Title : QGcover tip13 9-5-01gvp.qxd (Page 2) Description : Keywords : Author : ----------------------------------------------- Quick Guide For Clinicians Based on TIP 13 The Role and Current Status of Patient Placement Criteria in the Treatment of Substance Use Disorders ----------------------------------------------- Contents Why a Quick Guide? . . . . . . . . . . . . . . . . . . . 2 What is a TIP? . . . . . . . . . . . . . . . . . . . . . . . 3 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . 4 The Role of Patient Placement Criteria in a Managed Care Environment . . . . . . . . . . . . 7 Building Support of Adopting UPPC . . . . . . 13 Ethical and Legal Issues . . . . . . . . . . . . . . 17 Glossary of Terms . . . . . . . . . . . . . . . . . . . 19 ----------------------------------------------- Quick Guide For Clinicians This Quick Guide is based almost entirely on information con tained in TIP 13, published in 1995, and based on information updated through approximately 1993. No additional research has been conducted to update this topic since publication of the original TIP. Based on TIP 13 The Role and Current Status of Patient Placement Criteria in the Treatment of Substance Use Disorders ----------------------------------------------- 2 The Role and Current Status of Patient Placement Criteria in the Treatment of Substance Use Disorders WHY A QUICK GUIDE? This Quick Guide was developed to accompany The Role and Current Status of Patient Placement Criteria In the Treatment of Substance Use Disorders, Number 13 in the Treatment Improvement Protocol (TIP) Series published by the Center for Substance Abuse Treatment (CSAT), Substance Abuse and Mental Health Services Administration. This Quick Guide is based entirely on TIP 13 and is designed to meet the needs of the busy clinician for concise, easily accessed "how-to" information. The Guide is divided into five sections (see Contents) to help readers quickly locate relevant material. Terms related to placement criteria are listed on page 19 in the Glossary of Terms. Some of them are used in this Quick Guide; others are included to enable clinicians to talk knowledgeably with their clients and clients' medical providers. For more information on the topics in this Quick Guide, readers are referred to TIP 13. ----------------------------------------------- What Is a TIP? 3 WHAT IS A TIP? The TIP series has been in production since 1991. This series provides the substance abuse treat ment and related fields with consensus-based, field-reviewed guidelines on topics of substance abuse treatment. TIP 13, The Role and Current Status of Patient Placement Criteria In the Treatment of Substance Use Disorders • Addresses the concerns of a broad range of readers including clinicians, counselors, social workers, medical personnel, mental health workers, program administrators, and policy- makers • Lists numerous resources for further informa tion • Provides a reference on the status of patient placement criteria in the treatment of sub stance abuse disorders See the inside back cover for information on how to order TIPs and other related products. ----------------------------------------------- 4 The Role and Current Status of Patient Placement Criteria in the Treatment of Substance Use Disorders INTRODUCTION One of the goals of substance abuse treatment is to establish uniform patient placement criteria (UPPC) to accurately assess the severity of a client's problems in three areas: medical, psycho logical, and social. However, neither this Quick Guide nor TIP 13 set these criteria. Their purpose is to lay the ground work for developing the crite ria. These products vocalize the concerns of peo ple who have a stake in the creation of a UPPC and provide information on the sets of criteria and issues in development. Recommended Characteristics of Uniform Criteria UPPCs play an important role in matching place ment to cost-conscious, effective treatment. Both payers and providers may accept patient place ment criteria, assuming those criteria • Accurately describe their levels of care • Have validity regarding recommended place ment level • Are easy to use in real-time clinical decision- making • Include reliable and objective tools and lan guage ----------------------------------------------- Introduction 5 • Encourage positive treatment outcomes in the least restrictive environment Without uniformity, there are no common defini tions of care, no common language, and no capacity to effectively perform and compare the essential research. Advantages of UPPC • A common vocabulary can allow clinicians to more easily consult about clients or programs. • Uniform criteria can provide a common basis for study and continued improvement of both the criteria itself and services provided as a result. • UPPC can help alleviate the high cost of under- treatment by ensuring patients get all the treat ment they need. • UPPC can alleviate the