Participant Handout. The American Society of Addiction Medicine (ASAM) Patient Placement Criteria: Understanding and Using ASAM PPC-2R

Transcription

1 Participant Handout The American Society of Addiction Medicine (ASAM) Patient Placement Criteria: Understanding and Using ASAM PPC-2R tel: (775) toll-free: (888) fax: (775) Sigstrom Drive, Carson City, NV

2 9:00 AM Underlying Concepts of the ASAM Criteria Pretest Questions Generations of Clinical Care in Addiction Treatment Paradigm shift and Brief History of PPC Principles Guiding ASAM PPC Development and Implications Assessment of Biopsychosocial Severity and Function 10:30 AM Break Levels of Care and Service in ASAM PPC-2R I Outpatient Services II Intensive Outpatient/Partial Hospitalization Services III Residential/Inpatient Services IV Medically-Managed Intensive Inpatient Services 10:45 AM Content and Specifics about ASAM PPC-2R Terminology Improving Level I, Outpatient Services & Changes to Continued Service and Discharge Criteria ASAM PPC-2R s Approach to Co-occurring Disorders Revised Constructs for Dimension 5: Relapse/Continued Use Adolescent Criteria 12 Noon Lunch How to Organize Assessment Data to Focus Treatment Immediate Need Profile 1:00 PM How to Target and Focus Service Priorities Decision Tree to Match Assessment and Treatment/Placement Assignment Case exercises Tracy and Ann 3 H s Case Presentation Format 2:30 PM Break 2:45 PM Engaging the Client as a Participant in Treatment Stages of Change and How People Change Developing the Treatment Contract What Does the Client Want? Improving the Range and Use of Treatment Services Dimension 4, Readiness to Change Assessment and Matching Example Policy and Procedure to Deal with Recovery and Psychosocial Crises The Coerced Client and Working with Referral Sources Gathering Data on Policy and Payment Barriers 3:50 PM Wrap-Up What is one thing you have learned that you will do differently in your daily practice? Evaluation forms 4:00 PM Adjourn Agenda 2 Understanding and Using ASAM PPC-2R

3 A. Pretest Questions Select the Best Answer: 1. The best treatment system for addiction is: a. A 28-day stay in inpatient rehabilitation with much education. b. A broad continuum of care with all levels of care separated to maintain group trust. c. Not possible now that managed care has placed so much emphasis on cost-containment. d. A broad range of services designed to be as seamless as possible for continuity of care. e. Short stay inpatient hospitalization for psychoeducation. 2. The six assessment dimensions of the ASAM Criteria: a. Help assess the individual s comprehensive needs in treatment. b. Provide a structure for assessing severity of illness and level of function. c. Requires that there be access to medical and nursing personnel when necessary. d. Can help focus the treatment plan on the most important priorities. e. All of the above. 3. A multidimensional assessment in behavioral health treatment: a. Should include psychosocial factors such as readiness to change. b. Is ideal, but not necessary within a managed care environment. c. Should include biomedical and psychiatric problems, but not motivation or relapse potential. d. Is best done after detoxification is completed. e. Should be completed by the primary therapist only. 4. Criteria for Co-occurring Mental and Substance-Related Disorders: a. Helps define the kinds of programs that could meet the needs of dual diagnosis patients. b. Introduces a future directions matrix to match services to individual needs. c. Encourages addiction treatment providers to broaden access to care for dual diagnosis. d. Provides a common language for both mental health and addiction treatment systems. e. All of the above. Indicate True or False: 5. It is not the severity or functioning that determines the treatment plan, but the diagnosis, preferably in DSM terms. 6. There are six broad levels of care in the ASAM Criteria. 7. Dimension 5 focuses on internal attitudes, beliefs and coping skills to deal with relapse. 8. The level of care placement is the first decision to make in the assessment. 9. All programs should at least be Dual Diagnosis Capable (DDC). 10. Dimension 4, Readiness to Change, applies only to motivation for abstinence. 11. Clients in early stages of change need relapse prevention strategies. T F 3 Understanding and Using ASAM PPC-2R

