital units, and county-funded programs to provide treatment for public clients. Each of these sources had separate eligibility requirements. Several provided for treatment only in a specific setting or level of care. For example, persons who qualified financially for State hospital programs could receive only residential care. Halfway house programs were available only to residents of certain counties. With the implementation of CCDTF, Minnesota pooled these funding sources so that placement decisions were no longer dependent on the funding source. Now, payment from the fund is authorized only for clients placed according to the State's PPC.
Implicit in the concept of uniform patient placement criteria is the existence of an array of treatment services with varying levels of care. The actual range of treatment services is limited by available resources and will have a significant effect on the implementation of UPPC. The existence of the entire continuum of care is not necessary to begin implementation. When resources are unavailable at the optimum treatment level, next-best choices on another level will be necessary. Providers responsible for placement must be aware of local treatment resources, the level(s) of care they provide, and available slots.
As discussed in Chapter 4, use of UPPC can clarify the need for a State to reorganize and reorient treatment services. Some established systems may need adjustment to fit the new criteria. For example, a region with most of its resources invested in hospital-based services may find that funds should be shifted to support development of a more diverse range of community-based residential and outpatient options. When providers become aware of a market for services currently unavailable, they are likely to respond by developing new services.
Resources can be inventoried to answer such questions as:
The panel recommends that States develop a central directory identifying resources, levels of care, program availability, and detailed information about the programs, including specialized services and outcome data. A model for this directory can be found in the Target Cities project, which has established an automated system to track treatment services and slot availability. Other clinical management software has been developed (see Appendix B). A computerized directory can provide the most current information. However, treatment systems that do not have the resources or funding to develop a computerized directory can develop a manually implemented paper system, relying on frequent updates based on telephone communications.
Wraparound services enhance or supplement treatment services to meet patients' nonmedical needs. Family preservation services or transportation provided by a local department of social services are examples of wraparound services. A central resource directory can lead to referrals to wraparound services, which are often tied to programs. Wraparound services are an important adjunct to AOD abuse treatment and can be the key to successful treatment, although they are not usually considered treatment services in the clinical sense. The value of these services lends support to the concept that "medical necessity" is a broad multidimensional concept that goes beyond the narrow focus on physical and psychiatric severity.
When considering differences in cost, clinical treatment services should be distinguished from wraparound services, which may be less costly than medically managed services. Less intensive medical services will sometimes lead to better outcomes if they are combined with wraparound services that provide necessary social and logistical supports for patients. Wraparounds assist patients in learning to deal with real-life problems during treatment.
Inherent in the provision of wraparound services is some form of case management. Without case management, clients may have difficulty accessing services, or services may become fragmented.
Wraparounds can be divided into two categories: those that by their absence prohibit access or initiation of treatment, and those that are important to positive treatment outcomes. The first group of wraparound services may include:
The second group of services usually addresses problem areas in the patient's life other than AOD abuse, although these problems may be closely tied to substance abuse. Provision of these services enhances treatment retention and promotes improved outcomes. They include:
In some treatment settings, wraparound services are already included. Therapeutic communities routinely provide many of the services listed above. Other programs have obtained special funding in order to include specific wraparound services. Federal block grant set-asides have been used to increase the availability of programs for women with children by paying for necessary wraparounds.
Studies on the value of wraparound services have documented the contribution they can make toward positive outcomes. For example, an Association of Junior League International study of services for women in 39 communities identified childcare as the most needed resource for women in treatment for alcoholism (Wilsnack, 1991).
Funding of wraparound services can be a complex issue. Usually, the primary funding for wraparound services comes from agencies other than the SSA, although the block grants authorize services such as referrals for treatment of HIV disease and tuberculosis. Other Federal agencies, such as the Department of Housing and Urban Development, provide some funding. State general funds often support wraparound services, as do State departments of corrections and human services. Some costs of wraparounds may be covered by insurance companies or other third-party payers.
