Treatment Improvement Protocols (TIP) 13 |
The use of specific patient placement criteria (PPC) to determine placement of substance-using patients in treatment is a relatively new concept within a continually changing field. Increasing numbers of people with alcohol and other drug (AOD) addictions are accessing treatment through managed care organizations. These organizations attempt to place patients in the least restrictive and least expensive treatment setting that is most likely to produce positive treatment outcomes. In making decisions about the use of AOD services, each managed care organization must have a set of criteria by which to make patient placement decisions. In effect, for every managed care organization in existence, there is a separate set of PPC.
Both public and private treatment systems are increasingly developing and utilizing PPC. Treatment providers are using various sets of PPC to help move patients through their continuums of care.
No single set of existing PPC is uniformly applicable. However, the consensus panel that developed this Treatment Improvement Protocol (TIP) agreed that a comprehensive set of patient placement criteria should address the characteristics listed in Exhibit 3-1.
As a step toward achieving reasonable consensus on uniform patient placement criteria (UPPC), the panel chose to start with the criteria developed by the American Society of Addiction Medicine (ASAM). These criteria address more of the characteristics listed in Exhibit 3-1 than any other criteria. They also represent the most recent set of consensus criteria, as they arose from the National Association of Addiction Treatment Providers (NAATP) criteria and the Cleveland criteria. The panel also examined available PPC from both public and private treatment systems, aiming for recommendations that represented the best within all the criteria sets.
The panel undertook the analysis and discussion of existing patient placement criteria with the hope that others could build on what has already been accomplished by others in the public and private sectors.
Within this context, the ASAM criteria were examined at length. With the strengths and weaknesses of the ASAM PPC clearly identified, treatment systems developing and revising their own PPC may choose to incorporate the strongest elements of the ASAM criteria, adapting them as needed. It was determined that the ASAM criteria form the best existing base on which to add levels of care to develop an interim set of PPC, with the goal of eventually developing a completely revised set of criteria.
While the proliferation of private PPC prohibits discussing each set individually in this TIP, the panel offers a summary of the common characteristics. Review of these criteria sets played an important role in identifying the next steps in UPPC development. After examining the PPC currently in use, the panel identified several levels of care, services, and modalities for which additional criteria should be developed.
It is not just the wider recognition of the ASAM criteria that made them the focus of careful analysis. The ASAM criteria constitute the most comprehensive document to lay out a framework and specific descriptors for matching the patient's multidimensional clinical severity to a placement in the most appropriate level of care. They embody important concepts that promote individualized, cost-effective treatment. These concepts include the need for a broad continuum of care and for comprehensive assessment and treatment to address patients' physical, psychological, and social needs. The panel's analysis of the ASAM PPC is neither a criticism nor a defense of these criteria. Rather, the analysis is intended as instructional and of potential benefit in the development of UPPC.
| Exhibit 3-1 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, or legal services Attitude toward entering and continuing treatment Effects of environmental and social influences, such as living situation, family support, and susceptibility to abuse or neglect. |
Service Characteristics Intensity of services Intensity of environmental support Availability of medical services Variety of professional disciplines involved Availability of services specific to cultural background, age, sex, or disabilities Program elements Discharge planning Patient-to-staff ratio. |
Various critiques and some public-sector adaptations were used in the analysis of the ASAM PPC strengths and weaknesses. The critique described in this chapter represents what was learned from the analysis of the ASAM and other criteria and addresses issues related to the ongoing development of UPPC.
Three analyses of the ASAM criteria were reviewed by the consensus panel. While other authors have written critiques of the ASAM criteria, these three address most of the positive aspects and deficiencies mentioned in other reviews of ASAM's work. The analyses are:
The ASAM criteria establish four levels of care:
1. Level I: Outpatient Treatment
Nonresidential service or office visits, totaling fewer than 9 hours a week, in which directed treatment and recovery services are provided that help the patient cope with life tasks without the nonmedical use of psychoactive substances.
2. Level II: Intensive Outpatient/Partial Hospitalization
A programmatic therapeutic milieu consisting of regularly scheduled sessions for a minimum of 9 hours a week in a structured program, which provides patients with the opportunity to remain in their own environment.
