TIPS & TOPICS
David Mee-Lee, M.D.

Volume 8, No. 11
March 2011

In this issue
— SAVVY – The METHODS method for discharge planning
— SKILLS – RCA ceremonies – The new treatment completion Graduation?
— SOUL – Always the right answer

— STUMP THE SHRINK – Medical necessity, ASAM PPC and what levels of care?
— Until Next Time

Welcome and thanks for joining us for the March edition of TIPS and TOPICS (TNT).

SAVVY

Addiction treatment, at least in the USA, has seen residential treatment as the gold standard, with outpatient care as “step down” services.  Historically, this is the reason our field has used language like “primary care” and “aftercare”.  This perspective elevates residential treatment to be the first and best place for a good foundation in recovery.   Clients “graduate”, “complete treatment” and then “step down” to “aftercare”.  The aftercare is usually far less intensive and a huge decrease in support after weeks (and sometimes months) in a protected environment.

I have witnessed the power of peer support, group education and treatment in supportive residential settings free from the temptations and stresses of the home environment. The success of such settings is not to be diminished – it has literally saved the lives of hundreds of thousands, if not millions.  However there are sometimes negative, unintended consequences of our models and language.

Here are some:

• Clients “graduate” and are showered with positive feedback on their amazing progress since that first admission day when they showed up angry, feisty and resistant.   There is much truth about that to be told, acknowledged and recognized.

• Having now “graduated”, how is the graduate affected when within a month or two he or she relapses and feels a failure after having come so far?  Does one “graduate” from college, only to have to return a few months later for remedial classes?

• The general public still sees drug “rehab” as going off to some place to “complete treatment” usually associated with a predetermined completion date of x number of days, weeks or months.  Actually many addiction treatment professionals have the same view as evidenced by a documented “anticipated discharge date” of the admission date plus x number of days, weeks or months.

• We emphasize taking it “one day at a time.”  How do we focus on progress and functional outcomes when we set up treatment designed around a predetermined time to “complete the program”?  How do we teach about the chronic nature of addiction illness when our language contradicts?  We never speak of “completing” the schizophrenic or bipolar disorder program; or “graduating” from the diabetes, asthma or hypertension program?

For some clients, the unintended negative consequence is that they focus on “doing their time” in the program rather than “doing treatment”. We want their energy to be on taking responsibility to track their improvement in function, not their compliance with a predetermined length of stay.

So how to rethink and reframe the benefits of “graduation” and “completing the program” to eliminate as much as possible the unintended negative consequences?

TIP 1

Rename the Graduation or Treatment Completion Ceremony

Perhaps you could call it the RCA – the Reflection, Celebration and Anticipation ceremony or event.

• Reflection on what the client and family have learned, seen, gotten in touch with, changed since entering treatment.  It can also be a reflection not just of positive things, but in all honesty (this is an honest program), reflection about things still not resolved or still not accepted.  This is to model that this is about Progress not Perfection; about beginnings in recovery, not an end or completion of treatment; about reflecting on what might not yet be working, not just putting on a brave front to say everything is rosy.

• Celebration of any accomplishments in this piece of recovery work done at this time in this program. Celebrating what has worked and what the program community has given the person; a time to be thankful for the challenging work the person has done so far in their recovery that is just beginning, not ending. Celebrating the hope that can be there for the client and family when there was only despair and hopelessness.

• Anticipation of what lies ahead in their recovery – plans on how to continue gains that have been made; but also how to keep working on doubts or ambivalences or challenges that still may be there or are even likely to be there.
   Anticipation of what needs to be done to keep progressing and if not “perfect” and there is a slip or relapse, what is plan B to get back on track – not with shame or a sense of failure, but with determination and commitment to keep moving forward – a day at a time with serenity.

What do you think of an RCA ceremony?

SOUL

You probably have heard someone say: “There are no silly or wrong questions” meaning that you are encouraged to speak up and learn by asking questions.  But a few months ago I heard from a retired teacher a twist on that:  There are no silly or wrong answers.