4 B. Generations of Clinical Care in Addiction Treatment 1. Complications-driven Treatment No diagnosis of Substance Use Disorder Treatment of addiction complications with no continuing care Relapse triggers treatment of complications only No diagnosis Treatment of complications No continuing care Relapse 2. Diagnosis, Program-driven Treatment Diagnosis determines treatment Diagnosis Treatment is the primary program and aftercare Relapse triggers a repeat of the program Program Aftercare Relapse 3. Individualized, Clinically-driven Treatment PROGRESS Response to Treatment BIOPSYCHOSOCIAL Severity (SI) and Level of Functioning (LOF) PATIENT/PARTICIPANT ASSESSMENT Data from all BIOPSYCHOSOCIAL Dimensions PLAN BIOPSYCHOSOCIAL Treatment Intensity of Service (IS) - Modalities and Levels of Service PROBLEMS/PRIORITIES BIOPSYCHOSOCIAL Severity (SI) and Level of Functioning (LOF) 4 Understanding and Using ASAM PPC-2R

5 4. Client-Directed, Outcome-Informed Treatment PROGRESS Treatment Response: Clinical functioning,psychological, social/ interpersonal LOF Proximal Outcomes e.g., Session Rating Scale; Outcome Rating Scale PATIENT/PARTICIPANT ASSESSMENT Data from all BIOPSYCHOSOCIAL Dimensions PLAN BIOPSYCHOSOCIAL Treatment Intensity of Service (IS) - Modalities and Levels of Service PROBLEMS/PRIORITIES Build engagement and alliance working with multidimensional obstacles inhibiting the client from getting what they want. What will client do? 5. Paradigm Shift The Criteria have evolved over time to reflect the current scientific research. For example, since the first edition was published in 1991, the ASAM Criteria have evolved to encourage clinicians and programs to move: from unidimensional to more multidimensional assessments; from program-driven to more clinically driven treatment; from a fixed length of stay to variable length of service; and from a limited number of discrete levels of care to a continuum of care. (ASAM PPC-2R, p.1) C. Brief History of the ASAM Patient Placement Criteria (ASAM PPC-2R pp 12-14) 1987 Cleveland Criteria and the NAATP Criteria published 1991 ASAM PPC-1 published 1992 Coalition for National Clinical Criteria established 1994 ASAM Criteria Validity Study funded by NIDA 1995 The Role and Current Status of Patient Placement Criteria In the Treatment of Substance Use Disorders The Recommendations of a Consensus Panel. Co-Chairs: Lee Gartner and David Mee- Lee, M.D. Treatment Improvement Protocol. The Center for Substance Abuse Treatment ASAM PPC-2 published ASAM PPC endorsed by >20 states, DoD, VA, ValueOptions 1999 NIAAA funds Assessment Software project 2001 ASAM PPC-2R published 5 Understanding and Using ASAM PPC-2R