A barrier to obtaining needed wraparound services can arise if receiving a certain type of treatment makes a patient ineligible for needed services. For example, a mother can receive day care for her children if she is in a day treatment program in the community. Yet, if she is placed in a residential treatment facility, she may lose her eligibility for publicly funded day care. This example illustrates one of the potentially negative effects of differing eligibility requirements for services, as well as the need for coordinated, comprehensive care in a seamless system. It represents one of the challenges of implementing UPPC.
States may wish to consider a coordinated policy that defines the need, availability, and adequacy of wraparounds to complement AOD services. Typically, each of the agencies providing services has its own priority populations, which differ from agency to agency and State to State. It is up to the SSA to take a leadership role in making wraparound services for the AOD treatment population a high priority. Legislators need to be educated about the relationship between wraparound services and positive treatment outcomes, as well as the funding needed to make these services available.
In Minnesota, where PPC have been implemented, exceptions for situations in which rigid adherence to PPC would deny necessary treatment were clearly stated so that assessors would not be faced with the dilemma of placing patients in a level of care that would exclude them from needed wraparounds. Clearly, clinical factors alone do not determine placement. External pressures (financial, legal, or other) can drive placement to an inappropriate level of care. In the previous example, a mother would lose childcare eligibility if she were placed in a residential setting. The same example can be turned around to illustrate how placement can be driven to a more restrictive level: a woman may enter a residential setting when outpatient care is more appropriate, because the residential setting provides onsite childcare.
Coordination of multiple funding sources can have an enormous impact on the efficient use of UPPC. Since placement decisions may affect eligibility for wraparounds, the personnel making these decisions should identify ways to maximize support from other community agencies.
There are a number of special populations with needs that must be identified at assessment and considered in placement decisions. These populations can be defined in part by:
The characteristics of patients in these groups will have an impact on the implementation of patient placement criteria with regard to level of care, level of intensity, and length of stay. If there is a need for additional support services, special populations may require flexibility in the use of UPPC. Others may require intensified case management. Some programs do not have the ability to meet these needs. For example, seriously mentally ill patients, with their high relapse potential, may require mental health services that AOD treatment providers are not qualified to give. Adolescents placed in an adult program are not likely to receive the specialized treatment or social services they need; likewise, the elderly may need services that are not traditionally offered by a program serving patients in their 20s and 30s. Members of special populations may benefit from completely different types of treatment or from services provided by members of the same population group.
It is important to be aware that while specific populations often share a constellation of common needs, there are individual needs as well. It is a disservice to treat all those in a special population as if they have the same needs.
Factors that should be addressed for special populations include:
Efficient coordination of services for these populations can be accomplished in several ways. The least efficient way for the patient to receive services is to travel from one agency to another (for example, to social services or public housing) to establish eligibility and apply for services. Some States have established a "one-stop shopping" approach, with representatives from a variety of agencies present at the location where AOD services are coordinated. In some jurisdictions this process is even more streamlined, with one application form that can be completed to obtain many available services.
Patients with multiple needs for wraparounds are also likely to need intensive case management. Active case management provides another model for coordinating wraparound services with AOD abuse treatment.
Eligibility requirements are the first determination in patient placement, overriding and taking precedence over all other considerations, including UPPC. Eligibility criteria establish whether patients can get into the systems of care that are governed by UPPC. A patient's involvement in the criminal justice system is one determinant of eligibility for placement. Offenders who are incarcerated are obviously ineligible for referral to a community-based outpatient treatment program.
The steps of sequential assessment for placement can be described as:
The eligibility structure that represents current policy in most States is largely dependent on funding source. Other factors include: insurance, age, State or Federal priority populations, and whether or not the patient enters treatment through the criminal justice system. State regulations are also a consideration. For example, in Georgia, both low income and severity of illness must be factors for a patient to receive the highest level of priority for public programs. Additionally, the Federal Government requires States to set aside a portion of their Federal funds for certain types of programs or for services to a special population. Federal block grant set-asides limit the funding available (and therefore access to services) to population groups not covered by the set-asides. In most cases, the services for which a patient is eligible will directly influence that patient's placement and care.
Eligibility criteria are not only financially determined, but dictated in part by geographic considerations. Patients in one jurisdiction may be ineligible to receive services in another, even if those services better meet their needs.