Whoa, wait a second…that’s not right!  Of course there are silly and wrong answers.
Someone asks: “Does gravity work the same in the air, as on the ground, if you jump from a high-flying plane?”

You answer: “It’s OK to jump from a plane because you just float gently to the ground.”
You would say that was a silly and wrong answer as well as being life-threatening.

Back to the retired teacher. We were conversing and he said he had once taught religion class.
“How many books are in the Old Testament of the Bible?” he asked.

I guessed: “32.”  “That’s the right answer to a different question“, he replied and then had me count how many letters in “old” – 3; and how many letters in “testament” – 9.  Put them together and you have 39 books in the Old Testament!

“How many books in the New Testament?” was the next question.  I quickly counted letters, but that didn’t work.  It came out to the same 39 and I knew there were a fewer number of books.

“25”, I guessed.  “That’s the right answer to a different question“, he again replied and then had me count how many letters in “new” – 3; and how many letters in “testament” – 9.  But because this is the “new” testament, people were smarter and could multiply, he joked.  So 3 X 9 = 27 – 27 books in the New Testament!

So for all you Christians playing Christian-trivia, these are a couple of questions for your next game.

Now what about that gravity and plane question?  There are no silly or wrong answers.  If the question was: “Does gravity work the same in the air, as on the ground, if you jump from a high-flying plane with a functional parachute?”

Now the original “wrong” answer (“It’s OK to jump from a plane because you just float gently to the ground.”) was the RIGHT answer to this DIFFERENT question.

The answer is always right, but to what question?

STUMP THE SHRINK

With huge budget deficits and shrinking resources, more and more states are managing care and instituting tighter utilization review guidelines.  About 25 States use the American Society of Addiction Medicine’s Patient Placement Criteria, Second Edition Revised (ASAM PPC-2R, 2001) to some degree in managing their public-funded addiction services.  Here is some dialogue back and forth between the Medical Director of a large single state addiction agency and me (my responses are in italics):

Hello David:

I think I have written to you about the Medicaid efforts we are doing to institute utilization management oversight of alcohol and other drug services in our state.  I’m involved with this and am getting a lot of questions regarding the relationship between the American Society of Addiction Medicine’s Patient Placement Criteria (ASAM PPC) and other Utilization Review medical necessity criteria that may be implemented.  I wonder if you would verify that my responses seem accurate. Here’s what I understand:

1. The ASAM PPC are clinical guidelines and not prescriptive for individual patients.

The PPC are yes, clinical guidelines to be used to help individualize treatment and placement of individual patients.  So I am not sure what you mean by “prescriptive for individual patients”. Clinical judgment has to be used in the application of any criteria, but the hope of the PPC is that it will help provide efficient and effective care for individuals. It is true that the PPC don’t just add up numbers and place a person in a level of care using math algorithms in a prescriptive way.  But the PPC should allow for some level of standardization on how patients are assessed; provide a common language to improve communication between care managers and care providers; and increase access, efficiency and effectiveness of care.

2. There is no specific formula for how many and which criteria are necessary for placement in any particular Level of Care (LOC) but it is an interplay of a patient’s biopsychosocial clinical status in relation to the criteria.

No, actually, there are Dimensional Admission Criteria that are organized by clinical descriptions using the six assessment dimensions.  There are specifications like in DSM-IV that say for example, that appropriate admission to Level IV, Medically Managed Intensive Inpatient Treatment requires that the patient meet specifications in one of Dimensions 1, 2 or 3; and that problems only in Dimensions 4, 5 and 6 do not qualify a person for Level IV treatment.  There are different specifications for each level of care.  See ASAM PPC-2R (2001) for specifications in each level of care.

3. As stated in the introduction of the PPC the placement criteria need to be implemented in the real world environment of various payor requirements.

Yes, they must be used in the real world, but not sure what you mean and the implications of “in the real world environment of various payor requirements.” If you mean that the PPC are over-ridden by a payor’s own utilization management (UM) criteria, I wouldn’t agree with that if the payor is meant to be using the

PPC.  If you mean that payors often have benefit limitations, then yes, the PPC has to used in that context, but the PPC don’t have anything to say about what to do if a benefit runs out.  They are clinical guidelines designed to advance efficient, but safe quality care.