6 D. Principles Guiding ASAM PPC Development and Implications (ASAM-PPC-2R pp 15-17) Principle Objectivity Choice of Treatment Levels Continuum of Care Treatment Failure Length of Stay (LOS) Twelve Step/ Mutual/Self-Help Recovery Groups Implications 1. The criteria are as objective, measurable and quantifiable as possible. 2. Certain aspects of the criteria require subjective interpretation. 3. Like other medical or psychiatric conditions diagnosis, assessment and treatment is a mix of objectively measured criteria and experientially based professional judgments. 1. Referral to specific level of care is based on a multidimensional assessment of the patient. 2. The goal is a level of care that is least intensive that can accomplish the treatment objectives while providing safety and security. 3. Levels presented as discrete, but represent benchmarks or points along a continuum of treatment services used in a variety of ways depending on a patient s needs and response. 4. Patient enters the continuum at any level and moves through levels of care in consecutive order or skipping levels as needed. 1. Within and across the levels of care, there is a continuum of the severity of illnesses treated; and the intensities of services provided. 2. Funding and reimbursement needs to match this continuum of care and intensities of service. 3. If only one of many levels of care is offered, movement between levels requires linking patient with providers of other levels of care whenever indicated by the assessment of the patient s needs and progress. 1. A concern is the concept of treatment failure, which has been used by some reimbursement or managed care organizations as a prerequisite for approving admission to a more intensive level of care (e.g., failure in outpatient treatment as a prerequisite for admission to inpatient treatment). 2. Because ASAM believes that individual treatment decisions should be based upon an assessment of each patient, the requirements that a person fail one or more times in outpatient treatment before he or she can be considered for inpatient treatment is no more rational than treating every patient in an inpatient program or using a fixed length of stay for all. 1. No fixed LOS 2. LOS depends on severity of illness and progress/response to treatment 1. Initial consideration was given to including self-help recovery groups such as Alcoholics Anonymous, Narcotics Anonymous or Cocaine Anonymous as a formal treatment level. 2. As valuable as they are, these recovery groups do not constitute a treatment level and do not meet the criteria used to describe the programmatic aspects of different levels of treatment. Rather, it is best to consider them self problem identification, helpseeking options. 3. Significant consideration was given to specific inclusion of spiritual parameters as they relate to placement criteria. We acknowledge that spirituality is absolutely inherent in the comprehensive biopsychosocial multidimensional assessment, treatment, and continuity of care for substance-related disorders. Spiritual concepts, ideas, and relationships are integral to all levels of care and, to a certain degree, even transcend each level of care; nonetheless, they are difficult to define acceptably in objective, behavioral and measurable terms. Spirituality is implied in all dimensions and in all levels of care, and certainly is inherent in the Twelve Step philosophy. 6 Understanding and Using ASAM PPC-2R

7 1. Assessment of Biopsychosocial Severity and Function (ASAM PPC-2R, pp 5-7) The common language of the six assessment dimensions of the ASAM Patient Placement Criteria can be used to determine multidimensional assessment of severity and level of function; needs and resources; problems and strengths of people seeking addiction and mental health services. 1. Acute intoxication and/or withdrawal potential 2. Biomedical conditions and complications 3. Emotional/behavioral/cognitive conditions and complications 4. Readiness to Change 5. Relapse/Continued Use/Continued Problem potential 6. Recovery environment Assessment Dimensions 1. Acute Intoxication and/ or Withdrawal Potential 2. Biomedical Conditions and Complications 3. Emotional, Behavioral or Cognitive Conditions and Complications Assessment and Treatment Planning Focus Assessment for intoxication and/or withdrawal management. Detoxification in a variety of levels of care and preparation for continued addiction services. Assess and treat co-occurring physical health conditions or complications. Treatment provided within the level of care or through coordination of physical health services. Assess and treat co-occurring diagnostic or sub-diagnostic mental health conditions or complications. Treatment provided within the level of care or through coordination of mental health services. 4. Readiness to Change Assess stage of readiness to change. If not ready to commit to full recovery, engage into treatment using motivational enhancement strategies. If ready for recovery, consolidate and expand action for change. 5. Relapse, Continued Use or Continued Problem Potential Assess readiness for relapse prevention services and teach where appropriate. If still at early stages of change, focus on raising consciousness of consequences of continued use or continued problems as part of motivational enhancement strategies. 6. Recovery Environment Assess need for specific individualized family or significant other, housing, financial, vocational, educational, legal, transportation, childcare services. 2. Biopsychosocial Treatment - Overview: 5 M s * Motivate - Dimension 4 issues; engagement and alliance building * Manage - the family, significant others, work/school, legal * Medication - detox; HIV/AIDS; anti-craving anti-addiction meds; disulfiram, methadone; buprenorphine, naltrexone, acamprosate, psychotropic medication * Meetings - AA, NA, Al-Anon; Smart Recovery, Dual Recovery Anonymous, etc. * Monitor - continuity of care; relapse prevention; family and significant others 7 Understanding and Using ASAM PPC-2R

