PLACEMENT
CRITERIA
AND PATIENT‑TREATMENT MATCHING
David
Mee‑Lee, M.D,
ASAM
Patient Placement Criteria
Toward
a Unified Model of Addiction
Assessing
Severity of Illness
Matching
Levels of Care and Modalities of Treatment
Defining
the Continuum of Care
Monitoring
Treatment Outcomes
In the not too distant past, diagnosis alone defined treatment. If a
patient met the diagnostic criteria for alcoholism or other drug addiction, a
single treatment model was offered. Of such addiction treatment, which is
program based rather than clinically driven, it can be said that "one size
fits all." However, to protect access to quality treatment and conserve
health care resources, providers and payers increasingly are turning to an
approach that matches patients to levels of care and treatment modalities, thus
providing a range of options tailored to patient needs.
Such matching of patient needs to treatment services is based on an
assessment of the severity of the addiction, as well as verification of the
diagnosis. Addiction treatment today typically involves placement in a level of
care; movement through a continuum of services that is as seamless as possible;
and specific matching to a variety of treatment modalities at all levels of
care.
In such a system, diagnosis is a necessary but insufficient determinant
of treatment. Rather, the system requires use of criteria to guide proper
patient placement; practice guidelines to promote effective individualized
treatment modalities; and outcomes data to continuously improve both the
criteria and guidelines.
As a first step toward meeting the need for clinically sound, cost‑conscious
patient placement criteria, the American Society of Addiction Medicine (ASAM)
in 1991 published the Patient Placement Criteria for the Treatment of
Psychoactive Substance Use Disorders (Hoffmann et al, 1991). These criteria for
admission, continued stay and discharge define four levels of care (separate
for adults and adolescents) and reflect two years' work by two task forces of
addiction treatment specialists, involving counselors, psychologists, social
workers and physicians.
The National Association of Addiction Treatment Providers (NAATP)
joined with ASAM to create the criteria, based on a review of the literature
and careful clinical consensus representing many years of addiction treatment
experience. The task forces integrated and revised the Cleveland Criteria of
the Northern Ohio Chemical Dependency Treatment Directors Association (NOCDTDA)
(Hoffmann, Halikas & Mee‑Lee, 1987) with the NAATP Criteria (Weedman,
1987). Both ASAM and NAATP agreed to allow a third set of national criteria to
supersede their organizations' documents, despite considerable investments of
time, effort and financial resources in developing the separate criteria.
Ten draft sets of criteria were produced after seven two‑day,
face‑to‑face meetings and innumerable phone calls and individual
working sessions. Over 1,300 sets of field review draft criteria were
distributed; feedback from these reviews and 15 field test sites were entered
into the computerized database. The draft criteria were modified to accommodate
the field test results.
Among the hopes for the ASAM Criteria are that they might lead to a
common language to describe: (1) assessment of a patient's severity of illness;
(2) the treatment levels of care provided; and (3) the clinical criteria that
guide the most efficient placement of patients in the
continuum of care. Such a common language would allow payers
and managed care organizations to know exactly how treatment programs and
clinicians make decisions about patient placement and ongoing care, while at
the same time facilitating communication between and among all parties involved
in treatment and payment decisions.
Thus, the ASAM Patient Placement Criteria can provide an important
resource and impetus in promoting flexible, cost‑effective treatment that
conserves scarce health care resources. The Criteria give the addiction field
guidelines that can encourage clinicians, payers and policymakers to broaden
the scope of available treatment options by placing greater emphasis on the
continuum of care and encouraging flexible movement up or down the continuum.
At the same time, the Criteria uphold the legitimacy of inpatient care and
protect the integrity of clinical decision‑making processes.
The addiction treatment field recently has come under scrutiny during
the
1. Pre‑treatment
assessment of the various problems of individuals who seek treatment, so that a
decision can be made as to which treatment placement is most appropriate;
2. Treatment matching
"to ensure that each individual receives the kind of treatment most likely
to produce a positive outcome" (Institute of Medicine, 1990); and
3. Regular measurement of
treatment outcome to verify the effectiveness of the treatment and improve the
acuity of treatment matching decisions.
