TIP 1

How to make the paradigm shift from programs to people

I recently have been consulting with several States and counties going through a paradigm shift that the ASAM Criteria has promoted since its beginning in 1991.  It is a shift to encourage clinicians and programs to move:

*  From uni-dimensional (treating clients mainly on the basis of their diagnosis) to multidimensional assessment (a holistic, whole person approach);

*  From program-driven (plugging people into programs from which they graduate to aftercare) to more clinically-driven treatment (individualized, person-centered services);

*  From a fixed length of stay to variable length of service (moving from one-size-fits-all to treatment length-of-stay based on progress and outcomes); and

*  From a limited number of discrete levels of care (residential and outpatient) to a continuum of care (multiple levels of care in a seamless continuum).

[ASAM PPC-2R, 2001, p.1]

As Chief Editor of the ASAM Criteria, I have been talking about these shifts for over twenty years. Often, participants will come up to me after such a presentation and share their enthusiasm for what they are doing to implement such concepts.  Of course it is rare that participants come up to tell me how much they disagree – perhaps they are too polite to confront me to my face. Years ago though, one frustrated person who was not at a stage of readiness to embrace such a paradigm shift challenged me with: “How do you sleep at night, Dr. Mee-Lee?”

Recently John wrote to me: “I had the pleasure of attending a seminar at which you presented a year or so ago.  We talked briefly about the program with which I am associated and you were very encouraging about the changes we had made to our approach in the preceding 2-3 years.”  So he shared his program’s “Philosophy and Principles of Effective Treatment” which, he said “is meant to guide our staff in our Outpatient Behavioral Health Services.”

Here is a tiny excerpt:

*  Treatment in the Outpatient Behavioral Health Services is to be individualized, ‘patient-focused’ and ‘outcomes-informed’…as opposed to a ‘program-based’ approach that emphasizes the requirements of the program.  (My side comment: I recently heard about a program that takes the first month of their residential program to orient clients to the rules and regulations of the program in preparation for starting ‘real’ treatment.)

*  Our focus will be upon establishing a positive and collaborative helping relationship with the patient as an equal partner.

*  On the other hand, we will ensure a safe milieu for all patients, visitors and staff.

*  We will not treat someone who we do not believe can be safely treated or will not substantially benefit from our treatment.

So I was curious about how did they get THERE from HERE, since others need to hear from people actually making changes and implementing a new direction.  Here’s what I asked John:

–> What was the process he used to move the services and staff to the principles and tenets laid out in their philosophy guide?

–> What was hard about it?  What went smoothly and what didn’t?

–> What worked in making changes and what didn’t; and how did they handle that?

–> I also asked how they were evaluating their services from the client’s perspective; and whether the clinicians were ‘walking the talk’ about what the philosophy guides? I wondered because at the end of their “Philosophy and Principles of Effective Treatment” it stated:  “In conclusion, this document will serve as the standard by which we in the Outpatient Behavioral Services will evaluate our services and the treatments we offer.”

 

Here was John’s response:

“Regarding our processes, there have so far been several components involved in leading us to where we are today.

*   As a leadership team, we have had a discontent about simply doing ‘treatment-as-usual’; we didn’t want to accept worn-out ideas that scapegoated patients and led therapists to feel powerless in the face of clichés such as ‘needing to hit bottom’, ‘you can’t help someone who doesn’t want help’ and other such outdated ways of thinking.

*   We remained very open to the marketplace of ideas and were much affected by a wide range of progressive theorists and practitioners, people like William Miller, David Mee-Lee, Carlo DiClemente (My side comment: Both James Prochaska and William Miller are Senior Advisors to The Change Companies and have greatly influenced me in theory and practice), Scott Miller, David Burns, Robert Meyers…to name just a very few.

*   We had a kind of dialectical acceptance both of Transtheoretical Approaches as well as evidence-based models, finding room for both in our approaches.

*   We were struck especially by the need to partner with the client and to make treatment planning a living experience that involves a dynamic, phased (evolving) and collaborative approach to our treatment-planning process.

We evaluate our services from the patient’s point of view in several ways.

*   We do, of course, ask our patients to share their views in customer satisfaction forms.  For a long time, we have asked questions on the satisfaction form that focus not just on clinical outcomes, but also on questions that serve as proxies for therapeutic relationship/alliance.

*   For example, some of our questions seek their view on whether we have succeeded in generating an agreement on goals and methods, two pillars of therapeutic alliance.