8 3. Treatment Levels of Service (ASAM PPC-2R, pp 2-4) I Outpatient Services II Intensive Outpatient/Partial Hospitalization Services III Residential/Inpatient Services IV Medically-Managed Intensive Inpatient Services Levels of Care and Service in ASAM PPC-2R: (ASAM PPC-2R, pp 2-4) Level 0.5: Early Intervention Services (ASAM PPC-2R, pp 41-44; pp ) - Criteria for assessment and education services for individuals with problems or risk factors related to substance use, but for whom an immediate Substance Related Disorder cannot be confirmed. Further assessment is warranted to rule in or out addiction. Opioid Maintenance Therapy (OMT) (ASAM PPC-2R, pp ) - Criteria for Level I Outpatient OMT, with discussion that OMT can be in all levels of service, and not restricted to only being an outpatient treatment modality. Detoxification Services for Dimension 1 (Adult Criteria only) (ASAM PPC-2R pp ) I-D - Ambulatory Detoxification without Extended On-site Monitoring II-D - Ambulatory Detoxification with Extended On-site Monitoring III.2-D - Clinically-Managed Residential Detoxification Services (Social Detoxification) III.7-D - Medically-Monitored Inpatient Detoxification Services IV-D - Medically-Managed Inpatient Detoxification Services Level I Outpatient Services (ASAM PPC-2R, pp 45-56; pp ) I - Outpatient Treatment (<9 hours/week for Adults; <6 hours/week for Adolescents) Level II Intensive Outpatient/Partial Hospitalization Services (ASAM PPC-2R, pp 55-69; pp ) II.1 - Intensive Outpatient Treatment (9 hours/ week for Adults; 6 hours/week for Adolescents) II.5 - Partial Hospitalization Treatment Level III Residential/Inpatient Services (ASAM PPC-2R, pp ; pp ) III.1 - Clinically-Managed, Low Intensity Residential Treatment (Halfway House; Support. Living Envir.) III.3 - Clinically-Managed, Medium Intensity Residential Treatment (Therapeutic Rehabilitation Facility) (This level is not in the Adolescent Criteria continuum of care) III.5 - Clinically-Managed, Medium/High Intensity Residential Treatment (Therapeutic Community, Residential Treatment Center) III.7 - Medically-Monitored Intensive Inpatient Treatment (Inpatient Treatment Center) Level IV Medically-Managed Intensive Inpatient Services (ASAM PPC-2R, pp ; pp ) IV - Medically-Managed Intensive Inpatient Treatment 8 Understanding and Using ASAM PPC-2R