Shaffer (1986, 1987) reports that the ways in which clinicians label
situations tend to influence their patients' responses. In other words, what
physicians and others believe about the causes and consequences of addiction
shapes their assessments and, in turn, the treatments they prescribe. Thus, if
the addiction field is ever to move away from polarized views of addiction
etiology and treatment, toward a system ready to embrace matching, there must
be a model of addiction that transcends geographic, cognitive and theoretical
perspectives to achieve a unified field theory.
Engel raised the need for a more inclusive scientific model of general
medicine more than 17 years ago (Engel, 1977). Donovan (1988) and Wallace
(1990) have more recently articulated a biopsychosocial model of addictive
behaviors. Such a model facilitates understanding of the multiplicity of
clinical presentations in the addictions‑‑a necessary although not
sufficient element of matching.
Although the disease model has enjoyed widespread support, it also has
been challenged by those who embrace behaviorist perspectives (Marlatt &
Marlatt, 1983); the public health model (Beauchamp, 1980); and various
philosophical perspectives (Fingarette, 1988; Shaffer, 1985). A model is needed
that explains the clinical and research data yet transcends the
counterproductive debate over the disease model, while addressing other issues
that inhibit integration of perspectives.
Understanding addiction as a biopsychosocial illness in its etiology,
expression and treatment offers several advantages: it promotes productive
integration of diverse perspectives; it explains clinical heterogeneity while
preserving common clinical dimensions; it necessitates multidimensional
assessment; and it promotes matching through comprehensive, individually‑prescribed
treatment. A biopsychosocial treatment model requires the availability of (1) a
comprehensive system of assessing need for levels of care or settings, (2) a
range of treatment modalities within those levels and (3) a continuum of care
(Miller & Hester, 1986; Giuliani & Schnoll, 1985; Bonstedt et al,
1984).
If the biopsychosocial model can offer a
sufficiently broad and inclusive "umbrella" to allow clinicians to
focus on assessment, the next challenge is determining how to assess severity.
As with the treatment of other disorders, the severity of the alcoholism or
other drug addiction should determine the match to type and intensity of
treatment. Curiously, although most clinicians agree that treatment should be
individualized and based on assessment, their treatment plans often are
similar, if not identical, across the population of patients they treat (Miller
& Hester, 1986). However, even if a clinician aspires to meaningful
assessment of severity‑of‑illness (SI), there is not yet full
agreement on how to assess addiction severity and how to identify the best
match to the most effective treatment.
The ASAM Patient Placement Criteria focus on six dimensions to define
biopsychosocial severity: (1) potential for acute intoxication and/or
withdrawal; (2) biomedical conditions and complications; (3)
emotional/behavioral conditions or complications; (4) treatment
acceptance/resistance; (5) relapse potential; and (6) recovery environment
(Hoffmann et al, 1991). Criteria listed under these six dimensions help guide
placement to one of four levels of care, which is the first step in matching
patients to treatment.
Matching Levels of Care and Modalities of Treatment In transitioning
clinicians and programs toward a coherent system of efficient matching, the
next step after reaching consensus on an integrative model of addiction and of
assessing severity of illness is identification of the biopsychosocial
treatment modality to which the patient's severity of illness will be matched.
The range of treatment modalities depends on the variety of theoretical models
integrated into the biopsychosocial model. The IOM report described modalities
as "the specific activities that are used to relieve symptoms or to induce
behavior change" and "the content of treatment is usually referred to
as the technique, method, procedure, or modality" (Institute of Medicine,
1990).
Biomedical modalities focus on improved detoxification regimens; anti‑craving
medication; antagonist medications; methadone treatment; and
psychopharmacological approaches. Psychological treatments span the range from
addictions counseling to psychodynamic and cognitive behavioral treatment
modalities including insight‑oriented psychotherapy, aversion therapy and
behavioral self-control training.
In the sociocultural dimension, treatment
modalities include the Community Reinforcement Approach, family therapy,
therapeutic communities and various motivational techniques, such as
intervention and contingency management. In fact, many modalities‑such
as chemical aversion therapy, social skills training, relapse prevention
techniques and self/mutual help programs‑‑span more than one
dimension.
