Treatment Improvement Protocols (TIP) 13 |
Several types of materials may be useful to programs or systems seeking to create or adapt patient placement criteria (PPC). Information gained from careful assessment is essential for making appropriate placement decisions. This appendix describes instruments for assessing the severity of alcohol and other drug (AOD) use and related problems, the potential for withdrawal symptoms, and attitudes toward treatment. The Level of Care Index (LOCI) and Recovery Attitude and Treatment Evaluator (RAATE) instruments were designed to be compatible with the PPC developed by the American Society of Addiction Medicine (ASAM). The authors of these instruments were members of the consensus panel that developed this Treatment Improvement Protocol (TIP). Two software packages to aid clinical management and treatment planning are also described. Dr. Paul Earley, who developed one of the software packages, is an ex officio member of ASAM's board of directors.
For readers who wish to examine existing criteria in more detail, the next section lists information about how to obtain criteria sets from various States and private organizations. The final section of the appendix presents information on ordering a variety of materials on managed care to help programs and systems prepare for healthcare reform.
A comprehensive assessment of each patient entering treatment is needed and should include the following:
A number of assessment instruments are widely used to collect information that is helpful in diagnosis and treatment planning. The instruments that are especially pertinent to the concepts discussed in this TIP are listed below. Other instruments are also available that illustrate the ways in which individual treatment programs have developed or tailored assessment tools to meet the particular needs of their patient populations.
The listing of a particular assessment instrument in no way implies an endorsement of that instrument, nor is the following list intended to be inclusive or representative of all assessment instruments that may be used by treatment programs. The instruments included here are used or recommended by some treatment providers.
A collection of sample assessment instruments is available as a package from the National Clearinghouse for Alcohol and Drug Information (NCADI), P.O. Box 2345, Rockville, MD 20847-2345; (800) 729-6686; (301) 468-2600; TDD (for hearing impaired): (800) 487-4889; fax: (301) 468-6433.
The ASI, now in its fifth edition, is the most widely used standardized assessment tool in the field. It is a highly structured clinical interview consisting of 161 items. The ASI is designed for a trained technician to rate the severity of problems in six areas: medical, psychological, legal, family and social, employment and support, and use of alcohol and other drugs.
Source: McLellan, A.T.; Kushner, H., and Metzger, D. The fifth edition of the Addiction Severity Index. Journal of Substance Abuse Treatment 9(3):199-213, 1992. The National Institute on Drug Abuse (NIDA) has developed a technology transfer package, which includes the ASI, two 60-minute training videotapes on the use of the ASI, a training facilitator's manual, and a program administrator's handbook. The package is not available directly from NIDA, but information on obtaining it is available through NIDA's toll-free number.
Ordering Information: Available from NCADI; (800) 729-6686; fax: (301) 468-6433. Also, the clinical version of the fifth edition of the ASI is reproduced in the TIP Screening and Assessment for Alcohol and Other Drug Abuse Among Adults in the Criminal Justice System, which is also available from NCADI.
Cost: None for some materials
The CIWA-Ar aids in measuring acute intoxication and/or withdrawal potential. With the use of CIWA-Ar, 15 symptoms of withdrawal can be measured in 3 to 5 minutes. A 60-minute videotape, "The Alcohol Withdrawal Syndrome," has been developed to train clinical staff in use of the CIWA-A (longer version of revised CIWA).
Source: Sullivan, J., Sykora, K., Schneiderman, J., Naranjo, C., and Sellers, F. Assessment of alcohol withdrawal: the revised Clinical Institute Withdrawal Assessment for Alcohol Scale. British Journal of Addiction 84:1353-1357, 1989.
Ordering Information: Available from the Addiction Research Foundation, Marketing Department, 33 Russell St., Toronto, Ontario, Canada M5S-2S1; (800) 661-1111.
Cost: Instrument: none; videotape: $250, plus $25 shipping
The LOCI tools are clinical checklists that aid in decisionmaking about the appropriate level of care for patients with substance use disorders. Separate tools address decisions about: admission, continued stay, and discharge/transfer. The indexes are designed to be compatible with the ASAM patient placement criteria and summarize dimensions and decision points contained in those criteria. There are separate indexes for adults and adolescents.
Source: Mee-Lee, D., and Hoffmann, N.G. LOCI--Level of Care Index: A Concise Summary of ASAM Criteria's Factors to Document for Placement, Continued Stay, and Discharge. St. Paul, Minnesota: New Standards, 1992.
Ordering Information: Available from New Standards, Inc., 1080 Montreal Ave., Suite 300, St. Paul, MN 55116; (612) 690-1002; fax: (612) 690-1303. Forms are available for the separate assessment areas (admission, continued stay, and discharge/transfer) and are sold separately in packs of 25.