9 ASAM PPC-2R Level of Detoxification Service for Adults Ambulatory Detoxification without Extended On-Site Monitoring Ambulatory Detoxification with Extended On-Site Monitoring Clinically-Managed Residential Detoxification Medically-Monitored Inpatient Detoxification Medically-Managed Inpatient Detoxification Level I-D II-D III.2-D III.7-D IV-D Note: There are no separate Detoxification Services for Adolescents Mild withdrawal with daily or less than daily outpatient supervision; likely to complete detox. and to continue treatment or recovery Moderate withdrawal with all day detox. support and supervision; at night, has supportive family or living situation; likely to complete detox. Moderate withdrawal, but needs 24-hour support to complete detox. and increase likelihood of continuing treatment or recovery Severe withdrawal and needs 24-hour nursing care and physician visits as necessary; unlikely to complete detox. without medical, nursing monitoring Severe, unstable withdrawal and needs 24-hour nursing care and daily physician visits to modify detox. regimen and manage medical instability ASAM PPC-2R Levels of Care Level Same Levels of Care for Adolescents except Level III Early Intervention Assessment and education for at risk individuals who do not 0.5 meet diagnostic criteria for Substance-Related Disorder Outpatient Services Less than 9 hours of service/week (adults); less than 6 hours/ I week (adolescents) for recovery or motivational enhancement therapies/ strategies Intensive Outpatient 9 or more hours of service/week (adults); 6 or more hours/ II.1 week (adolescents) to treat multidimensional instability Partial Hospitalization 20 or more hours of service/week for multidimensional II.5 instability not requiring 24 hour care Clinically-Managed Low-Intensity 24 hour structure with available trained personnel; at least 5 III.1 Residential hours of clinical service/week Clinically-Managed Med-Intensity Residential 24 hour care with trained counselors to stabilize multidimensional imminent danger. Less intense milieu III.3 and group treatment for those with cognitive or other impairments unable to use full active milieu or therapeutic community Clinically-Managed High-Intensity Residential Medically-Monitored Intensive Inpatient Medically-Managed Intensive Inpatient III.5 III.7 IV 24 hour care with trained counselors to stabilize multidimensional imminent danger and prepare for outpatient treatment. Able to tolerate and use full active milieu or therapeutic community 24 hour nursing care with physician availability for significant problems in Dimensions 1, 2 or 3. Sixteen hour/day counselor ability 24 hour nursing care and daily physician care for severe, unstable problems in Dimensions 1, 2 or 3. Counseling available to engage patient in treatment 9 Understanding and Using ASAM PPC-2R

10 E. Terminology Decimal point system (ASAM PPC-2R, p.2) Assessment dimensions use regular Arabic numbers Levels of Service - Levels I-IV since 1991 to maintain common language Roman numerals Examples, Setting, Support Systems, Staff, Therapies, Assessment/Treatment Plan Review, Documentation (ASAM PPC-2R, Adult Level II, pp.57-61; Adolescent Level III, p ) DSM-IV diagnoses - Substance-Induced and Substance Use Disorders; Diagnostic Admission Criteria Diagnostic Admission Criteria (ASAM PPC-2R, Adult Level III, p.98; Adolescent Level III, p. 254) Dimensional Admission Criteria (ASAM PPC-2R, Adult Level I, p.50; Adult Level IV, p. 132) Clinically-Managed (ASAM PPC-2R, p. 360) Residential versus Inpatient Length of Stay (ASAM PPC-2R, p. 16); Length of Service (ASAM PPC-2R, p. 45) F. Selected ASAM PPC-2R Changes 1. Improving Level I, Outpatient Services (ASAM PPC-2R, p. 52; p. 215) The additional admission criteria for Dimension 4, Level I services (page 52, 2001) are as follows: (c) The patient is ambivalent about a substance-related and/or mental health problem. He or she requires monitoring and motivating strategies, but not a structured milieu program. For example, the patient has sufficient awareness and recognition of a substance use and/or mental health problems to allow engagement and follow-through with attendance at intermittent treatment sessions as scheduled; or (d) The patient may not recognize that he or she has a substance-related and/or mental health problem. For example, he or she is more invested in avoiding a negative consequence than in the recovery effort. Such a patient may require monitoring and motivating strategies to engage in treatment and to progress through the stages of change. 2. Changes to Continued Service and Discharge Criteria (ASAM PPC-2R, pp. 7, 35-40; pp ) In the process of patient assessment, certain problems and priorities are identified as justifying admission to a particular level of care. The resolution of those problems and priorities determines when a patient can be treated at a different level or discharged from treatment. The appearance of new problems may require services that can be provided effectively at the same level of care, or they may require a more or less intensive level of care. After the admission criteria for a given level of care have been met, the criteria for continued service, discharge or transfer from that level of care are as follows: 10 Understanding and Using ASAM PPC-2R