3. Level III: Medically Monitored Intensive Inpatient Inpatient treatment in a planned regimen of 24-hour observation, monitoring, and treatment; utilizes a multidisciplinary staff for patients whose biomedical, emotional, and/or behavioral problems are severe enough to require inpatient services.
4. Level IV: Medically Managed Intensive Inpatient
Primary medical and nursing services and the full resources of a general hospital available on a 24-hour basis with a multidisciplinary staff to provide support services for both alcohol and other drug treatment and coexisting acute biomedical, emotional, and behavioral conditions that need to be addressed.
The purpose of the criteria is to use a comprehensive biopsychosocial assessment to make objective, clinically based patient placement decisions regarding the most appropriate level of care. These assessments and assignments to levels of care are based on six patient problem areas that are referred to as dimensions:
Dimension 1: Acute intoxication and/or withdrawal potentialThe ASAM criteria were designed to provide guidelines for placing patients with specific combinations of problems in appropriate levels of safe and cost-efficient care. It should be noted that they are not treatment/service matching criteria. Matching is based on the identification of patient needs for a wide range of services. PPC are not meant to address every individual need.
Several important aspects of the ASAM criteria that are instructional for the future development of UPPC are summarized below. Many of these points also apply to several sets of public-sector PPC.
The ASAM criteria were developed through the consensus of a range of clinicians representing counselors, social workers, psychologists, and physicians. By creating and rewriting drafts for consensus approval, ASAM produced a document that has undergone extensive field review.
However, there were several shortcomings in the consensus process for the ASAM criteria. The most active contributors had similar clinical backgrounds and the volunteer consensus was achieved by groups familiar with one another, so that the treatment field was only partially represented. Therefore, the ASAM PPC have gaps that must be identified and filled by other groups in the AOD treatment field.
The ASAM criteria, with over 4,000 copies in circulation, have received high visibility in the
treatment field. But a negative consequence of being sponsored by a voluntary professional organization is the lack of financial support to widely distribute information. There is room for broader distribution of the criteria in the treatment, policy, and research areas. For instance, nurses and psychologists, who were underrepresented in the development of the criteria, will use PPC. However, they have not been as aware of the ASAM PPC as others in the field.
A particular strength of the ASAM criteria is that they address adult and adolescent treatment separately and encourage a broader continuum of care than the traditional focus on inpatient and aftercare only. However, some omissions limit the usefulness of the ASAM-defined continuum of care for substantial sectors of the treatment field, particularly the public sector.
A strength of ASAM's criteria is that they characterize levels of care and patients in some detail. This common language of levels of care, multidimensional assessment of severity, and specific placements of patients in a level of care give the treatment field systematic ways to describe the treatment continuum and identify where patients belong in the continuum.
However, all current PPC, including the ASAM criteria, use categorized levels of care in which a specified set of services and modalities are "bundled" into one level of care. For example, a Level IV treatment program must offer acute hospital resources; physician management; life support services; psychoeducation programming; individual, group, and family counseling; and continued care planning. Any one patient may not need all of the services, but the categorized, bundled level of care discourages full flexibility to meet the individualized needs of patients.
Categorized or bundled levels of care in the ASAM criteria are limited by their rigidity and are beginning to give way to "unbundled" sets of services, settings, and environmental structures.
A strength of the ASAM criteria is the potential for cost savings. A major difference in cost is spanned in distinguishing between Level III and Level IV treatment (medically managed vs. medically monitored; acute care vs. subacute care). Previously, Level III (short-term, medically monitored, residential treatment) was frequently provided in hospital settings at acute-care rates. The codification of a continuum of care, although limited to four levels of care with the gaps mentioned above, provides PPC that can help move the treatment field toward more comprehensive and cost-effective continuums of care.
While a strength of the ASAM criteria is that they incorporate a broad and comprehensive multidimensional assessment of the patient to determine the appropriate level of care, a related weakness is that there are currently no reliable and widely accepted ways to measure these dimensions. A great challenge in the development of any PPC is accurately determining the degree of specificity or generality that will most clearly, objectively, and validly guide appropriate clinical decisionmaking.
