TIPS & TOPICS
Volume 6, No.7
November 2008

In this issue
— SAVVY
— SKILLS
— SOUL
— SUCCESS STORIES
— Until Next Time

SAVVY

I get a lot of questions about the American Society of Addiction Medicine’s Patient Placement Criteria for the Treatment of Substance-Related Disorders (ASAM PPC). That is to be expected as I have chaired the development of all three editions since first published in 1991. I received a straightforward question this month that could have warranted a brief response and a simple yes or no answer. But the question actually raises several attitudinal, clinical and systems issues that are not obvious with just an initial surface glance.

TIP:

• Use Placement Criteria to Match Services to Needs, not Plug People into Programs

Question:

Hello Dr Mee-Lee:

I thought you would be able to clarify a question I have regarding the genesis of the ASAM requirement for Intensive Outpatient Treatment, that it meets a minimum of 9 hours per week. For many years it was six hours per week.

I have been in the field for 27 years and have never been able to explain (to myself and others) why 9 hours is somehow more therapeutic than 6. On an Outpatient basis – 6 hours allowed us to have patients utilize self-help more willingly. Ever since it was changed to 9 hours per week, it is a much harder to sell them on attending self-help meetings.

I would be interested in your opinion on this, and also wonder if the requirement has ever been the subject of possible revision – back to 6 hours?

Thank you

Lauren Carter, Clinical Director
Talbot County Addictions Program
Easton, Maryland

My Response:

Lauren:
Thanks for your question. When you say Intensive Outpatient (IOP) has been six hours per week for many years, that may be true in your region. As regards the ASAM Patient Placement Criteria (PPC), ever since the first edition in 1991, Level II.1 (IOP) has been defined as nine hours per week. In the revision of the Adolescent Criteria in the 2001, Second Edition Revised (ASAM PPC-2R), Level II.1 for adolescents was defined by the Adolescent Workgroup as six hours of service per week. The rationale was that adolescents could not sit for more than a couple of hours per day, three days a week in a structured program – hence six hours a week.

When 9 hours/week was chosen in the late 1980’s as we were preparing the first edition of the ASAM criteria, it was the consensus that most IOP programs were three days per week, three hours a day. That may not have been the case where you live and work, and there is nothing magical about nine hours. We simply went with what the prevailing hours were in most parts of the country.

In fact, the way I teach the ASAM Criteria is not to focus on putting people into programs, but to focus on what are the services needed. To decide on the level of care needed, consider these 3 factors:

1. What dose and intensity of service(s) is needed?
2. What is the least intensive level that can provide those services?
3. Can the services be safely delivered in that level?

To illustrate-
If a person only needs 6 hours of service per week and can readily embrace AA or other recovery groups that is what they should get. In ASAM PPC terms, such a person would be receiving services in Level I, Outpatient treatment. If the client is an adolescent, they would be receiving services to meet their needs in a Level II.1 Intensive Outpatient service, defined as six hours per week in the ASAM PPC.

So you are right- 9 hours is not intrinsically more therapeutic than 6 hours, just as IOP is not inherently more therapeutic than Level I Outpatient services. The point is to give clients the services and hours they need after you assess their particular situation. Our clients deserve services which match their needs, not more as that wastes resources, not less as they deteriorate and then use more services anyway.
This is the primary intent of the ASAM PPC- not to automatically place people into programs, but to match the exact services to their needs.

David

Lauren’s Response:

Thanks for your quick response. I guess time flies, as I had been involved in an Adult IOP in the late 80’s – 2 hours per day; 3 days per week – and it was very workable – for patients and staff. ….then I went and did something else – and when I was re-involved with Adult IOP in 2000 – it was up to 9 hours.

At this point, the 9 hours of ASAM Level II.1 is carved in stone because it is in the Code of Maryland, and therefore, we must deliver 9 hours of services per week in order to be designated an IOP, and Certified as an IOP in Maryland. . As you know I am sure – bureaucracies take things quite literally – so the 9 hours would need to be 9 hours every week, unless we discharged the person from Level II.1 and then readmitted them to a Level I service. There is no flexibility week to week as the State reviewer would ask why the client didn’t show he had changed to a Level I service when he was enrolled in a Level II.1?

A better question might be:
Now that the Substance Abuse and Mental Health Services Administration (SAMHSA) has identified Substance Dependence as a Chronic Illness, why do funders persist in counting patients treatment visits in 30-day increments? Our patients come in and out over the years – but administratively we must count them as admitted and discharged – if we don’t see them in 30 days. Even 45 or 60 days would be more realistic for our patients who do not always show up when they say they will. It may be days or weeks later.

My Additional Response:

Lauren:

You are right about the “better question.” Quality and contract compliance audits, funding and bureaucracies have not caught up with treating addiction as a potentially chronic illness; this needs a continuum of care, not admission and discharge from one program to the next. Such regulations are rigid, and don’t allow for easy flexibility and movement of a client from one intensity setting to the next. But the “blame” doesn’t lie just with bureaucracies.