Programs established to serve special populations are often limited to a specific level of care. Program specialization tends to override PPC, particularly for clients who fit well into the niche described by the specialization. To illustrate, if the only program in the client's native tongue is residential, the client will most likely be placed in residential treatment, even if PPC are not satisfied by the placement.
Other eligibility requirements are linked to the requirements of third-party payers. If an insurance company will pay for only 7 days of inpatient treatment, that limitation may override PPC recommendations. If managed care lengths of stay expire, so too will eligibility for placement, unless public-sector services are available for these patients. These are constraints that can limit the universality of PPC and raise ethical issues as well. Negotiation and mediation will be required as the dialogue on UPPC progresses.
This panel notes that rigid eligibility requirements will interfere with the implementation of UPPC. If eligibility alone dictates placement, an appropriate level-of-care determination is difficult at best. The panel recommends that all patients enter the AOD treatment system at the same level of eligibility. In other words, eligibility and patient placement criteria should be merged.
Single State agencies can influence such eligibility policies, particularly when requirements are established by providers that the SSA funds. It is important that consensus on these issues be reached by policymakers, and that nonclinical caps for treatment eligibility be prevented from undermining the integrity of a uniform PPC system.
An approach that States can use to merge eligibility requirements and PPC is the examination of aggregate AOD treatment needs of its population. The number of patients needing services at each level of care—including patients moving from one level to another—can be estimated using UPPC, as described in Chapter 4. These estimates can form the basis for an approximation of the overall cost of AOD treatment. These statistics can be presented to State legislators or other bodies making policy and funding decisions—along with statistics about the cost of implementing UPPC and financial offsets of AOD treatment. It will then be apparent that treatment costs for substance abuse treatment are measurable and can be clearly defined by an appropriate system of placement.
States can also tie eligibility criteria to UPPC, funding individual admissions rather than contracting for a specific service from a treatment provider. Usually, public treatment is funded by a contract for a specific number of beds, admissions, or slots in a level of care. It is through the existence of multiple contracts that an array of services is offered. An alternative is to fund an individual client for a specific level of care, much as fee-for-service insurance and Medicaid operates. The appropriateness of the service could then be determined using PPC. Minnesota's Consolidated Chemical Dependency Treatment Fund described earlier in this chapter is an example of the successful implementation of such a strategy.
Assessment for the purpose of placement for AOD treatment is a complex process involving an individualized, multidimensional approach for each patient. The American Society of Addiction Medicine (ASAM) patient placement criteria define assessment as "those procedures by which a program evaluates an individual's strengths, weaknesses, problems, and needs, so that a treatment plan can be developed" (ASAM, 1991). Another definition of assessment comes from the Institute of Medicine, which describes assessment as "the systematic process of interaction with an individual to observe, elicit, and subsequently assemble the relevant information required to deal with his or her case, both immediately and for the foreseeable future" (Institute of Medicine, 1990).
The process of assessment has long been recognized as a critical element in providing effective AOD abuse treatment.
Figure 5-1 Variables Considered in Assessing and Placing a Client
Public and private developers of patient placement criteria have recognized this fact by placing assessment at the core of their criteria. All those involved in implementing UPPC should understand the central importance of assessment and its place in AOD abuse treatment. Many Treatment Improvement Protocols (TIPs) in this series describe assessment and related issues. Three TIPs address assessment of special populations—Screening and Assessment of Alcohol- and Other Drug-Abusing Adolescents, Assessment and Treatment Planning of Patients With Coexisting Mental Illness and Alcohol and Other Drug Abuse, and Screening and Assessment for Alcohol and Other Drug Abuse Among Adults in the Criminal Justice System. The TIP Matching Patient Needs in Opioid Substitution Therapy (in development) has a chapter on conducting ongoing assessments during methadone treatment to match patients with needed wraparound services. The TIP Screening for Alcohol and Other Drug Abuse Among Hospitalized Trauma Patients (in development) discusses the importance of careful AOD assessment in preventing devastating injuries.