The ASAM PPC address a wide range of clinical presentations by using the multidimensional assessment and systems approach to describe a variety of clinical severities. The criteria simulate expert human thinking that looks at patients as individuals with specific needs, often spanning several assessment dimensions. However, this approach can be cumbersome because it is a written method of complex human decisionmaking. This makes it difficult to standardize and makes rules difficult to learn, memorize, and use. The ASAM PPC are perceived by some as too complicated for use as a utilization management tool and best used as a treatment planning tool.
Some have argued that the six dimensions for assessment lack clarity and should be more specific about the conditions in the various levels of care. The lack of clarity allows for significant variability in interpretation. On the other hand, too much specificity leads to rigid, rule-bound decisionmaking and too detailed and cumbersome a document. There is no substitute for clinical judgment by a credentialed professional in comprehensive assessment and placement decisions.
Future versions of PPC would benefit from greater clarity of the criteria, explanatory detail, examples, and easily accessible footnotes and appendices. Objective tools must be developed to give clinicians some direction for the systematic use of PPC.
A current effort to address this problem is a checklist version of the ASAM PPC known as the Level of Care Index (LOCI) that is commercially available (see Appendix B). It condenses paragraphs of prose from the ASAM PPC to a few words, and greatly facilitates use of the criteria. This model of condensing complicated prose into a more usable format is a good one. However, a risk inherent in use of such tools, especially without adequate training, is that it may lead to superficial assessments without sufficient clinical analysis.
Treatment planning software that incorporates the ASAM six dimensions is also commercially available (see Appendix B). The software allows problem statements in treatment plans to be organized under the six dimensions. The use of computers to rapidly analyze, order, and focus assessment data to facilitate clinical decisionmaking about patient placement and treatment planning is relatively in its infancy. Such developments would help address the need for improved specificity and user friendliness.
The ASAM PPC offer a framework for continuity of treatment, including admission and continued stay and discharge criteria. These phases of treatment are subject to guidelines for utilization review and quality improvement that require ongoing assessment of patient performance and treatment response. The length of stay in any one level of care depends on the
clinical severity of illness and the patient's response to treatment. Treatment is seen not as the completion of a level of care in a fixed length of stay, but as having flexible continuity throughout the continuum of care. However, the concepts of admission and discharge do not allow for the tapered intensity of treatment that patients might need. For example, when a patient moves from 10 to 9 hours of treatment weekly, the guidelines of the ASAM PPC would automatically discharge the patient from Level II (Intensive Outpatient/Partial Hospitalization Treatment) to Level I (Outpatient Treatment).
Although the ASAM criteria are copyrighted, ASAM has taken a consensus-building approach and has given permission to use the ASAM patient placement criteria as a base from which to fashion other criteria. Permission can be requested by contacting James F. Callahan, D.P.A., Executive Vice President, American Society of Addiction Medicine, 4601 North Park Ave. Suite 101, Chevy Chase, MD 20815. Telephone: (301) 656-3920.
Additionally, ASAM has expressed willingness to give up its authorship and copyright to a more multidisciplinary body, provided that the new UPPC embody the essential elements of the ASAM UPPC.
The ASAM criteria may form a solid base upon which to add criteria for additional levels of care. They may be useful in the development of a uniform set of PPC for the short term as well as a starting point for a reconceptualized set of criteria for the future. Treatment systems developing, revising, or adapting their own PPC may choose to incorporate the strongest components of the ASAM criteria, adapt them as needed, and add components to fit their own situations. However, a proliferation of different criteria sets will result. Thus, individual treatment systems may have PPC to meet their internal needs but this will not achieve the goal of uniform PPC.