Cost: $24.50 for a pack of 25
The RAATE is an instrument used for determining severity of addiction based on assessment of five dimensions. These include: resistance to treatment, resistance to continuing care, acuity of biomedical problems, acuity of psychiatric and psychological problems, and social/family environmental status. The RAATE Clinical Evaluation is completed by the clinician, and scores in each dimension are keyed to the four levels of care described in the ASAM criteria. The RAATE Questionnaire I is a 94-item true-false instrument completed by the patient, which elicits information about the five dimensions.
Source: Mee-Lee, D. An instrument for treatment progress and matching: the Recovery Attitude and Treatment Evaluator (RAATE). Journal of Substance Abuse Treatment 5:183-186, 1988.
Ordering information: Available from New Standards, Inc., 1080 Montreal Ave., Suite 300, St. Paul, MN 55116; (612) 690-1002; fax: (612) 690-1303. An introductory kit is available that includes a manual, 25 Clinical Evaluation (CE) forms, 25 Questionnaire I (QI) forms, and a scoring template. PC disks can be prepared upon request.
Cost: Introductory kit: $125; Extra CE and QI forms: $56.25 for pack of 25 forms; PC disk, $4.50 per interview
The POSIT is a self-administered 139-item screening questionnaire that was developed by NIDA. It was designed as part of a more extensive system for adolescents, the Adolescent Assessment/Referral System (AARS). It measures problem severity in 10 domains that are often related to substance abuse and that are amenable to treatment intervention. Domains include substance abuse, physical health, mental health, family relations, peer relations, educational status, vocational status, social skills, leisure/recreation, and aggressive behavior.
Source: Radhert, E.R. The Problem Oriented Screening Instrument for Teenagers, in Radhert, E.R., ed., The Adolescent Assessment/Referral System Manual. DHHS pub. (ADM)91-1735. Washington, D.C.: Government Printing Office, 1991.
Ordering information: Available from NCADI; (800) 729-6686; TDD (for hearing impaired), (800) 487-4889; fax: (301) 468-6433. Request the Adolescent Assessment/Referral System Manual.
Cost: None
This patient placement management software allows users to structure the system according to their own criteria and rules. Based on the criteria, the system generates a placement form to be filled out by the clinician during patient assessment. When these data are entered, the system produces a placement matrix and a continued stay review form, with a due date based on placement rules, for the clinician's use. Additional continued stay forms for each patient are generated as needed. To facilitate management of large numbers of patients, the system generates a list of forms and reports due each day, as well as summary data of several kinds. A treatment planning module is being developed.
Ordering information: Contact Michael Ruppert, MRM Enterprises, P.O. Box 1153, Helena, MT 59624; fax only: (406) 443-5490.
Cost: $2 per patient unit; discounts for large orders
TxPlan is a professionally developed, highly customizable, clinical management software system. It tracks patients from intake and facilitates the writing of individualized treatment plans, progress notes, and discharge summaries. Problem databases can be created for any patient population or level of care. TxPlan's chemical dependency database of approximately 100 problems is organized according to the six dimensions of the ASAM criteria. Clinicians can identify a patient's problems in each dimension and then have a choice of up to 15 objectives and interventions for each problem.
Ordering information: Contact Judith K. Earley, Ph.D., President, Earley Corp., 407 Ponce De Leon Ave., Decatur, GA 30030; (404) 370-1212; fax: (404) 378-0346.
Cost: Single-user license: $1,295; network license: $2,590 (up to three users) to $10,590 (unlimited users); customization programming: $80/hour; onsite installation and training: $975/day plus expenses.
Patient placement criteria developed by the American Society of Addiction Medicine and by several States and private organizations can be used as models in creating, adapting, or amending patient placement criteria. Several criteria sets are described below, with ordering information.
Patient Placement Criteria for the Treatment of Psychoactive Substance Use Disorders
These criteria offer clinical guidelines for matching patients with substance use disorders to appropriate levels of care. Four levels of care are described: outpatient treatment, intensive outpatient/partial hospitalization, medically monitored intensive inpatient treatment, and medically managed intensive inpatient treatment.
Ordering information: Available from the American Society of Addiction Medicine, 4601 North Park Ave., Suite 101, Chevy Chase, MD 20815; (301) 656-3920.