cost of overtreatment by ensuring patients get only the treatment they need based on assessment and uniform criteria. • Common definitions of levels of care, common standards of assessment, and common stan dards for continued stay and discharge can establish the same framework for public and private programs. ----------------------------------------------- 6 The Role and Current Status of Patient Placement Criteria in the Treatment of Substance Use Disorders Bringing consistency to placement decisions has a number of advantages, but the development of the criteria presents challenges. In some situations, the advantages are not recognized. In other situa tions, the task of implementation is daunting because of limited resources, geography, multiple funding systems, or separate treatment systems for public and private clients. For more detailed information, see TIP 13, pp. 1–4. ----------------------------------------------- The Role of PPC in a Managed Care Environment 7 THE ROLE OF PPC IN A MANAGED CARE ENVIRONMENT Recently there has been a move toward using a variety of treatment models to ensure quality while conserving health care resources. Clinicians must focus on matching patients with appropriate and specific treatment. The success of clinically driven treatment relies on an accurate diagnosis that must take into account severity of addiction. This can result in • Placement of patients in the correct level of care • Movement to less intensive or more intensive levels of care when appropriate • Matching patients individually to a variety of treatment models at all case levels Development of Patient Placement Criteria The addiction treatment field needs • Uniform criteria to guide proper patient place ment • Guidelines to promote the establishment of effective individualized treatment modalities • Data regarding outcomes to continually improve both the criteria and the guidelines ----------------------------------------------- 8 The Role and Current Status of Patient Placement Criteria in the Treatment of Substance Use Disorders Assessment Follows Theory Attitudes about assessment across the country are important. The many and varied beliefs that exist must give way to a common standard if the addiction field is to uniformly offer quality care. The biopsychosocial definition (one that takes into account biological, psychological and social per spectives) of addiction provides a framework for creating uniform assessment standards. Biopsychosocial Perspective on Addiction Understanding addiction as a biopsychosocial ill ness in its origins, expression, and treatment has four important results. 1.Promoting the integration of different perspec tives on the illness 2.Explaining and preserving common clinical dimensions 3.Necessitating multidimensional assessment 4.Promoting effective matching of the patient with individually prescribed treatment Biopsychosocial Treatment and Matching Once a uniform model of assessment is agreed upon, the next step is to define treatment that matches the severity of the patient's problems. When a patient is placed in an appropriate level of care, selection of the specific assessment-based ----------------------------------------------- The Role of PPC in a Managed Care Environment 9 model completes the individualized treatment match. Levels of Care The State of Minnesota, the Institute of Medicine and the American Society of Addiction Medicine (ASAM) have all established levels of care. • By Minnesota standards, patients are placed in a particular level of care, ranging from residen tial treatment to outpatient treatment, based on their level of chemical involvement and other criteria. • The Institute of Medicine defines four levels of care: inpatient, residential, intermediate, and outpatient. • The ASAM patient placement criteria describes four levels of care and are descriptive about the intensity of service provided: outpatient treat ment, intensive outpatient treatment/partial hospitalization, medically monitored intensive inpatient treatment, and medically managed intensive inpatient treatment. Modalities of Treatment • Biomedical modalities focus on improved detoxification regimens and treating substance abuse with medications. ----------------------------------------------- 10 The Role and Current Status of Patient Placement Criteria in the Treatment of Substance Use Disorders • Psychological treatment modalities range from addiction counseling to psychodynamic and cog nitive–behavioral treatment modalities. • Sociocultural treatment modalities include the community reinforcement approach, family ther apy, therapeutic communities, vocational reha bilitation and various other techniques. Implications The "retooling" of the addiction treatment system necessary to promote individualized treatment requires a shift that has broad implications. If the shift occurs successfully • The substance abuse treatment field will devel op one uniform