In addition to the ASAM criteria, the consensus panel reviewed all sets of available public and private PPC. The objective was to identify the set of criteria representing the best effort to date, and provide a solid base upon which to build. As stated earlier, the panel decided that the ASAM criteria best met these requirements.
| Exhibit 3-2
|
|
|---|---|
| Positive Aspects: | However: |
| Developed by consensus | AOD treatment field only partially represented |
| Widely circulated in the AOD treatment field | Lack of financial support for broad enough distribution |
| Encourage a broad continuum of care | Some levels of care and treatment modalities not included |
| Use common language for levels of care | Categorizing levels of care can discourage individualized treatment |
| Potential for cost savings | Cost savings may not be realized in the "gaps" that exist in the four levels of care |
| Broad, multidimensional assessment | Currently no reliable way to measure these dimensions |
| Systems approach simulates expert human thinking | Can be difficult to use |
| Provide framework for admission, continued stay, and discharge. | May not adequately allow for tapering intensity of treatment. |
However, several sets of PPC, both public and private, were impressive in numerous ways and represent improvements to the ASAM PPC and models for future PPC development. A full review, analysis, and discussion of all documents would require work beyond the scope of the consensus panel. Other PPC that were not in the possession of the panel will need review as well. Appendix B includes information about obtaining copies of most of the criteria sets reviewed by the panel.
Several States have adopted variations of the ASAM criteria to fit their systems. PPC from public treatment systems that were modeled on the ASAM criteria clearly share many of the fundamental strengths and weaknesses of those criteria. However, many States have made significant improvements in the ASAM criteria to make them more appropriate to their systems and easier to use.
The developers of the Iowa PPC adapted the ASAM model and developed PPC for other levels of care. A significant contribution of the Iowa criteria is that they include PPC for some levels of care that are missing in many public treatment systems such as halfway houses and longer term residential treatment. The Iowa criteria also provide an excellent glossary. The panel was impressed by both efforts but questioned the description of long-term residential PPC. Two distinct levels of care are described: primary residential treatment (50 hours/week of rehabilitation sessions) and extended residential treatment (30 hours/week of rehabilitation followed by other rehabilitation and community services). The panel workgroup felt the PPC should more clearly define the distinctions between the two levels of care.
Illinois is creating a short draft addendum to the ASAM PPC, which was not available to the consensus panel. The goal is to make the ASAM criteria more compatible with publicly funded systems. This goal should be a consideration in any adaptation of ASAM criteria.
Massachusetts has made a significant contribution by creating a statewide consensus panel to recommend changes to ASAM criteria that reflect the State's unique characteristics. It produced PPC for Level I
(outpatient), Level III (detoxification), youth residential, and methadone treatment. It is worth noting that the ASAM Level IV criteria were used for the foundation of their Level III, with language adapted to better reflect the clients treated in the public system. Each amendment the State made to the ASAM text was footnoted, a procedure worth duplicating by others.
A large managed care company has begun to manage the bulk of the Massachusetts Medicaid population. Using the Massachusetts PPC as a conceptual base for decisionmaking, the company has redirected clients from Level IV hospitals to Level III facilities. When this transition began, 50 percent of detoxification episodes were in Level IV hospital programs. In less than 1 year, this rate has been reduced to less than 10 percent.
Recent State healthcare reform, which will replace mandated chemical dependency healthcare with case-managed chemical dependency treatment services, has stimulated acceptance of the ASAM criteria as the tool for case management. Efforts are now under way to incorporate specific reference to the ASAM criteria into healthcare reform efforts. Training in the use of the ASAM criteria is ongoing.
The Minnesota PPC preceded the ASAM criteria and are particularly useful as a resource for future PPC. They are more compact and standardized than the ASAM criteria, making them more likely to be applied consistently, but also making them more arbitrary and rigid. Perhaps the greatest usefulness of the effort to establish criteria in Minnesota is not the criteria themselves, but the lessons learned in the 8 years of experience implementing them.
Private behavioral health managed care companies are actively taking steps to examine the PPC that they collectively use. They recently formed a Managed Care Coalition on Substance Use Disorders, a subcommittee of the Coalition for National Clinical Criteria, with the goal of creating a unified voice for their services in the healthcare reform environment. In this process, they have shared information that was previously withheld as proprietary and are demonstrating a willingness to explore and support the development of standardized PPC.