The Center for Substance Abuse Treatment has noted that the following elements, consistent with the biopsychosocial perspective, should be included in a model assessment:
There are two basic (and sometimes overlapping) goals of assessment: to determine patient placement, and to determine an appropriate treatment plan. There are important distinctions between assessment and the concept of PPC discussed in this TIP. Assessment is an individualized process. PPC describe gross characteristics that lead to a recommendation for a level of care. Once a placement decision is made, the PPC serve as a foundation for individualized treatment planning.
As shown in Figure 5-1, patient placement is based on a process of assessment that considers three sets of variables: assessment variables, matching variables, and modifying variables. Using patient placement criteria, the clinician moves from the most general information about the patient and the patient's addiction through a set of variables that match the patient to a discrete level of care to a set of intervening variables that may modify the level of care determination.
Assessment is an ongoing, cumulative process that can provide certification to authorize certain levels of care, particularly if reimbursement is to come from a private entity. As a patient moves from one level of care to another, one assessment builds on another, leading to a discharge plan. Again, a number of different models exist for these phases of assessment, and the addition of managed care to the equation has meant a rapidly changing landscape in this regard.
This TIP panel believes that there is room for a variety of assessment models among the various States and AOD treatment systems. These can range from decentralized, provider-driven models to the central intake and assessment agencies that some States have set up. One model of the decentralized form of assessment is the Target Cities program, which provides services to populations in metropolitan areas at greatest risk for AOD addiction. The program has at its core comprehensive independent assessment evaluation from treatment providers, including physical examinations, psychological testing, and placement criteria.
Each State must evaluate its own needs to determine how resources can best be used in the assessment process. This evaluation process is related to the issue of building organized systems of care, a critical issue in healthcare reform.
Urban systems handling large numbers of patients are likely to have more comprehensive assessment systems than smaller rural systems, which may depend on informal evaluations by public health or criminal justice personnel to place patients in treatment.
Because of the increasing complexity of patient profiles, assessments are best performed by professionals highly trained in comprehensive evaluation. Unfortunately, AOD treatment is a profession with a high rate of personnel turnover, particularly in the public sector, where intake workers may be relatively inexperienced. In many systems, the least skilled personnel do assessments, while more highly trained clinicians resist intake work.
When UPPC are being implemented, it will be necessary for intake and assessment workers to be thoroughly trained in the use of the criteria. While the training of these personnel may be the highest priority, all staff must be trained. This will ensure that the benefits of continued stay criteria and individualized treatment planning are realized.
The training must include:
To some degree, the nature of training will depend on the methods by which UPPC are being implemented and the qualifications of the assessors. For instance, if the professionals given the responsibility for assessing and making placement decisions are credentialed AOD counselors who are already doing assessments, the training could focus on the specific placement criteria. For corrections department, human services, or mental health professionals who are inexperienced assessors, the training may include discussion of the nature of AOD use and the treatment delivery systems, as well as the placement criteria. Each State, depending on its resources and implementation plan, must set the specific minimum education, experience, and training requirements for assessors.
When implementing a new public policy that requires significant training, the States can expect to underwrite a substantial portion of the cost. Training will probably be the most expensive aspect of UPPC implementation. It is also true that programs and individual professionals have a responsibility for continuing education. Existing program budgets for training of personnel can defray some of the expense.
The essential question in choosing the setting for placement decisions is whether to rely on AOD treatment providers or to use agencies with some degree of separateness from the treatment provider. The decision must be made on a State level, based on knowledge of the treatment community and the availability and accessibility of the resources.
The primary arguments for independent assessment is concern about AOD providers having a conflict of interest and the likelihood that the independent assessor can draw on a wider variety of treatment programs.
The primary argument for relying on treatment providers for assessment is continuity of care. Assessments can be more readily linked to individual treatment plans. If assessment information from an independent assessor is not relayed to the treatment provider quickly, the client may have to undergo another assessment.
Many States will find that mixing and matching assessment settings will best meet their needs. A State may, for example, prefer that detoxification programs perform assessments, but many localities have no such dedicated programs. Therefore, this State may permit local social service or public health agencies to perform assessments.