*   We have questions designed to determine if patients experience us as compassionate and empathetic.  Have we taken into account the patient’s view of what will help them?  To quote a wise Australian man, we sometimes tell the patient, “I (the therapist) am in charge of the treatment plan, but YOU are in charge of me!”  (I wonder who I got that from?)

 

All of this is helpful but is not enough because such feedback typically comes towards the end of the treatment.

*   So what we use from the beginning is that we frequently seek the patient’s view of how we are doing both with regard to clinical outcomes and with regard also to the therapeutic relationship.

*   Regarding clinical outcomes, all patients in our structured Partial Hospital Program or Intensive Outpatient programs complete a daily symptom checklist from which we track their progress on a number of clinical indicators.  Not only does this give us a daily idea of whether they are trending in the right direction or not, we also use it in one of our performance improvement studies.

*   Specifically, we take the patient’s scores at admission on each indicator and compare it to their score on discharge.  We sort the data by groups such as whether the patient successfully completed the treatment, returned to the hospital, dropped out, or whatever.

*   We also regularly seek their view of the therapeutic relationship by means of validated forms such as the Burns ‘Evaluation of Therapy Session’ or ‘Empathy Scale.”  This way we can identify early threats to the treatment engagement.

 

Regarding staff response:

*  Some were more willing and others less so to engage robustly in exploring and implementing these progressive approaches.  Introducing a new culture and getting it to take hold is very challenging.

*   I am sure that we are not yet all the way where we need to be in this regard, but we seem to be getting there.  We have improved a lot, but need to get better at ‘walking the talk’.

*   Part of how we help the staff transition is the targeted use of outside seminars, monthly in-house in-service training, monthly case presentations, patient staffings, targeted competency demonstrations and clinical supervision and consultation.

*   We are fortunate to have an enlightened management and administration, one that financially supports these staff activities.

*   We certainly also seek staff response and input.

But how to test fidelity and insure staff make use of these approaches?

*   That’s the thing….  I am mindful of a number of studies that suggest that therapists consistently believe they are doing one kind of treatment when they actually are not.

*   The primary source of insight as to whether these approaches are resonating with the therapists and are being used is supervision/consultation and patient staffings.

*   Other than that, we recognize that we are not a research setting and do the best we can with issues such as fidelity.  We have recently just started discussions of whether we might try to generate some reasonable measurement strategy for staff.

If you want to talk with a fellow traveler on the path to new directions, here is John’s contact information:

John A. Brogan, BCD, LCSW

Clinical Supervisor

Outpatient Behavioral Health Services

Palos Community Hospital

15300 West AV, Suite 313

Orland Park, IL 60462

708/460-2721

jbrogan@paloscomm.org

 

Reference:

Mee-Lee D, Shulman GD, Fishman M, Gastfriend DR, and Griffith JH, eds. (2001). ASAM Patient Placement Criteria for the Treatment of Substance-Related Disorders, Second Edition-Revised (ASAM PPC-2R). Chevy Chase, MD: American Society of Addiction Medicine, Inc.

To order the ASAM Criteria from the American Society of Addiction Medicine – 4601 Nth. Park Ave., Arcade Suite 101, Chevy Chase, MD 20815. (301) 656-3920; go online to www.asam.org and click on Publications, then Patient Placement Criteria.