set of clinically-based place ment criteria. • Public- and private-sector programs will develop a single system of comprehensive care that can be matched with the placement criteria. • Programs will expand their continuums of care to provide multiple levels of care with flexible lengths of stay. • Payers will reimburse and fund all levels of care to allow patients to be placed in and move among the most efficient and effective settings. • Clinicians will become more skilled at compre hensive assessment and have a broader knowl- ----------------------------------------------- The Role of PPC in a Managed Care Environment 11 edge of placement criteria and treatment modalities. • Patients will receive care that is not only more cost efficient but more cost effective. • As patients receive treatment in the least inten sive yet safe setting, they can test recovery skills in situations as close to "real world" condi tions as possible and minimize reentry prob lems. Characteristics of a Comprehensive Set of Patient Placement Criteria Client Characteristics • Age, gender, ethnic, and cultural background • Severity and course of illness, experiences with previous treatment • Relapse potential • Need for medical or addiction treatment or pharmacological, psychiatric, familial, and social employment • Need for legal services • Attitude toward entering and continuing treat ment • Effects of environmental and social influences, such as living situation, family support, and sus ceptibility to abuse or neglect ----------------------------------------------- 12 The Role and Current Status of Patient Placement Criteria in the Treatment of Substance Use Disorders Service Characteristics • Intensity of services • Intensity of environmental support • Availability of medical services • Variety of professional disciplines involved • Availability of services specific to cultural back ground, age, sex, or disabilities • Program elements • Discharge planning • Patient-to-staff ratio For more detailed information, see TIP 13, pp. 5–9. ----------------------------------------------- Building Support for Adopting UPPC 13 BUILDING SUPPORT FOR ADOPTING UPPC Benefits of Adopting UPPC Improving Assessments • Can be used to take into account the various dimensions of patient care and to look at the whole person • Can become a positive force that assists providers in looking at the broad range of treat ment options • Will guarantee that assessment addresses the components necessary for successful treatment • Will require physicians to focus on observable measures of the severity of illness • Will provide for the development of more pre cise screening and assessment instruments Improving Treatment Planning • Because of a thorough assessment that identi fies the patient's strengths and needs, the clini cian will be able to make better decisions about the level and models of treatment. • Continued stay criteria will address why the patient is staying in treatment and what out comes are expected. ----------------------------------------------- Building Support for Adopting UPPC 13 BUILDING SUPPORT FOR ADOPTING UPPC Benefits of Adopting UPPC Improving Assessments • Can be used to take into account the various dimensions of patient care and to look at the whole person • Can become a positive force that assists providers in looking at the broad range of treat ment options • Will guarantee that assessment addresses the components necessary for successful treatment • Will require physicians to focus on observable measures of the severity of illness • Will provide for the development of more pre cise screening and assessment instruments Improving Treatment Planning • Because of a thorough assessment that identi fies the patient's strengths and needs, the clini cian will be able to make better decisions about the level and models of treatment. • Continued stay criteria will address why the patient is staying in treatment and what out comes are expected. ----------------------------------------------- 14 The Role and Current Status of Patient Placement Criteria in the Treatment of Substance Use Disorders • Patients can be more effective partners in their own treatment when the problems being addressed and the desired outcomes are clearly articulated. Economic Benefits Some managed care systems are finding that patients are placed into a particular level of care for treatment services simply because it is avail able. This is neither cost effective nor beneficial to the patient. UPPC can promote more efficient con tracting for services independent of the availability of treatment slots. An additional clinical and eco nomic benefit of UPPC is that it will alter less effective treatment paths that can result from established referral relationships or other nonclini cally based referrals. Establishing a Common Language Uniform criteria can bring stability and consistency to the substance abuse treatment field, allowing