Treatment providers are convinced their program is best designed as a fixed length-of-stay residential or intensive OP program of 28 days, or 24 IOP sessions over eight weeks; or a Therapeutic Community program where the client must commit to 4-6 months of treatment as a condition for admission etc.

It is hard to know which is the chicken or the egg. But providers, payers, auditors and regulators, still today, set up criteria, procedures and oversight as if addiction is an illness which can be treated in neat increments and blocks of programming. The ASAM PPC under “Length of Service” does not indicate any fixed length of stay for each level of care. How long someone stays depends on how severe the illness is, his response to treatment, and the progress made (or not).

David

For many addiction treatment services, we still live in a “program-driven” and “diagnosis-driven” world.

If you have the diagnosis of Substance Dependence, come on into our 28 day residential program; or our six to nine month TC (Therapeutic Community); or our eight week Intensive Outpatient Program!

Managed care manages a benefit that has fixed increments of time – 20 outpatient sessions; or 30 days annual benefit of residential care.

Regulators and payers develop contracts and compliance rules that address for example, only Medically Monitored Inpatient Detoxification as if all clients need that intensity of service. The Adult ASAM Criteria describes criteria for five levels of detoxification.

Instead, if we used a continuum of withdrawal management services, our clients could receive 2 weeks of monitored care in place of what we now spend on 4-5 days in more intensive levels of detoxification services.

We know about huge state and federal budget deficits and shrinking treatment dollars. Now more than ever, it is time to move away from program and diagnosis-driven services to clinical and outcome-driven services.

References and Resources:

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.

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

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

SKILLS

If you work in an addiction treatment service, take this little test. It’s a cross between Dave Letterman’s Top Ten List and Jeff Foxworthy’s “You know you’re a redneck when…..”.

TIP

• Top Ten Ways You Know You’re a Program-Driven Service When……

1. You know the client’s anticipated discharge date upon admission e.g., July 1 + 28 = July 29.

–> When a client is discharged should depend on their treatment progress. When the services needed can be safely delivered in a different level of care, that is when and where they should be discharged to.

2. You read a treatment plan and it sounds much the same as the next chart.

–> In other words, every client is receiving basically the same program where the treatment plan is focused more on completing tasks of the program rather than individualized strategies matched to the client’s unique assessed needs e.g., Client will complete their Step 1 workbook and Relapse Prevention Plan and present to group.

3. There are 5 to 9 problems each with three to five objectives, interventions or strategies.

–> Some treatment plans I have reviewed have so many problems and objectives that no client could remember to do all those strategies; and you wouldn’t want to track, monitor and document on all those problems. This is an “occupational hazard” of the electronic treatment planning process where it is easy to point and click from a menu of pre-programmed problems, goals, objectives and interventions.

4. The treatment plan is still being developed three to five days after admission.

–> How do you know what level of care to place a person into unless you have done sufficient assessment and initial treatment planning? The treatment plan is based on an assessment of the client’s need for services, the dose and intensity of which can only safely be delivered in this level of care.

5. You say things like “the full program” or “must complete the program.”

–> What is the full program for major depression or diabetes or hypertension or bipolar disorder? When do you complete the program for asthma or schizophrenic disorder or anxiety disorder?

6. The “P = Plan” part of the “Data Assessment and Plan (DAP)” or “Subjective Objective Assessment and Plan (SOAP)” in the progress note says: “Continue present course of treatment” or “Continue treatment regimen” or “Continue treatment objectives”.

–> “Continue treatment of what in particular for this client at this point in time with what progress they have or have not made?” “Continue what treatment regimen for what problems for this client at this point in their treatment?” “Continue with what treatment objectives to address what goal for what unique problems or needs for this client at this time?”

7. The treatment plan is preprinted.

–> This is a good way to save time – just pre-print the treatment plan for all clients in the program. But how would you indicate the difference between this client’s “unsupportive recovery environment” and the next person’s equally “unsupportive recovery environment”? How would a pre-printed plan indicate this particular client’s “lack of understanding of their addiction” (“I just want to cut back”) versus another client’s “lack of understanding of their addiction” (“I want to stop drinking, but keep smoking marijuana”)?

8. You see the same numbers in more than one chart e.g. 28 days, 24 sessions, or 3 months.

–> The focus is on the client’s completing the pre-determined program length of stay, rather than on the changes in attitudes, knowledge and function. That is why clients ask “How long do I have to be here?” and you can have an answer that includes numbers. That is why clients can be more focused on “doing time” than on “doing treatment”.

9. Assessment documentation indicates the person is mandated for care, and is not sure they have a drug problem (Contemplation and ambivalent), yet the treatment plan is the same as for the client who is sure they have a problem and wants recovery (Action for change)

–> Programs treat all clients as if they are wanting serenity and sobriety one day at a time, and need “recovery, relapse prevention” services. What they actually need are motivational enhancement strategies and “discovery, drop-out prevention” services. “Discovery” treatment plans are quite different from “recovery” plans.