http://asam.org/publications/patient-placement-criteria

When it comes to making major shifts in the culture of treatment services, those ready to embrace these changes often complain about the administrators, clinicians, counselors, payers and manage care organizations who are “just so resistant!”TIP 1 When you see people “so resistant”, remember that just means they are at a different stage of change and readiness than you are. This is where Prochaska’s Transtheoretical Model of Change is so helpful. It reminds you that other colleagues just happen to be in the stage of Precontemplation – not yet ready to embrace new ideas or innovations in the design, delivery and payment of services. Just because you happen to be at Action for change doesn’t mean that they should automatically be there too, just at the same time you want them to be. And you won’t move them to Action by yelling, shaming, coercing or criticizing them either. Here’s what you can do: *  If you are a supervisor or clinical director….. You can collaborate with the team member to create an Individualized Staff (Member) Development Plan. This plan would start at the current stage of change of the counselor, supervisee or employee and focus on an agreed upon goal which moves in the direction of the paradigm shift being made. * For example…. Perhaps the supervisee needs more information or data to raise their consciousness as to why a change in treatment philosophy is even needed. Or they may need a development plan focused on Motivational Interviewing skills. This might be due to their self-awareness they aren’t good at collaboration with clients, if they have always used confrontation and authority with their clients. * If you are managing a system of care… You can institute an Individualized Agency Development Plan for all the different sites in your system; or for the different departments in your organization. Each site or department is likely at some particular stage of change as well; they may well not be “at Action” for the changes you want. As manager, you can require them to develop, with consultation and training, a change plan that starts where their site or department is at with clear expectations for progress and change. * If you are working with payers and managed care organizations (MCO)…… All stakeholders (consumers, clinicians, treatment providers, State or county personnel, licensing and quality assurance administrators, payers) need to work together on a Payer Development Plan. The focus of those conflict resolution meetings would be to reach an understanding on utilization review and care management criteria, definitions of “Medical Necessity” and necessary biopsychosocial services, the design and content of Insurance Benefit Plans to be managed by the MCO. Change, especially systems change, is very challenging because there are so many moving parts, stakeholders, conflicting and competing interests. It takes many deep cleansing breaths; repetitions of the Serenity Prayer; and combinations of incentives and leverages to facilitate continuing change and development. Reference: Prochaska, JO; Norcross, JC; DiClemente, CC (1994): “Changing For Good” Avon Books, New York

You know I talk a lot about engaging people, listening to them and providing person-centered services. But it’s nice to be on the other side of that, which is what happened when I slipped on a wet floor at a recent hotel stay. As I was rushing to check out – having already tried to cram in one more e-mail response before the training- I slid onto my behind on a just-mopped tile floor. No “Wet floor” warning cone, but plenty of worried looks on nearby housekeeping staff who saw it all happen.

“How was your stay and how are you today, sir?” the checkout person said as I plonked my room key on the front desk.

“Not good. I just slipped on a wet floor and could have really hurt myself” I said annoyingly.

“I’m so sorry to hear that, sir” as she proceeded to get my receipt. As she handed me the receipt, she said: “And I took $15 off your bill for the trouble you had.”

It’s amazing to me how that immediate, customer-friendly initiative soothed my butt and my annoyance. She didn’t scold me for rushing and not looking for potential hazards. She didn’t make some smart remark like “Yeah, s-t happens.” That would really have ticked me off. She listened and assertively did what she could to smooth the situation.

(My skeptical side turned a nice act into a suspicion that they have been trained to quickly apologize and prevent a lawsuit, even if it was the customer’s fault for slipping. But I’m trying not to go there mentally and choose to see it as a thoughtful act.)

This incident reminded me of an even more annoying situation when I waited almost and hour for my doctor’s appointment. When my name was finally called, I was ready to hand them a bill for my wasted time and it wouldn’t have been $15. As I entered the hallway to the doctor’s office, the nurse met me and immediately handed me a $5 gift card to Starbucks. Before I could get my full grumble out about how much my time would have cost them if I could charge, she apologized for the wait and ushered me into the office.

Again, five measly bucks was soothing. They know I couldn’t sue them, nor would they lose me as a patient just for one long wait. They didn’t have to do that. It was a customer-friendly initiative that builds and maintains good relationships.

How much more (with people who are disenfranchised, demoralized and discriminated against) should we be looking for opportunities to serve up a little milk of human kindness? I don’t know what would be most meaningful for them and cost-efficient for us as providers of care. But it’s worth thinking about, asking them and proactively reaching out.

I don’t often get a question from a utilization reviewer involved in approving levels of care. So here is a question involving when to increase the intensity of level of care:

“Several external reviewers (including me) are in the midst of an issue with an insurer. The insurer uses the ASAM Patient Placement Criteria, Second Edition Revised (PPC-2R) to approve or deny various levels of addiction treatment. Some of the discussion has revolved around whether a patient has received certain levels of care in the past.

The particular discussion of concern involves a patient who has been seeing a psychologist as an outpatient, with treatment focused on the patient’s addiction. The patient has also been attending Twelve-Step meetings. Despite this treatment, he has not yet achieved abstinence and is therefore seeking a higher level of care. The PPC-2R specifically defines Level I care as including care delivered by various professionals, including a psychologist. The insurer has argued that the patient has not obtained appropriate medical care – he has never been seen by a psychiatrist or an addiction specialist physician – and that therefore an increased level of care is not indicated. The reviewers, again including me, have all agreed with the insurer. The patient argues that he has been in Level I care – and failed – and that therefore he is eligible for a higher level of care.