11 Continued Service Criteria: It is appropriate to retain the patient at the present level of care if: 1. The patient is making progress, but has not yet achieved the goals articulated in the individualized treatment plan. Continued treatment at the present level of care is assessed as necessary to permit the patient to continue to work toward his or her treatment goals; 2. The patient is not yet making progress but has the capacity to resolve his or her problems. He or she is actively working on the goals articulated in the individualized treatment plan. Continued treatment at the present level of care is assessed as necessary to permit the patient to continue to work toward his or her treatment goals; or and/or 3. New problems have been identified that are appropriately treated at the present level of care. This level is the least intensive at which the patient s new problems can be addressed effectively. To document and communicate the patient s readiness for discharge or need for transfer to another level of care, each of the six dimensions of the ASAM criteria should be reviewed. If the criteria apply to the patient s existing or new problem(s), the patient should continue in treatment at the present level of care. If not, refer the Discharge/Transfer Criteria, below. Discharge/Transfer Criteria: It is appropriate to transfer or discharge the patient from the present level of care if he or she meets the following criteria: 1. The patient has achieved the goals articulated in his or her individualized treatment plan, thus resolving the problem(s) that justified admission to the current level of care; or 2. The patient has been unable to resolve the problem(s) that justified admission to the present level of care, despite amendments to the treatment plan. Treatment at another level of care or type of service therefore is indicated; 3. The patient has demonstrated a lack of capacity to resolve his or her problem(s). Treatment at another level of care or type of service therefore is indicated; 4. The patient has experienced an intensification of his or her problem(s), or has developed a new problem(s), and can be treated effectively only at a more intensive level of care. or or To document and communicate the patient s readiness for discharge or need for transfer to another level of care, each of the six dimensions of the ASAM criteria should be reviewed. If the criteria apply to the existing or new problem(s), the patient should be discharged or transferred, as appropriate. If not, refer to the Continued Service criteria. 11 Understanding and Using ASAM PPC-2R

12 3. ASAM PPC-2R s Approach to Co-occurring Disorders (ASAM PPC-2R, pp. 7-12) (a) Historical context of the ASAM PPC Dimension : Emotional/Behavioral Conditions and Complications versus Psychiatric Conditions, which would keep Dimension 3 too focused on mental health treatment and dual diagnosis; and diminish interest in mental health issues as an expected part of addiction and recovery Conditions refers to co-occurring mental disorders (dual diagnosis) Complications refers to addiction-related, mental health problems that can distract the client s attention from primary addiction recovery treatment (b) Terminology Used The addiction and mental health fields have not yet reached consensus on terminology to describe individuals who are experiencing simultaneous addictive and mental health disorders. Clearly, this issue requires further discussion and consensus building. In the interim, the ASAM PPC 2R has adopted the term Co-occurring Mental and Substance Related Disorders in formal titles so as to remain consistent with the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association. Throughout the text, however, the term dual diagnosis is used for the sake of simplicity and because it appears to have the widest acceptance nationally. (The authors recognize that dual diagnosis is an inexact term and that it fails to accommodate populations other than those with mental and substance related disorders such as persons with coexisting addictive and biomedical or developmental disorders but the advantages of simplicity and wide acceptance were judged to outweigh these deficits. We expect to revisit this decision in future editions of the Patient Placement Criteria.) (c) Adult versus Adolescent Criteria Differences Dimension 3 Subdomains Assumptions about Adolescent Criteria developmental issues; co-occurring emotional, behavioral and cognitive issues and the need for a more clinically-sophisticated staff More focus on mental health issues for adolescents who often have co-occurring emotional/ behavioral issues. No AOS, DDC or DDE descriptions in adolescent criteria (d) Dual Diagnosis Program Descriptions AOS, MHOS, DDC, DDE When the first edition of the ASAM Patient Placement Criteria (ASAM PPC 1) was published in 1991, the criteria generally were designed for programs that offered only addiction treatment services. However, the PPC 1 also acknowledged that some patients had co-occurring mental and substance use problems and thus included Dimension 3, Emotional/Behavioral Conditions and Complications. Such patients are not adequately treated in programs that offer only addiction treatment services. The ASAM PPC 2R describes three types of services: those that offer Addiction-Only Services (AOS), those that are Dual Diagnosis Capable (DDC), and those that are Dual Diagnosis Enhanced (DDE). AOS has been modified to describe Mental Health-Only Services (MHOS). Programs capabilities are defined as follows: 12 Understanding and Using ASAM PPC-2R