It is important to note that, for the most part, the criteria are specifically designed as utilization management tools, indicating the minimum requirements for entering a level of care. This approach substantially differs from that of the ASAM PPC, which were not designed as a utilization management tool, but to provide the conceptual framework and specifics for patient placement.
The panel workgroup reviewed several sets of criteria from private managed care providers and compared them with the ASAM PPC. Generally, the workgroup found that the criteria devised by managed care entities consistently differ from the ASAM PPC. They are more concise and substantially more restrictive regarding access to the intensive levels of care. In addition, they emphasize the distinction between the use of partial hospitalization and intensive outpatient treatment (Level II). They tend to focus on psychiatric factors and often demonstrate less awareness of the unique aspects of substance abuse treatment as compared with other components of their services.
The panel workgroup found many similarities among the sets of criteria developed by managed care companies. They have, in some cases, divided the services designated as Level II services by ASAM into two distinct components: partial hospitalization and intensive outpatient care.
The common core elements of the partial hospitalization level of care include:
The common core elements of the intensive outpatient level of care include:
These systems have been leaders in the development of ambulatory outpatient detoxification services.
The managed care PPC appear to be highly restrictive in terms of permitting any 24-hour level of AOD care. Examples included requiring severe psychiatric problems as a condition of admission or not allowing a readmission to residential treatment if such treatment has been delivered in the last 5 years.
Another TIP in this series, Intensive Outpatient Treatment for Alcohol and Other Drug Abuse, documents the clinical viability and utility of the intensive outpatient level of care.
Some managed care providers use "restorative potential" (the ability and willingness of a client to benefit from treatment) as a factor in deciding level of care. The concept of restorative potential has been used to limit or deny services to clients who are perceived as using treatment services excessively or who have a bad track record of complying with treatment. Some providers use it to assign the client to a less intensive level of care. For the client with a history of relapse problems, a more appropriate clinical approach would be a careful assessment and identification of the barriers to recovery. However, addressing recovery barriers does not absolve patients from responsibility. The appropriate use of restorative potential involves assessment of both external barriers to recovery and the patient's investment in the process. Failure to address specific recovery barriers and match the client to appropriate services and settings only increases the human and financial cost to the client and society.
For public and private institutions preparing to adopt, write, or amend PPC for their clients with AOD addictions, the consensus panel recommends interim steps until a new set of criteria can be developed. The interim criteria must effectively address the accepted shortcomings of the ASAM PPC and incorporate the best components and aspects of other excellent PPC now available. The panel recommends that:
A discussion of each of these recommendations is presented in the following sections.
The Coalition for National Clinical Criteria has, in the course of three meetings, discussed the need for modifications to the ASAM criteria. These modifications address many of the same gaps in service identified by the consensus panel workgroup. On September 9, 1994, the coalition voted to proceed with the development of a supplement to the ASAM criteria that substantially addresses the panel's interim recommendations. ASAM has expressed a willingness to fund the publication of this supplement with a projected publication date of June 1995.
The ASAM criteria were chosen by the panel as a baseline document for many reasons. Although incomplete and flawed in some respects, they provide the most thorough and systematic model to date for assessing key dimensions of patient need. They systematically link these dimensions with a specified level of care.
Additional PPC should be added to the ASAM base document to include levels of care that are widely recognized as missing from the ASAM criteria. Several have been identified that are well developed and consistent with the ASAM PPC methodology.
Systems preparing to incorporate, develop, or revise existing PPC would benefit from studying the following PPC and incorporating portions of them—as is or amended—into their PPC.
These include:
In reconceptualizing the level of care model in this interim period, the panel suggests that the four-level system be maintained as an umbrella system under which other more specific criteria and "sublevels" of criteria can be incorporated. The panel suggests the following structure for temporarily organizing multiple levels of care.
Under Level I, Outpatient Treatment, there are currently a wide range of outpatient treatment models used in the AOD treatment field. The ASAM PPC now include outpatient care and methadone treatment, but there is nothing specifically designed for the many other low-intensity treatment models.