A strict interpretation of the ASAM Criteria would suggest that even if the claimant had only been seeing a certified alcohol counselor, that would suffice for a trial of Level I care.

I am unable to find anything in the PPC-2R that indicates that a Level of Care within an ambulatory setting is increased or decreased if a physician is involved or not involved, respectively. This appears to differ from the situation in an inpatient setting, again at least as far as I’m able to tell from the text.

Am I missing something?”

From a physician reviewer

 

Here is my response:

There are a few issues raised in this case:

Issue 1: When you aren’t achieving a good outcome with a patient/client

Issue 2: If/when a physician should be involved in a case

Issue 1: Good outcomes or poor outcomes?

Simply not achieving a good outcome in a level of care is not the automatic criterion to offer a more intensive level of care. Our field has gotten into the habit of placing someone in a set program, or prescribing going “up” to the next level of care. We must redirect our thinking and attention to is: the type(s), dose and intensity of services required by this individual.

→ What services is this person actually needing right now? ( The type question)

→ What amount of service is needed right now? (The dose and intensity question)

If these questions are top-of-mind when assessing the client, then what level of care to place someone in unfolds and becomes very clear.

When success is not happening, the assumption is often made that this current treatment is a “failure” – and that “failure” means automatically moving the client to a more intensive level of care.

When a poor outcome (or “failure”) is recognized, the next step is to ask more questions. Assess and assess again.

a….Why is the outcome not being achieved?

b….What ASAM Criteria dimension(s) are involved in this case?

c….What services would address the problem(s) and priorities in those dimensions identified  in b.?

d….What dose and intensity of service will meet the patient’s needs?

e….Where can we provide those services for the patient, so that he/she remains safe, and that the level of care will achieve those objectives efficiently?

Applying this to the case of the patient seeing the psychologist……

Let’s say the patient actually wants abstinence (Dimension 4, Readiness to Change), but relapses or has difficulty with stopping his use (Dimension 5, Relapse, Continued Use and/or Continued Problem Potential) then what?

In the counseling sessions, both the patient and therapist need to pinpoint/ make concrete the exact nature of difficulties the patient is having. They discuss which difficulties – if any- warrant treatment in a more intensive setting.   The therapist is questioning in his/her mind all the time- is this difficulty able to be handled/ overcome in other ways that are productive & helpful? Perhaps there are strategies/ solutions that have not been explored or utilized so the patient can achieve results without “automatically” moving into a more intensive and more costly setting. Examples follow.

*   It could be a Dimension 6, Recovery Environment issue:

Even though the person is attending AA, we may assume he is gaining the full benefit from all the program offers. We might assume he is working it to its fullest. Perhaps if we probe, we could find that the client has not gotten any names or numbers nor a sponsor that he actually uses. He might still hang out with friends who continue using. Perhaps he has lost his job and is stressed.

*  It could be a Dimension 3, Emotional, Behavioral or Cognitive Conditions and Complications issue:

The sponsor or therapist might be saying “don’t drink and go to meetings”, yet hasn’t diagnosed a co-occurring adult Attention Deficit Hyperactivity Disorder which truly needs treatment and even medication.

*   It could be a Dimension 4, Readiness to Change issue:

The client may be quite ambivalent about abstinence. The treatment needed is motivational strategies in working with his family members. We must check out that there are no “enabling” significant others in his life. When all of the reasons for the poor outcome are assessed, we may find we are able to deliver the necessary services in Level I.   However, after all that exploration, if the services can only be delivered safely and effectively in a more intensive level of care, then that is reason to be transferred.

Issue 2: Physician involvement- when?

Calling in a physician is more critical at inpatient and more intensive levels in the ASAM Criteria. What justifies admission to those levels are usually more biomedical and psychiatric severities, which would exclude a person being safely treated in outpatient.

In Outpatient levels, physician involvement is relevant if there are Dimensions 1 (Acute Intoxication and Withdrawal Potential), 2 (Biomedical Conditions and Complications) or 3 issues affecting the outcome. In this case, lack of abstinence may be due to problems in Dimensions 1-3, but may also be due to untreated or ineffectively treated issues in Dimensions 4, 5 and/or 6.

The bottom line on level of care determination is this: What problems/priorities in which of the six ASAM Criteria dimensions require services, the dose and intensity of which can only safely and effectively be delivered in the level of care requested? The specifics of each of those steps are what should inform the clinical discussion on requests for changes in levels of care.

Hope this helps.

David

Thanks for reading. Join us in late July.David