4. I believe that the term “medical necessity” is inclusive of what people may want to call “clinical  necessity” or in fact they are interchangable terms.

In the Introduction of the PPC, we address Clinical Necessity versus Medical Necessity. Yes, the terms are interchangeable if Medical Necessity is seen in a multidimensional, holistic, biopsychosocial way.  But if Medical Necessity is used to only mean severity of Dimensions 1, 2 and 3 i.e. traditional acute care (severe withdrawal; severe physical health problems and severe mental health problems respectively) then no, the terms are not interchangeable.

5. The ASAM PPC is not synonymous with medical necessity.  (If not, what would you say the relationship is between the ASAM PPC and medical necessity criteria?)

I think I answered that in #4.  But you should also read the Introduction of the PPC where we address clinical versus medical necessity and the importance for effective treatment to take into account Dimensions 4, 5 and 6 just as importantly as Dimensions 1, 2 and 3 which are the traditional medical necessity dimensions. Without a holistic “clinical necessity”, the outcomes are poor and it perpetuates revolving door through costly and ineffective acute care services.

Thank you very much for your thoughtful responses.

Of course, consistent with medical necessity, real life constraints and our interest in developing a recovery oriented system of care, our state’s addiction treatment providers need to shorten lengths of stay in the highest intensity services and admit patients to these services with the highest severity of illness.  We want people to get needed treatment but it will need to be in settings that can be safe, are the least restrictive and allow for patient choice.  The “least restrictive setting” language is not something I see in ASAM PPC, which actually seems to promote the default level of care as being the highest of those indicated.

As regards “least restrictive” language in PPC-2R, we don’t use the word “restrictive” because we are trying to be neutral about matching patients to the appropriate level of care. “Restrictive” belongs to an era when we thought of addiction and mental health treatment as restricting people’s freedom to be in the community etc.  We don’t use, I don’t think, “restrictive” to define any level of care in healthcare in general.  For example, it’s not the Restrictive Care Unit, it’s the Intensive Care Unit to connote that the person needs intensive services in a unit that can safely deliver that care.

If you note in ASAM PPC-2R (2001) on page 15, second paragraph, second sentence: the emphasis is on assessing the strategies in the treatment plan and that this determines the most effective and efficient level of service that can safely provide such services.

Also at the bottom of page 15, last line and top of page 16, “the preferred level of care is the least intensive level that meets treatment objectives, while providing safety and security for the patient”

Why it appears that the default is to the most intensive level of care indicated in the six assessment dimensions has to do with the safety issue.  If a patient is most severe in Dimension 1, then that will preempt any other dimension for safety reasons.  But what level of care of the five detox levels the patient ends up in will depend on the least intensive detox level that can safely meet that highest severity dimension if you get my drift.  The placement level could be Level I-D, Ambulatory Detox without extended onsite monitoring even though Dimension 1 may be the most severe dimension that drives the placement decision.  Similarly, if a patient is most severe in Dimension 5 of all the six dimensions, that relapse potential will drive the placement decision.  But the least intensive but safe level of care to take care of that Dimension 5 issue could be Level II.5, Partial Hospital or even Level II.1 Intensive OP, not Level III.5,which many clinicians often turn to as a default placement level.

Thus clinicians often mix the concept of most severe dimension with the placement of most intensive level of care in the continuum.  That is not necessarily the sequence.  It is what happens if you don’t have a

continuum of care and the only choice for a severe dimension is the most intensive level of care in that dimension’s service level.  For example, if you only have Level IV-D or Level I-D and not five levels of detox as in PPC-2R for Dimension 1, Acute Intoxication and/or Withdrawal Potential, then if Dimension 1 is the most severe dimension, it is going to default to Level IV-D as there are no gradations of intensity that would allow a more nuanced detoxification placement determination.

Until Next Time

See you in April for the start of the 9th year of Tips and Topics

David