Cost: ASAM members: $45; nonmembers, $65
Iowa Client/Patient Placement Criteria: Treatment of Psychoactive Substance Use Disorders (1991)
These criteria were developed by the Chemical Dependency Treatment Programs of Iowa and the Iowa Substance Abuse Program Directors Association. Seven levels of care are described: continuing care, halfway house, extended outpatient treatment, intensive outpatient treatment, primary/extended residential treatment, medically monitored inpatient treatment, and medically managed inpatient treatment.
Ordering information: Contact Janet Zwick, Director, Division of Substance Abuse, Iowa Department of Public Health, Lucas State Office Building, Third Floor, Des Moines, IA 50319; (515) 281-3641; fax: (515) 281-4535.
Cost: No cost at this time
Substance Abuse Outpatient Counseling; Detoxification Services; Youth Residential Criteria; Methadone Treatment Criteria (draft)
The Bureau of Substance Abuse Services has collaborated with substance abuse treatment providers throughout the State to develop standardized admission, discharge, and continuing care criteria for several substance abuse treatment modalities, which are available in a single document. The criteria are modeled on the ASAM patient placement criteria but were modified and supplemented to better represent needs of public-sector clients and available services. The State is now developing criteria for residential recovery services.
Ordering information: Contact Shelly Steenrod, M.S.W., L.I.C.S.W., Regional Manager, Massachusetts Bureau of Substance Abuse Services, 150 Tremont Street, Boston, MA 02111; (617) 727-7985.
Cost: No cost at this time
Rule 25: Assessment and Placement for Public Assistance Recipients
The State developed these criteria in collaboration with treatment providers and county social service agencies. They were implemented in 1988 with a consolidated funding system. Rule 25 is more concise and user friendly than the ASAM criteria but does not describe as comprehensive an assessment or contain continued stay criteria.
Ordering information: Contact Lee Gartner, Planner Principal, Chemical Dependency Program Division, Minnesota Department of Human Services, 444 Lafayette Road, St. Paul, MN 55155-3823; (612) 296-3991; fax: (612) 297-1862.
Cost: No cost at this time
Administrative Rules of Montana, Chapter 3, Chemical Dependency Rules
The Montana rules for patient placement are conceptually based on the ASAM criteria. Three levels were added to ASAM's four levels to allow more flexibility within the medical levels of care.
Ordering information: Contact Norma Jean Boles, R.N., Manager, Montana Department of Corrections and Human Services, 1539 11th Ave., Helena, MT 59620; (406) 444-4931; fax: (406) 444-4920.
Cost: None
Criteria for the Admission and Transfer/Discharge of Adult Chemical Dependency Patients in Washington State
These criteria were developed by chemical dependency assessment and treatment professionals, in consultation with representatives of the insurance industry and their agents, to address problems created by the impact of managed care practices on the chemical dependency treatment system and patients. They were modeled on the ASAM criteria, and modified to better reflect needs of the public sector and of small outpatient treatment providers.
Ordering information: Contact Henry L. Govert, M.A., Program Manager, Division of Alcohol and Substance Abuse, Washington Department of Social and Health Services; (206) 438-8092.
Cost: None
Green Spring Health Services, Inc.
Green Spring Utilization Review Criteria
These criteria, developed to guide patient placement in the least intensive, least restrictive level of care, describe six levels of substance abuse treatment, and include guidelines for admission, continued stay, and discharge.
Ordering information: Contact Jonathan Book, M.D., Senior Vice President, Chief Medical Officer, Green Spring Health Services, Inc., 5565 Sterrett Pl., Suite 500, Columbia, MD 21044; (410) 964-6092.
Cost: None
Mental Health Review Criteria
These psychiatric and substance use criteria constitute the entire spectrum of utilization management screening guidelines used by Health Management Strategies International, Inc.
Ordering information: Write Health Management Strategies International, Inc., 1725 Duke St., Attention: Criteria Request, Suite 300, Alexandria, VA 22314.
Cost: $10
Level of Care Guidelines for Mental Health; and Substance Abuse Preferred Practices Guide
These two documents provide information to decisionmakers about appropriate mental health and substance abuse treatment. The level of care guidelines help define and promote an appropriate and flexible approach to the treatment continuum. The practices guide is used by case managers to review proposed levels of mental health and substance abuse placement.
Ordering information: Contact John Bartlett, M.D., Vice President, Corporate Medical Director, MCC Behavioral Care, 11095 Viking Dr., Suite 350, Eden Prairie, MN 55344; (612) 943-9577.
Cost: None
Mental Health/Substance Abuse Medical Necessity Utilization Review Criteria
Mutual of Omaha Companies' Integrated Behavioral Services has developed five sets of utilization management criteria for mental health/substance abuse treatment services. These criteria are designed to assist in matching patient need, level of functioning, or status with the characteristics of each level of care. The criteria sets are: adult/adolescent mental health 24-hour services, adult/adolescent substance abuse 24-hour services detoxification, adult/adolescent substance abuse 24-hour postdetoxification services, child mental health 24-hour services, and mental health/substance abuse non-24-hour services.