diverse disciplines and organizations to work together. Once implemented, they can provide a common agenda, a common language, and shared expectations about treatment across dif ferent service providers, payers, policy makers and others. In addition to standardizing terminolo gy, UPPC can provide a common basis for under standing the immediate and long-range needs of patients in treatment. They constitute a frame- ----------------------------------------------- Building Support for Adopting UPPC 15 work for a variety of groups to use as they engage in a collaborative planning process, especially when more than one system is involved (such as the criminal justice system or human services). Special Considerations • Not all areas will have the array of levels of care described in the criteria. In some cases, criteria can be adapted to fit the available resources. • No set of criteria is likely to address the needs of every client. The implementation of criteria must allow for flexibility on the part of clinicians to deviate from the levels of care to address the needs of the individual client. • Care must be taken to ensure creativity in pro gram development is not stifled by PPC. The substance abuse treatment field is continually seeking ways to improve programs, and criteria should not force providers to fit molds or adhere to rigid descriptions of programs. Implementing UPPC A number of important considerations must be examined when discussing implementation of UPPC: • Tying UPPC to licensing requirements and fund ing sources ----------------------------------------------- 16 The Role and Current Status of Patient Placement Criteria in the Treatment of Substance Use Disorders • The relationship between UPPC and the actual range and availability of treatment • Wraparound services • Factors that should be addressed for special populations • Possible conflicts of eligibility with UPPC • Elements and goals of assessment • Assessment instruments and tools • Strengths and weaknesses of assessment settings For more detailed information, see TIP 13, pp. 23–40. ----------------------------------------------- Ethical and Legal Issues 17 ETHICAL AND LEGAL ISSUES With respect to documenting and supporting sub stance abuse treatment decisions based on UPPC, the following recommendations are made: • Every provider who makes an entry in a patient's records should do so with the under standing that it will be reviewed and scrutinized by the insurer or third-party payers. • Providers in facilities that have adopted patient placement criteria must learn to speak the lan guage of the criteria. The evaluation forms, progress notes and other components of the patient's record must relate specifically to the criteria that use the same terminology. • The patient record should include specific illus trations to demonstrate that a patient has been assessed on a specific dimension outlined in the criteria and the ongoing attention is focused on that area. Include specific examples of observed patient behavior, statements, or histo ry that clearly indicate treatment resistance. • Before making an entry, providers should review previous entries. Conflicting or inconsistent entries damage the credibility of the entire record. ----------------------------------------------- 18 The Role and Current Status of Patient Placement Criteria in the Treatment of Substance Use Disorders • While a "defensive" or "patient welfare" approach to recordkeeping is prudent, the integrity of patient records should not be com promised by deliberate misstatements or alter ations. For more detailed information, see TIP 13, pp. 51–55. ----------------------------------------------- Glossary 19 GLOSSARY OF TERMS American Society of Addiction Medicine (ASAM): ASAM is an international organization of 3,000 physicians dedicated to improving the treatment of persons with substance use disorders by edu cating physicians and medical students, promot ing research and prevention, and informing the medical community and the public about issues related to substance use. In 1991, ASAM pub lished a set of patient placement criteria that have been widely used and analyzed in the sub stance abuse treatment field. Assessment: The process of collecting detailed information about a person's alcohol and other drug use, emotional and physical health, family and social problems, roles and supports, educa tional and employment status, legal status, and other areas as a basis for identifying the appropri ate level and intensity of substance abuse treat ment as well as needs for other services. Client: An individual receiving substance abuse treatment. The terms client and patient are some times used interchangeably, although staff in medical settings more commonly use the term patient. ----------------------------------------------- 20 The Role and Current Status of Patient Placement Criteria in the Treatment of Substance Use Disorders Dimension: A term used in the ASAM patient placement criteria to refer to one of six patient problem areas that must be assessed when mak ing placement decisions. Healthcare reform: Efforts occurring at the national, State, and local levels to change the delivery of healthcare services to meet three goals: improved access to care, better quality care, and reduced costs goals that are shared by those seeking to implement uniform patient place ment criteria. Instrument: A measurement tool, usually a ques tionnaire, that is used for used for gathering infor mation about an individual to aid screening, assessment, diagnosis, and/or clinical decision- making. Managed care: An approach to delivering health and mental health services that seeks to improve the cost effectiveness of care (i.e., improved serv ices at reduced cost) by monitoring service seek ing and delivery. Methods include managing the overall delivery of care by selecting providers (for example, health maintenance organizations or other provider networks) and managing treatment decisions by individual providers for individual patients (for example, utilization review). ----------------------------------------------- Glossary 21 Modality: A specific type of treatment (technique, method, or procedure) that is used to relieve symptoms or induce behavior change. Modalities of substance abuse treatment include, for exam ple, inpatient social milieu treatment, group thera py, and individual substance abuse counseling. Needs assessment: A process by which an indi vidual or system (e.g., an organization or commu nity) examines existing resources to determine what new resources are needed or how to reallo cate resources to achieve a desired goal. Use of patient placement criteria can reveal gaps in the continuum of care and can aid in needs assess ment at the community and State levels. Outcomes monitoring: Collection and analysis of data from persons in substance abuse treatment to determine the effects of treatment, especially in relation to improvements in functioning (treat ment outcomes monitoring); the same type of process can be performed at the program level to determine whether programs are meeting their goals (program outcomes monitoring). In publicly supported systems, outcomes monitoring will also help to establish accountability for the expendi ture of public funds. Patient: An individual receiving substance abuse treatment. The terms client and patient are some times used interchangeably, although persons in ----------------------------------------------- 22 The Role and Current Status of Patient Placement Criteria in the Treatment of Substance Use Disorders medical settings more commonly use the term patient. Rationing: The act of limiting treatment or other services to certain individuals or populations, usu ally due to limited resources. Third-party payers: Payers for services other than the client or patient who receives the services, including private insurance and public payers such as Medicare and Medicaid. Utilization review: A method used in managed care approaches in which an outside organization reviews clinical decisions in areas such as hospi tal admission, length of stay, and discharge, as well as choices regarding placement and treat ment modality in order to improve the quality of care and reduce costs. Wraparound services: Services in addition to sub stance abuse treatment that are provided to patients to improve retention in treatment and treatment outcomes. ----------------------------------------------- Ordering Information TIP 13 The Role and Current Status of Patient Placement Criteria in the Treatment of Substance Use Disorders TIP 13-Related Products KAP Keys for Clinicians based on TIP 13 Quick Guide for Administrators based on TIP 13 Do not reproduce or distribute this publication for a fee without spe cific, written authorization from the Office of Communications, Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services. Easy Ways to Obtain Free Copies of All TIP Products 1. Call SAMHSA's National Clearinghouse for Alcohol and Drug Information (NCADI) at 800-729-6686, TDD (hearing impaired) 800-487-4889 2. Visit CSAT's Website at www.csat.samhsa.gov ----------------------------------------------- Other Treatment Improvement Protocols (TIPs) that are relevant to this Quick Guide: See the inside back cover for ordering information for all TIPs and related products. DHHS Publication No. (SMA) 01-3563 Printed 2001 TIP 8, Intensive Outpatient Treatment for Alcohol and Other Drug Abuse (1994) BKD139 TIP 11, Simple Screening Instruments for Outreach for Alcohol and Other Drug Abuse and Infectious Diseases (1994) BKD143 TIP 14, Developing State Outcomes Monitoring Systems for Alcohol and Other Drug Abuse Treatment (1995) BKD162 TIP 20, Matching Treatment to Patient Needs in Opioid Substitution Therapy (1995) BKD168 TIP 27, Comprehensive Case Management for Substance Abuse Treatment (1998) BKD251