Regardless of the setting(s) chosen, individual clinicians may prefer to refer patients to programs or treatment modalities with which they are well acquainted. The existence of UPPC may not necessarily avoid this dilemma. Ongoing technical assistance, monitoring, and treatment review will be necessary to ensure consistent implementation of assessment and placement standards.
An important strength of treatment programs as a setting for the assessment process are the qualified addiction treatment professionals on staff who can learn to use UPPC. In addition, the treatment provider is often sensitive to cultural and local community issues. Another advantage of conducting assessments in treatment programs is that less duplication of effort occurs in treatment than when separate entities perform assessments, as the information obtained can be used immediately for treatment planning.
However, these strengths have parallel weaknesses. Some programs may not have staff members who can deal with issues of cultural sensitivity or the concerns of special populations. Less comprehensive treatment programs will have less comprehensive resources to lend to assessment.
A major problem with assessments performed by treatment programs is the possibility of conflict of interest. Placement decisions may have implications for a program's success in filling its treatment slots. Also, in organizations that offer multiple levels of care, there may be a temptation to place patients at the most expensive level. While professional substance abuse personnel can be expected to make placement decisions based on best practice and the patient's best interest, these can be compelling pressures, particularly in the current atmosphere of financial uncertainty.
The impact of these issues can be minimized by individual programs establishing—and using—internal policies and procedures in which the expectation is that client assessment will determine placement. Providers can then establish internal quality improvement indicators to evaluate the appropriateness of placement decisions. There are already parallels to this with the "at risk" managed care organizations and capitated contracts.
Detoxification services have a unique opportunity to identify individuals who need AOD abuse treatment. Many persons who eventually receive AOD treatment are first screened and assessed when undergoing detoxification from alcohol or other drugs. Detoxification service sites may also be used as assessment sites for anyone needing AOD treatment. One advantage is that those who are in danger of or experiencing severe withdrawal, for which specific detoxification services are clinically indicated, can receive an immediate referral. (Another TIP in this series, currently in development, is Detoxification From Alcohol and Other Drugs, which provides a detailed examination of detoxification services.)
A body of AOD abuse treatment literature has found that the assessment process should occur at the first intervention point. This is another advantage of performing assessment while a person is receiving detoxification services. During this period, the individual may engage in self-evaluation and reexperience feelings of crisis, leading to an appreciation of the seriousness of the AOD problem. This can be considered a "teachable moment."
There are some drawbacks in performing assessments at sites that provide detoxification services. First, rural areas often lack dedicated detoxification centers. Second, across the country, many detoxification services are provided in acute care hospitals. Many of these hospitals do not have staff who are trained in AOD assessment or treatment and many physicians lack sufficient training to adequately assess their addicted patients' needs. Third, many people who need AOD treatment do not enter the system through a detoxification center. Some receive detoxification in outpatient settings. Whether or not detoxification settings can perform assessments depends on staffing and other resources.
Managed care organizations may have a role in assessment in several different models. An example is an organization that manages an employee assistance program (EAP) for a business, performing initial assessments and referring for treatment.
Some managed care organizations do not have face-to-face contact with patients. Involving these organizations in the assessment process can provide this contact between the patient and the organization, a human element that is often missing in the managed care environment. A weakness of this model is that most managed care organizations are not licensed for substance abuse programs.
Some managed care providers have, or contract for, trained staff to perform assessments. This approach may have some disadvantages, as the involvement of more personnel contributes to the separation of assessment and treatment planning. This problem is avoided by managed care providers who not only have trained assessment staff, but also operate their own treatment centers.
A major weakness in using managed care providers as the primary assessment resource is that they, like treatment providers, may have a conflict in that they have an interest in placing the patient in the least expensive, least intensive level of care.
In some States where most providers of services are private, assessment may be the primary role of the public sector. The underlying philosophy of this approach is that assessment and oversight are where the public interest is preserved, while the State removes itself from the actual provision of services.
A major advantage of this assessment model is that it reduces the potential for conflict of interest. When public agencies are involved, the process is open to public examination and input.