The IOM report defined four levels as essential to a continuum of care:
inpatient, residential, intermediate and outpatient (Institute of Medicine,
1990). The ASAM Patient Placement Criteria defined four roughly corresponding
levels of care, but named them to be more descriptive of the intensity of
services provided: Level I Outpatient Treatment; Level II‑Intensive
Outpatient/Partial Hospitalization; Level III‑‑Medically Monitored
Intensive Inpatient Treatment; and Level IV‑‑Medically Managed
Intensive Inpatient Treatment (Hoffmann et al, 1991).
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Better training in
biopsychosocial theories, modalities of treatment, assessment and documentation
skills.
Increased
interdisciplinary teamwork.
Increased
individualized treatment and thorough case management.
Increased
curiosity and reliance on research. functioning and
One
quality and system of care integrating public and private programs.
One common set of criteria
clinically‑based not program‑based.
Increase interdependence ‑
improve incentives and equalize over/under capacities.
Flexible
lengths‑of‑stay in all levels of care.
Overlapping
levels of care for better continuity and efficiency.
Expanded
intensities of service involving a wide continuum of service.
More
modalities of treatment from all biopsychosocial schools of thought.
Innovative program
structures that preserve the milieu yet allow individualized treatment.
Reimburse or fund all levels
of care.
Increase incentives for less
costly care. Fund thorough case management.
Expand understanding of
"medical necessity" to be biopsychosocial severity.
**************************************************************************************************
While the ASAM Criteria provide specific guidelines as to what kinds of
settings, services, staff, assessments and documentation attend each level of care, they do not mandate the location of each level: e.g.,
that Level III must be in a freestanding residential facility or Level IV in a
hospital. In fact, Level III might well be provided in a hospital in
conjunction with a Level IV program, thus allowing flexible movement of
patients through the continuum more efficiently.
Matching patients to treatment involves matching severity of illness
with intensity of service. It is the process of moving from multidimensional,
biopsychosocial assessment to determination of biopsychosocial severity of
illness. Dimensions that show high severity allow for ready identification of
specific problems that require priority attention. The resulting treatment plan
responds to these problems with the appropriate intensity of services; i.e., placement
in the least intensive, safe level of care, and treatment strategies selected
from a range of biopsychosocial treatment modalities.
The
patient's treatment response then is monitored (the third part of the IOM
committee's vision) by assessing the changing biopsychosocial severity of
illness for improvement or deterioration in any or all of the dimensions (but
particularly the high‑severity dimensions). Matching is the ongoing
repetition of this cycle and process, as the regularly assessed biopsychosocial
severity of illness is matched with the appropriate intensity of service (see
Figure 1).
The "re‑tooling" of the addictions treatment system
necessary to promote individualized treatment requires a paradigm shift that
has broad implications for personnel, programs, payment systems and the public
and private sectors (Table 1).
If clinicians are to continue to be able to deliver high quality
treatment while demonstrating fiscal responsibility, increased attention must
be given to the three IOM considerations of pretreatment assessment, treatment
matching and outcome monitoring. Rising health care costs preclude the
selection of inefficient care offered by programs with a single level of care
and a unitary treatment protocol for all patients, regardless of the clinical
heterogeneity assessed or (too often) not assessed.
As the population of patients in need of treatment becomes increasingly
diverse‑‑representing polydrug users; dual diagnosis, younger,
psychologically impoverished patients who are more diverse in gender and
ethnicity‑‑so too must the staff mix become more diverse. As
assessment and severity of illness become multidimensional, old definitions of
medical necessity that focused only on physical and psychiatric problems must
give way to severity profiles that allow better matching and diminish
inefficient assignments to inappropriate levels of care.
Matching patients to treatment represents high‑quality clinical
care, respectful human concern, good financial and public health policy and
sensible application of treatment outcome research. Without payment, funding
and policy changes, however, clinicians and programs cannot be expected to
develop systems of care for which they cannot be reimbursed or funded.
Note:
Summaries of the ASAM Patient Placement Criteria for Adolescents and Adults are
presented in Appendix
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