Under Level II, Intensive Outpatient Treatment/Partial Hospitalization, there are two distinct types of services in the treatment field, Intensive Outpatient and Partial Hospitalization. While there are no ASAM-type criteria that separate these "sublevels," managed care organizations do have basic admission criteria for them. A review of some of their criteria suggests certain core elements that generally define these two services (described earlier in this chapter). These core elements should be developed into PPC of the ASAM type. In addition, a TIP in this series, entitled Intensive Outpatient Treatment for Alcohol and Other Drug Abuse, describes one approach and a range of services and core components at this level of care.
Under Level III, Medically Monitored Intensive Inpatient Treatment, there are several types of 24-hour residential treatment programs, some of which provide medically monitored detoxification services. These include halfway houses, social detoxification centers, therapeutic communities, extended (low-intensity) residential, and short-term intensive rehabilitation treatment. The ASAM PCC are now available for halfway houses and, with some amendment, short- and long-term residential treatment. They are not currently available for therapeutic communities or social detoxification; with the exception of halfway houses, no criteria seem to adequately characterize 24-hour residential programs.
Level IV, Medically Managed Treatment, requires no division into sublevels. However, as noted earlier, the criteria overstate the need for the hospital level of care in today's treatment environment. Programs are finding they can perform detoxification in various nonhospital inpatient and outpatient settings. Further work needs to be done to update these criteria and determine the most appropriate clients to be detoxified in less intensive inpatient and outpatient settings without substantial physician involvement. A TIP under development in this series, Detoxification from Alcohol and Other Drugs, provides extensive detoxification guidelines for use in a variety of settings, including outpatient settings.
Some have argued that the level-of-care umbrella might be more useful if Level III were redefined as 24-hour Residential Treatment (that may or may not be medically monitored). Under this umbrella, all of the sublevels now under Level III would remain except Level III, Detoxification, which would be recategorized under a new Level IV (24-hour Residential Detoxification). The panel is not recommending this amendment, but the idea may be useful to consider during this interim period.
A necessary additional level of care in future PPC development is Prevention/Early Intervention. Many health maintenance organizations (HMOs) and public treatment systems already include prevention as a major part of their budgets, and the prevention system is a key component of certain treatment systems. For instance, HMOs and other capitated/fixed-payment systems of care have financial and clinical incentives to reach out to their served population. They offer preventive education (primary prevention) and identify high-risk individuals, to whom they provide education and intervention (tertiary prevention). They may also provide interventions to minimize the risk of relapse or more expensive treatment at a later time.
In the future, one can expect to see an increasing number of systems with this level of care as well as more attention focused on prevention. Prevention efforts could include training for doctors and other medical personnel, educators, criminal justice workers, and social service providers in the methods for brief but effective interventions that consist of one or a few meetings.
|
The prevention level of care could include structured relapse prevention services in Level I (outpatient care). For example, in the current system, access to AOD benefits usually requires a recent episode of AOD abuse. But patients experiencing stress and in danger of relapse may require immediate addiction treatment expertise. When funders exclude access to AOD benefits in these situations, the likelihood of relapse increases, which leads to the costly need for acute care. Criteria in this area would allow a client to enter the treatment system at a prevention level before an acute episode necessitated treatment at a more intensive level.
The CSAT consensus panel members were unanimous in their belief that future PPC need to become far less categorized, allowing treatment providers and purchasers to choose the most appropriate combination of setting, treatment, and intensity of services to meet the client's individual needs.
To address the rigidity of the current system, many managed care companies and public treatment systems are now suggesting that treatment modality and intensity be "unbundled" from the treatment setting. Unbundling is a practice that allows any type of clinical service (such as psychiatric consultation) to be delivered in any setting (such as a therapeutic community). With unbundling, the type and intensity of treatment are based on client need and not on limitations imposed by the "category" of care they are in, or whether they are sleeping in a halfway house or hospital. Indeed, a new type of care is emerging that combines partial hospitalization with room and board. The unbundling concept is designed to maximize individualized care and encourage the delivery of necessary treatment in any clinically feasible setting.