Ordering information: Contact Mutual of Omaha Companies--Integrated Behavioral Services, Mutual of Omaha Plaza, Omaha, NE 68175; (402) 342-7600.
Cost: $49.95
Guidelines for Level of Care Decisions
This document is designed to assist care managers in determining appropriate levels of care for patients with substance use disorders.
Ordering information: Contact Bill Goldman, Senior Vice President for Medical Affairs, U.S. Behavioral Health, 2000 Powell St., Suite 1180, Emeryville, CA 94608-1832; (510) 601-2230.
Cost: None
Clinical Protocol and Procedures Manual, Section D, Adult/Adolescent Substance Abuse (draft)
Patient placement criteria and substance abuse treatment planning guidelines for adults and adolescents are included.
Ordering information: Contact Ian Schaffer, M.D., Executive Vice President and Chief Medical Officer, Value Behavioral Health, Inc., 3110 Fairview Park Drive South, Falls Church, VA 22042; (703) 205-6700.
Cost: None
The Center for Substance Abuse Treatment (CSAT) has developed a variety of reports and other documents to assist States in preparing for healthcare reform and the effects of managed care on the delivery of substance abuse treatment services. Some of them are described below. Other documents and articles that may be helpful are included.
Annotated Bibliography of Managed Care Materials (October 1994)
This bibliography lists useful materials, many of which are free of charge, on topics related to managed care. Sections include: preparing for managed care, needs assessment, performance measures, screening and assessment tools, uniform patient placement and utilization review criteria, peer review, finance, program evaluation, treatment outcomes monitoring systems, and outcomes evaluation.
Ordering information: Contact David Griffith, M.S., M.Ed., Public Health Advisor, CSAT, Division of State Programs; (301) 443-8391.
Cost: None
Some of the materials listed in the annotated bibliography described above include:
This checklist identifies strengths and weaknesses in substance abuse provider systems and can be used to facilitate a strategic planning process to assist an organization in preparing to succeed in a managed care environment. The accompanying guide provides suggestions on how to use the checklist and enhance discussion of the critical issues.
Ordering information: Contact David Griffith, M.S., M.Ed., Public Health Advisor, CSAT, Division of State Programs; (301) 443-8391.
Cost: None
This document explores managed care and its relationship to AOD abuse treatment. Sections include: the current fiscal crisis within the healthcare system, the development and expansion of managed care as a key response to the crisis in healthcare, and the critical importance of establishing treatment protocols for different levels of care.
Ordering information: Contact David Griffith, M.S., M.Ed., Public Health Advisor, CSAT, Division of State Programs; (301) 443-8391.
Cost: None
This publication illustrates the processes involved in purchasing, monitoring, and managing managed care services for individuals with alcohol or other drug problems. It is designed to help prepare single State agency (SSA) directors to successfully interface with managed care entities in the context of current healthcare reform.
Ordering information: Contact David Griffith, Public Health Advisor, Division of State Programs; (301) 443-3820.
Cost: None
This document includes Minnesota's chemical dependency treatment outcome charts; Oregon's cost savings, avoidance, and offsets information; Washington State's economic data; and Vermont's recommended principles of the mental health/substance abuse advisory group on healthcare reform.
Ordering information: Contact David Griffith, M.S., M.Ed., Public Health Advisor, CSAT, Division of State Programs; (301) 443-8391.
Cost: None
This document presents an analysis of the activities in key States pursuant to healthcare reform legislation affecting substance abuse and mental health treatment.
Ordering information: Contact David Griffith, M.S., M.Ed., Public Health Advisor, CSAT, Division of State Programs; (301) 443-8391.
Cost: None
Health Insurance: How Health Care Reform May Affect State Regulation (November 1993)
This document summarizes results of a survey of States' regulation of health insurance. It examines the portion of the health insurance market currently regulated by State insurance departments, the budget and staff of State insurance departments committed to regulating health insurance, and the key activities insurance departments perform.
Ordering information: Contact Documents Distribution, GAO; (202) 512-6000.
Cost: None
Health Reform for Communities: Financing Substance Abuse Services (no date)
This document includes seven recommendations from a national policy panel for ensuring financing for substance abuse services.
Ordering information: Contact Ben Rivers, Join Together, 441 Stuart St., 6th Floor, Boston, MA 02116; (617) 437-1500.
Cost: First copy free; additional copies $1 each