13 Description of Services 1. Programs that offer Addiction-Only Services (AOS)/Mental Health-Only Services (MHOS) Cannot accommodate patients with psychiatric illnesses that require ongoing treatment, however stable the illness and however well functioning the individual. Such programs are said to provide Addiction-Only Services (AOS). Cannot accommodate those with addiction illness are Mental Health-Only Services. The policies and procedures typically do not accommodate co-occurring disorders: for example, individuals on certain psychotropic medications generally are not accepted in AOS, coordination or collaboration between chemical and mental health services is not routinely present, and mental health issues are not usually addressed in treatment planning or content in AOS and vice versa in MHOS. 2. Dual Diagnosis Capable (DDC) Programs Dual Diagnosis Capable (DDC) programs routinely accept individuals who have co-occurring mental and substance related disorders. DDC programs can meet such patients needs so long as their psychiatric disorders are sufficiently stabilized and the individuals are capable of independent functioning to such a degree that their mental disorders do not interfere with participation in addiction treatment in AOS; and vice versa. DDC programs address dual diagnoses in their policies and procedures, assessment, treatment planning, program content, and discharge planning. They have arrangements in place for coordination and collaboration between chemical and mental health services. They also can provide addiction consultation, psychopharmacologic monitoring and psychological assessment and consultation on site; or by well-coordinated consultation off-site. 3. Dual Diagnosis Enhanced (DDE) Programs DDE programs can accommodate individuals with dual diagnoses who may be unstable or disabled to such an extent that specific psychiatric and mental health support, monitoring and accommodation are necessary in order for the individual to participate in addiction treatment. DDE programs are staffed by psychiatric and mental health clinicians as well as addiction treatment professionals. Cross training is provided to all staff. Such programs tend to have relatively high ratios of staff to patients and provide close monitoring of patients who demonstrate psychiatric instability and disability. DDE programs typically have policies, procedures, assessment, treatment planning and discharge planning that accommodate patients with dual diagnoses. Dual diagnosis-specific and mental health symptom management groups are incorporated into addiction treatment. Motivational enhancement therapies are more likely to be available (particularly in outpatient settings) Ideally, there is close collaboration or integration with a mental health program that provides crisis back-up services and access to mental health case management and continuing care. 13 Understanding and Using ASAM PPC-2R

14 4. Experimental Matrix and Co-occurring Disorders (ASAM PPC-2R, pp ; pp ) Matrix for Matching Services to Needs Risk Rating and Description Assess severity and level of function to identify needs for services in all six ASAM assessment dimensions Risk ratings are benchmarked on a scale of 0 to 4 with 0 indicating full function and no risk in this assessment dimension If risk rating is 1-4, the severity and risk level rises with the higher number in whatever assessment dimension is being assessed Types of Services and Modalities Needed Identify what variety of services are required to address priority needs based on the risk assessment in each dimension If 0, no specific services are needed in this assessment dimension Specific services in an individualized treatment plan are designed to match the severity, level of function and risk in this assessment dimension Intensity of Service/ Level of Care/Setting Determine what type of service setting and level of care can efficiently, safely provide the needed intensities of service Intensity of services are benchmarked on a scale of 0 to 4 with 0, indicating that no specific level of care or treatment setting is needed in this assessment dimension The intensity of services will rise with the higher risk rating in Dimensions 1-3, but will be variable for Dimensions 4-6 depending on the mix of services in the middle column Risk Description. The risk descriptions and ratings within each assessment dimension help staff determine the immediacy and scope of the service plan by guiding what types and modalities of service are needed. They also indicate the intensity or level of service at which the patient can be treated with safety and efficacy. Risk Domains. A Risk Domain is an assessment subcategory within Dimension 3, as described below: (ASAM PPC-2R, p. 182) Dangerousness/Lethality. This Risk Domain describes how impulsive an individual may be with regard to homicide, suicide, or other forms of harm to self or others and/or to property. The seriousness and immediacy of the individual s ideation, plans and behavior as well as his or her ability to act on such impulses determine patient s risk rating and type/intensity of services needed. 14 Understanding and Using ASAM PPC-2R