Assessments may be done at agencies such as departments of public health, mental health, social services, and criminal or juvenile justice. Since criminal and juvenile justice personnel have many clients who need AOD treatment, it may be appropriate for such agencies to perform assessments, as they are often familiar with the patient's history and have a sound basis for their treatment recommendations.
Assessments for public clients in Minnesota are provided by county social service agencies and American Indian tribal alcohol and substance abuse programs. Each has specially trained assessors. Assessments are accepted from treatment providers only when the provider has specific expertise in working with a special population or when the county agency is too small to have a trained assessor. When an assessment is performed by a treatment provider, the placement decision is reviewed by the county.
The Target Cities programs provide another model for using an independent assessment model for public clients. A strength of this approach is that assessors are not invested in placement and have little conflict of interest. It also offers an easy point of access into the AOD treatment system. Assessors are specialists in assessment, ensuring that assessments will be performed consistently, systemwide. Assessment by independent agencies may simplify the task of collecting aggregate data.
A weakness to this approach is that when agencies such as mental health and criminal justice become involved in assessment, there can be disagreement about priorities, the process can become unfocused, and fragmentation and inconsistency of services can result. Strong interagency agreements specifying the responsibilities of each agency are essential to coordinating services. Oversight and review are necessary to ensure adherence to standards.
A second disadvantage of this public sector approach is the deterrent effect for some patients because of the association with the enforcement side of government. For example, some women may not want to become involved with a State assessor because they fear their children will be taken away from them once their AOD abuse is known. This critical obstacle prevents some women from seeking or entering treatment. Likewise, fear of incarceration may keep people from revealing information about illicit drug use to a State assessor. In these situations, it is crucial to strictly comply with Federal confidentiality regulations.
Another weakness is the potential duplication of services and the fact that assessment by independent agencies may add another provider to the process. Each additional provider means something else to fund. It is also another potential drop-out point for the patient. Reliance on agencies that are not primarily AOD treatment providers has major implications for staffing in those agencies and for the State's training plan.
Most current assessment tools do not relate directly to patient placement decisions. Adoption of uniform patient placement criteria will probably lead to the development of more instruments that match agreed-upon assessment dimensions.
A few tools are under development, but they must go through the rigors of reliability and validity testing before they can be used on a widespread basis. Tools should be readily usable by professional staff, providing semiquantitative results that match the various dimensions of the PPC, and should be available in different languages. Automated tools facilitate data collection, ease of administration, and transfer of information in a system. Data from assessment tools should link to treatment outcomes.
Ideally, an instrument should involve a patient interview. The use of an instrument should not be seen as a substitute for the patient interview, which should validate the findings of the instrument. If an assessor focuses wholly on the instrument, it will limit the scope of information obtained.
Some instruments exist that correspond with specific PPC. For example, the Clinical Institute Withdrawal Assessment for Alcohol—Revised (CIWA-Ar) is useful to measure Dimension 1, acute intoxication and/or withdrawal potential as described in the ASAM PPC. For Dimension 2, biomedical conditions and complications, there are no quantitative scales, although the Addiction Severity Index (ASI) does have a medical category. A medical history, a physical examination, and laboratory tests provide the best information to measure this dimension, and special attention should be paid to physical conditions associated with AOD use, such as liver disease or HIV disease.
Dimension 3 addresses emotional/behavioral conditions or complications, which can be measured by the psychiatric or psychological scales on the ASI. There are a variety of psychiatric diagnostic and severity scales, many of which provide useful information but none of which correlate directly with the ASAM PPC.
There are only a handful of instruments that measure Dimension 4, treatment acceptance/resistance; Dimension 5, relapse potential; or Dimension 6, recovery environment. Some existing tools include the ASI, the Level of Care Index (LOCI), and the Recovery Attitude and Treatment Evaluator (RAATE). More information on these and other assessment instruments is included in Appendix B of this TIP. The other TIPs on assessment mentioned at the beginning of this section describe a variety of useful instruments.
A number of important considerations must be examined when discussing implemention of UPPC. Some of these issues include: