TIPS & TOPICS
Volume 5, No.11
March 2008

In this issue
— SAVVY
— SKILLS
— SOUL
— SHAMELESS SELLING
— As a RESULT of your FEEDBACK
— Until Next Time

Welcome to March’s Tips and Topics (TNT), especially to the many new subscribers. As usual we are running late, so this March edition will likely get to you in early April. It is after all, free, so I guess you get what you pay for!

SAVVY

Glossary of abbreviations:

ASAM PPC or ASAM Criteria = Patient Placement Criteria of the American Society of Addiction Medicine
ASAM = American Society of Addiction Medicine
MDA = Multidimensional Assessment
OP = Outpatient
IOP = Intensive Outpatient
MCO = Managed Care Organization

It has been a year since a TNT edition covered the ASAM PPC. In the meantime I often receive questions about these criteria – criteria used in about 30 US States, the Department of Defense addiction services around the world, plus many managed care organizations and providers.

Perhaps you have asked one of these questions below. The answers emerge from over 20 years of work on placement criteria.

Question 1: How does the ASAM PPC help with managed care?

Answer 1: The Criteria are useful for both care providers and care managers in a MCO. The 6 ASAM assessment dimensions organize a client’s biopsychosocial data in a common language; this optimizes communication between a clinician and utilization reviewer, or between provider and payer. The MDA helps identify treatment needs, strengths and priorities. The ASAM Criteria provide guidelines as to who is best admitted to a level of care, who stays, and who is discharged or transferred.

Question 2: But will the ASAM PPC help me get our 28 day residential program authorized, because now managed care only gives us a week at most, if that?

Answer 2: The ASAM PPC supports care which is clinically-driven and client-driven, rather than diagnosis-driven or program-driven. What does this mean? A client should only stay at any one level of care depending on how mild to severe his/her illness is, what level he/she is functioning at, plus how fast and how well he/she responds to treatment. There are no recommended fixed lengths of stay in the ASAM PPC. The criteria emphasizes giving people all the care they need in a broad, seamless continuum of care – not more, not less. “More” care than needed wastes resources. It ties up space/slots for others who really need treatment in a specific level of care, therefore access to the best care is blocked because the slot is now occupied by another. “Less” care than needed may result in a worsening illness. A client can then end up needing more acute services (like detoxification, medical or psychiatric care.)

Question 3: When do you do treatment plan reviews?

Answer 3: The ASAM PPC does not prescribe specific time intervals for reviews. What influences treatment plan reviews is how volatile or stable a client is. If your client is severely ill and unstable, she will need a more intensive level of care; that is the only safe place that can meet her needs. In high-intensity levels, reviews are done more frequently; in low-intensity levels they can safely be spaced out more.

Before I give some general recommendations, here are the qualifiers:

• ASAM PPC does not dictate the time a review should take place.
• Also different clinicians might have varying opinions on the timing of reviews.

So—–

• For OP services –> About every six sessions is a general principle.
• Say your client is in Level 1, and they come once a week. If they are stable, and there are no rapid changes in functioning, you would review the treatment plan about every six weeks. However if your client needs Intensive Outpatient three days a week, then a treatment review would be every two weeks.
• Clients in a Level III.5, Clinically Managed High Intensity Residential service (such as a therapeutic community) –> reviews may be done weekly.
• If a client is severe enough to need 24 hour nursing care with physician availability –> clearly you review much more frequently. In fact, with 24 hour nursing, the client will be reviewed every shift (day, evening & night).
• In Detox levels –> reviews range from several times a day to once a day. Clients in detox fluctuate more quickly. It’s likely that detox cases will be looked at each day to see if someone can move to a less intensive level of detox. Conversely if things deteriorate, someone might have to move to a more intensive level of care. For example, in a Level IV-D detox (Medically Managed Intensive Detoxification), each change of shift again will likely conduct a review.

A review of the ASAM MDA does not have to be tedious- a long form re-asking every question of the initial assessment. The continual question to ask is: What has changed (or not) in any of the dimensions?

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 purchase the ASAM PPC: American Society of Addiction Medicine – 4601 Nth. Park Ave., Arcade Suite 101, Chevy Chase, MD 20815. (301) 656-3920; Fax: (301) 656-3815; To order ASAM PPC-2R online: www.asam.org or call: (800) 844- 8948.

For more tidbits on the ASAM Criteria, refer to previous editions:
April 2003: in Savvy & Skills
June 2003: in Savvy & Skills
September 2003: in Stump the Shrink
November 2003: in Skills
January 2004: in Stump the Shrink
March 2004: in Savvy & Skills
October 2004: in Savvy
December 2005: in Savvy, Skills & Stump the Shrink
October-November 2006: in Savvy & Skills
March 2007: in Savvy & Skills

SKILLS

Glossary of Abbreviations:

LOCUS = Level of Care Utilization System
AACP = American Association of Community Psychiatrists
ASAM = The American Society of Addiction Medicine
ASAM PPC-2R = ASAM’s Patient Placement Criteria
ADL = Activities of Daily Living

Many systems all over the country are integrating services for people with both mental health and substance use problems. So which level of care placement criteria do you use in such cases? Some mental health systems have adopted the LOCUS, and some addiction treatment systems use the ASAM PPC 2-R.