10. There are preprinted progress notes.

–> I once read a chart with this pre-printed family session progress note inside:
“Family attended family group and learned about the effects of addiction on the family, about self-help and mutual help groups like Alanon and Alateen.” After the pre-printed progress note was a handwritten progress note that documented: “Family did not attend family group.” So here was a pre-printed family progress note for a family that didn’t even attend the family group!

• So are you a program-driven service or a clinical, outcomes-driven service?
• How many of the Top Ten fit your program?
• What can you do about it and when?

SOUL

In the USA, it is easy for us to forget about the rest of the world, unless we have military personnel or loved ones in harm’s way overseas. Surprisingly when it came to the long race for the Presidency, this was one marathon the rest of the world seemed to be as interested in as us all of us here in the USA. While 53% of US citizens voted for Barack Obama, it seemed like 93% of interested overseas observers ‘voted’ for the President-Elect.

Friends, relatives and acquaintances from Australia, the UK, Lebanon, Chile, Brazil and Germany all seemed as invested in the outcome of the Presidential election as we were. And they all overwhelmingly were cheering for Obama. So I got to thinking why Obama won.

Here are three ideas which won’t make me a political consultant any time soon, but may be true. Both candidates tried to achieve these goals. Barack Obama did it better and won.

• Attracting people to the hope of real change.

This spoke to the public’s demoralization about overwhelming national and international problems, with no apparent easy way out. Both candidates emphasized change and that they could deliver on that.

• Empathizing with the needs and aspirations of a broad and expanding population of citizens from all walks, cultures and values of life.

Both presidential and vice presidential candidates represented backgrounds diverse by birth and upbringing in ethnically and culturally different worlds; unique by virtue of geography; ground-breaking by virtue of gender; compelling by virtue of rare life experiences in a POW camp followed by years of public service.

• Having the combination of “smarts”, passion and organization.

Both candidates had to be tenacious and committed to achieving the best outcome for themselves and the people of the United States of America. Both candidates had to be intelligent and disciplined to keep their eye on the prize in spite of unforeseen circumstances and obstacles as well as triumphs. Yet the process demanded they shift tactics and strategies when something was not working.

It may occur to you that these three goals bear great similarity to what we strive for in helping people change:

–> Hope for recovery
–> Empathy and an alliance with what is important to clients
–> Belief in what you do, but with flexibility to shift methods and models if not achieving good outcomes.

Enough of politics. But actually, what the politicians do for a season, in behavioral health we do everyday- attracting and inspiring people to change.

SUCCESS STORIES

Thanksgiving is obviously a time to give thanks! Having worked in full-time training and consulting now for over 12 years, I have been involved in learning opportunities for thousands of counselors and other clinicians. It is always gratifying to receive thanks for a satisfying learning experience from participants at a workshop.

Here are two recent messages from addiction counselors who attended workshops, where we were talking about engaging “resistant” clients in collaborative treatment planning. What I’d like you to notice is how employing motivational strategies that empower the client and meets them at their stage of change is good not only for the client, but equally as beneficial for the health, well-being and stress level of the counselor.

(I have edited the counselors’ comments as I did not clear their permission in time to get this out to you. But if you would like to talk to them, I’m sure they would be happy to share their experience.)

Story # 1

“Dr. Mee-Lee,
Good Morning. I am an addiction counselor at a residential program and recently participated in one of your workshops on treatment planning. I just wanted to pass on to you that I was really inspired by your presentation and, as a result, have had a discussion with my supervisor about applying your practices in my work with Young Adult Male patients. I would like to keep you informed of my progress/struggles and, perhaps, get feedback from you down the road, if you would be willing to do so. I know you are probably very busy, as most of us in this field seem to be. Any guidance you can offer would be greatly appreciated. I look forward to future communication with you, if your time permits. Thanks again for the information and the inspiration.”
Dan
Addiction Counselor

Two weeks later

“Just wanted to pass on two things: 1) The patients that I am using your treatment planning model with are responding in a very positive way! One of them, who has been in treatment several times, said, “Wow! You are really good at this! I’ve never had it done this way before.” My rapport with this patient has been excellent.
2) My own level of stress has been reduced and I am not so weary of doing “paperwork” as I am now viewing the treatment plan and other records as “living documents” instead of “tedious, irrelevant tasks that just need to get done.”

I cannot thank you enough.

One note, these charts have not been reviewed by my supervisor yet. So, I do not know how this will be viewed from an organizational standpoint, but I can safely say that, from my perspective and the perspective of the patients I am working with, this has improved the quality of my work. Thanks again.

Will be in touch.”

Dan

Story # 2

“Hi Dr. Mee-Lee,
I attended your training earlier this year with other adolescent addiction counselors, and I just wanted to let you know, it has been a life altering experience. Now, I no longer have to worry about no-shows and having any client who is resistant to change.

So as a bonus, my blood pressure must have gone down quite a bit ever since. 🙂

Thank you again.”

Alice
Adolescent Addiction Counselor

Until Next Time

Thanks for joining me this month. December’s TNT will be out earlier than usual before the holidays.

David