There is a pilot program under way in Montana with Blue Cross and Blue Shield that offers reimbursement based on a continuum of service. Blue Cross and Blue Shield offers a $500 benefit for a segment of treatment but does not specify the setting. The treatment can take place in a hotel, halfway house, or during a short-term retreat. Other examples of unbundling include providers who have capitated contacts with managed care companies or other insurers. They have the option and are financially motivated to arrange for a modality of care wherever it is clinically appropriate. This maximizes positive outcomes in the most cost-efficient manner.
The following are hypothetical examples of an unbundled system delivering unique treatment plans that a rigid, categorized system may not easily deliver.
The possibility of an unbundled system delivering a range of levels of care with limited resources is shown in the cases of Mrs. R. and Mr. Q. (see boxes on this page and next). Their options in a system with little flexibility are described first, followed by possible options in an unbundled system.
|
|
An example of a setting in which unbundled treatment might be easily delivered is a large treatment campus that has a variety of services available at one site. This campus might include a hospital-based addiction program with a methadone clinic, a day and evening structured outpatient program, a psychiatrist, childcare and transportation services, and a low-cost residential setting. Clients would easily receive an individualized treatment plan that would specify the appropriate frequency, intensity, and type of treatment services. Clients would move from one treatment modality and setting to another, based on assessment of their immediate needs rather than on some categorized, preset time schedule.
Another example is a halfway house that might minimally require a 24-hour setting with possibly 5 hours of group counseling per week. However, a particular halfway house might have a licensed practical nurse on staff 20 hours a week to provide medical services and a psychiatrist or other mental health clinician who visits the program once a week. Additionally, this program might offer transportation to employment and other treatment services. The purchaser might pay $50 per day for the minimum core halfway house service and a specified additional amount for the nursing, psychiatric, and transportation services.
Other examples of services and modalities that might be provided in an unbundled system to supplement minimum core services might include child care, onsite or community-based case management, overnight accommodations or sleeping quarters with or without supervision, psychiatric evaluation and medication management, ambulatory detoxification capability, nursing coverage, mental health professional staff coverage, specialized ethnic and cultural capabilities, and high-intensity clinical programming. A treatment provider would create a menu of services offered with the unit cost of each. This cost would either be billed to the appropriate agency or agencies or monitored in a capitated arrangement (as described below).
If patient placement criteria are designed to address both categorized and unbundled treatment, they will contribute to the most clinically appropriate and cost-effective care possible.
Two methods of payment are most likely for unbundled services.
Incremental charges. There would be a charge for core-level treatment, and each incremental "unit" of treatment or service.
Capitation. The other main option is capitation, the establishment of a fixed amount of payment for services for an individual client during a specified period. There is wide variety in the way capitation principles are carried out in different localities. The basic principles used in a capitation method of paying for AOD treatment include:
It is important that capitation include money for nontreatment services (such as hotel, childcare, and increased case management costs) that are required to support clients who need such services. Future developments in UPPC that include capitation should incorporate financial incentives that encourage quality care, cost effectiveness, and outcomes-based management with strong monitoring of access and quality of treatment.
There are several challenges that must be faced in the development of UPPC that unbundle modalities and intensity of care from the setting:
Unbundling of services need not mean that separate services are provided in separate locations. Unbundled treatment may be available as a program offering a menu of services provided in a single location, from which the client and case manager can choose.
Essential to unbundling is the idea that a standard course of treatment can be separated into its component parts, and that those parts can be provided independently of each other in the necessary level of intensity and duration.
While all current criteria—including the ASAM criteria—are categorized systems and thus somewhat limited in their flexibility, it would be a mistake to abandon them and leap immediately to an unbundled system. An essential interim step is to do a better job of defining categorized levels and establishing widely accepted PPC for each level. The refined categorized levels could be seen as stepping stones to unbundling, which will probably occur very gradually and will need thoughtful development.
While PPC play an important role in matching placements to cost-conscious, effective treatment, current models of PPC need improvement to better match patients to specific modalities, not just to a level of care.
Both payers and providers may accept uniform patient placement criteria, assuming those criteria:
Without uniformity, there are no common definitions of care, no common language, and no capacity to effectively perform and compare the essential research.