Let me provide a quick history here:

* 1991 ASAM PPC was first published
* 1996 ASAM PPC was first revised
* 1998 The LOCUS was introduced by the Am Assoc of Community Psychiatrists
* 2001 ASAM PPC Revised 2nd Edition was published, containing criteria for co-occurring disorders.

The LOCUS evaluation parameters were influenced by the ASAM multidimensional assessment and other placement tools. But AACP designed the LOCUS system more specifically for mental health. The ASAM Second Revised Edition was published in 2001 containing criteria for co- occurring disorders. The authors specifically broadened and updated the assessment dimensions to apply to both mental health and addiction. Both sets of criteria focus on a multidimensional assessment of the client. Both assess severity and level of function in a variety of important clinical and psychosocial areas.

Tip 1

• Whatever assessment and criteria you use, focus more broadly on a holistic perspective rather than just a focus on traditional “medical necessity”.

Here are the LOCUS evaluation parameters:

I. Risk of Harm
II. Functional Status
III. Medical, Addictive, and Psychiatric Co-Morbidity
IV. Recovery Environment – Level of Stress and Level of Support
V. Treatment and Recovery History
VI. Engagement

Here are the ASAM PPC assessment dimensions:

1. Acute Intoxication and/or Withdrawal Potential
2. Biomedical Conditions and Complications
3. Emotional/Behavioral/Cognitive Conditions and Complications
4. Readiness to Change
5. Relapse/Continued Use/Continued Problem Potential
6. Recovery Environment

In the 2001 ASAM PPC-2R, sub-domains were added under Dimension 3 to address more comprehensively emotional, behavioral or cognitive issues:

(a) Dangerousness/Lethality – suicidal, homicidal, violent
(b) Interference with Addiction Recovery Efforts – to what extent does the mental health problem interfere with addiction recovery?
(c) Social Functioning – interpersonal skills
(d) Ability for Self Care – Activities of Daily Living (ADL); personal hygiene and self care skills
(e) Course of Illness – what can be expected is influenced by past and present behavior e.g., a person who has been suicidal before, but never acted on impulses may be at less risk if currently suicidal compared with another person who has always been hospitalized with severe suicidal behavior

In both the LOCUS and ASAM PPC, the assessment areas cover much more than just medical, psychiatric and intoxication and withdrawal dimensions. The original LOCUS parameters were influenced by ASAM dimensions. In ASAM PPC-2R, the subdomains under Dimension 3 were influenced by some of the LOCUS parameters.

Tip 2

• Compare and contrast your favored biopsychosocial assessment tool with other tools or instruments to see if it covers all clinically relevant areas.

As Chief Editor of ASAM PPC-2R, I am biased towards the use of the ASAM PPC and multidimensional assessment for reasons that include, but not limited to:

–· The ASAM multidimensional assessment (MDA) assists in assessing both addiction and mental health
–· The LOCUS is more focused just on mental health
–· ASAM PPC has specific criteria for a broad continuum of care e.g., there are five levels of detox in the adult criteria with specific criteria classified by drug class- such as alcohol, sedative-hypnotics, stimulants etc.
–. The ASAM MDA is instructive to healthcare professionals in primary care, not just behavioral health. As such it can provide a common language to assess whoever comes to whatever “door” and facilitates “every door is the right door”.
–· Over $7 million has been invested in research on the ASAM PPC. The LOCUS has had a fraction of research investment.

Other comparisons:
–· The LOCUS severity ratings on a scale of 1 (Minimal, low) to 5 (Extreme, severe) and scoring formulas that match to level of care are attractive to some clinicians
–· ASAM PPC’s DSM-like criteria require various combinations of dimensional criteria e.g., Must meet specifications in all six ASAM dimensions to be eligible for Level I, Outpatient Services; or Must meet specifications in one of Dimensions 1, 2 or 3 to be eligible for Level IV, Medical Managed Intensive Inpatient Treatment
–· ASAM PPC has many more levels of care than are described in the LOCUS. Some find the comprehensive continuum of care more complicated than the narrower continuum of care in the LOCUS
–· The LOCUS can be accessed for free, whereas the ASAM PPC is sold like DSM-IV.

CORRELATION BETWEEN ASAM PPC-2R AND LOCUS
ASAM Dimensions LOCUS Evaluation Parameters
1. Acute Intoxication and/ or Withdrawal Potential I. Risk of Harm
III. Medical, Addictive Co-Morbidity
2. Biomedical Conditions and Complications III. Medical, Addictive Co-Morbidity

3. Emotional/Behavioral/Cognitive Conditions and Complications
Subdomains:
Social Functioning
Course of Illness

I. Risk of Harm
III. Psychiatric Co-Morbidity
II. Functional Status
V. Treatment and Recovery History
4. Readiness to Change

VI. Engagement
5. Relapse/Continued Use/Continued Problem Potential

V. Treatment and Recovery History
6. Recovery Environment

IV A. Level of Stress
IV B. Level of Support

For the last several years Ken Minkoff, M.D. has hosted a symposium at the American Psychiatric Association’s Institute on Psychiatric Services each Fall. Wes Sowers, M.D. explains the LOCUS and I present the ASAM PPC. The audience then works on a case using both sets of criteria. On Saturday, October 4, 2008 we will do it again in Chicago.

Reference:
.. To obtain LOCUS: http://www.wpic.pitt.edu/aacp/finds/locus.html
.. To obtain ASAM PPC: Order online at www.asam.org and click on Patient Placement Criteria

SOUL

I heard an advertisement for the New York Times which captured how the information age has blossomed into so many facets.

The ad read: “The NY Times – all the news that’s fit to:
* Print
* Stream
* Blog
* Archive
* Broadcast
* Critique
* Attach
* Forward and
* Click “

Who would have thought that I could send out a newsletter every month to over 5,000 people without that costing an arm and a leg? I can still remember when we would duplicate a newsletter using those mimeograph (Roneo) purple ink machines that produced a fuzzy printed page with its distinct smell. But then again that was last century.

I wouldn’t want to go back to those times and methods of communication. It is so much easier to Google some information than leafing through the encyclopedia, or even the Yellow Pages. So I am not nostalgically focused on “the old days were better”. But finding the balance between people communication and electronic communication is a challenge our parents never had to face.

There is a funny cartoon that depicts a couple in bed. One partner is clearly indicating that tonight is not the night for any hanky panky: “Not tonight, Dear. Didn’t you get my e-mail?”

Soon, we plan on making it easier for you to access information from TIPS and TOPICS. I also want to expand communication between readers of TIPS and TOPICS and those of you who have attended my workshops. It won’t be the NY Times, but the times they are a-changing.

SHAMELESS SELLING

Here are some proprietary resources to help implement the ASAM Patient Placement Criteria:

For Assessment Instruments

1. Level of Care Index (LOCI-2R): Checklist tool listing ASAM PPC-2R Criteria to aid in decision-making and documentation of placement.

2. Dimensional Assessment for Patient Placement Engagement and Recovery (DAPPER): Severity ratings within each of the six ASAM PPC-2R dimensions.

To order: The Change Companies at 888-889-8866, www.changecompanies.net

For clinical questions or statistical information about the instruments, contact Norman Hoffmann, Ph.D. at 828-454-9960 in Waynesville, North Carolina; or by e- mail at evinceassessment@aol.com

For Home Study and Online Courses

1. “ASAM 101: Basics on Understanding and Using ASAM Patient Placement Criteria, Revised Second Edition (ASAM PPC-2R)”

A 3-hour course that will introduce students to key concepts and issues of the ASAM Patient Placement Criteria. Clinicians involved in planning and managing care often lack a common language and systematic assessment and treatment approach that allows for effective, individualized services. The Patient Placement Criteria of the American Society of Addiction Medicine (ASAM) first published in 1991, provided common language to help the field develop a broader continuum of care. They were updated and the second edition (ASAM PPC-2) was published in April 1996. A revised second edition was published in April 2001.

The Distance Learning Center for Addiction Studies (DLCAS) is an internet based educational service that provides comprehensive training and information in the field of addiction studies. It is a joint presentation of the Betty Ford Center and the Distance Learning Center, LLC. Toll-free phone: 866 471-1742. Website: Distance Learning Center
Course Name: ASAM 101 – Basics on Understanding and Using ASAM Patient Placement Criteria, Revised Second Edition- by David Mee-Lee, M.D.

2. Hazelden’s Clinical Innovators Series “Applying ASAM Placement Criteria” DVD and 104 page Manual with more detail based on the DVD with Continuing Education test (10 CE hrs), 75 minute DVD David Mee-Lee (DVD) and Kathyleen M. Tomlin (DVD manual) You can order from www.Hazelden.org

AS a RESULT of your FEEDBACK

Readers last month gave wonderful suggestions about upgrading my website. A “biggie” was to make Tips and Topics searchable. I hear you. I find it frustrating when I can’t search a certain topic, find resources, or see what’s already written about a clinical dilemma or a system’s issue.
We are working on this and other suggestions. Within the next month or two, we hope to adopt a platform to make using TIPS and TOPICS and other articles of mine much more user-friendly.

So stay tuned—–

Until Next Time

See you in late April.
David