15 Interference with Addiction Recovery Efforts. This Risk Domain describes the degree to which a patient is distracted from addiction recovery efforts by emotional, behavioral and/or cognitive problems and, conversely, the degree to which a patient is able to focus on addiction recovery. (High risk and severe impairment in this domain do not, alone, require services in a Level IV program.) Social Functioning. This Risk Domain describes the degree to which an individual s relationships (e.g., coping with friends, significant others or family; vocational or educational demands; and ability to meet personal responsibilities) are affected by his or her substance use and/or other emotional, behavioral and cognitive problems. (Note that high risk and severe impairment in this domain do not, in themselves, require services in a Level IV program.) Ability for Self Care. This Risk Domain describes the degree to which an individual s ability to perform activities of daily living (such as grooming, food and shelter) are affected by his or her substance use and/or other emotional, behavioral and cognitive problems. (Note that high risk and severe impairment in this domain do not, in themselves, require services in a Level IV program.) Course of Illness. This Risk Domain employs the history of the patient s illness and response to treatment to interpret the patient s current signs, symptoms and presentation and predict the patient s likely response to treatment. Thus, the domain assesses the interaction between the chronicity and acuity of the patient s current deficits. A high risk rating is warranted when the individual is assessed at significant risk and vulnerability for dangerous consequences either because of severe, acute life threatening symptoms, or because a history of such instability suggests that high intensity services are needed to prevent dangerous consequences. For example, a patient may present with medication adherence problems, having discontinued antipsychotic medication two days ago. If a patient is known to rapidly decompensate when medication is stopped, his or her rating is high. However, if it the patient slowly isolates without any rapid deterioration when medication is stopped, the risk rating would be less. Another example is the patient who has been depressed and socially withdrawn. If this has been a problem for six weeks, the risk rating is much higher than for a patient who has been chronically withdrawn and isolated for six years with a severe and persistent schizophrenic disorder. 15 Understanding and Using ASAM PPC-2R

16 5. Revised Constructs for Dimension 5: Relapse/Continued Use Potential (ASAM PPC- 2R, pp ) A. Historical Pattern of Use 1. Chronicity of Problem Use Since when and how long has the individual had problem use or dependence and at what level of severity? 2 2. Treatment or Change Response Has he/she managed brief or extended abstinence or reduction in the past? B. Pharmacologic Responsivity 3. Positive Reinforcement (pleasure, euphoria) 4. Negative Reinforcement (withdrawal discomfort, fear) C. External Stimuli Responsivity 5. Reactivity to Acute Cues (trigger objects and situations) 6. Reactivity to Chronic Stress (positive and negative stressors) D. Cognitive and behavioral measures of strengths and weaknesses 7. Locus of Control and Self-efficacy Is there an internal sense of self-determination and confidence that the individual can direct his/her own behavioral change? 8. Coping Skills (including stimulus control, other cognitive strategies) 9. Impulsivity (risk-taking, thrill-seeking) 10. Passive and passive/aggressive behavior Does the individual demonstrate active efforts to anticipate and cope with internal and external stressors, or is there a tendency to leave or assign responsibility to others? 6. The Adolescent Criteria Dimension 3 subdomains added The traditional format of levels of service maintained for PPC-2R Level I is less than six hours/week not less than nine hours as in the adult criteria Level II.1 is six hours per week not nine hours /week as in adult criteria Levels of Service similar to those of Adult PPC-2 Criteria with one less Level III service no III.3 No separate detoxification levels of service A proposed new format of criteria (modeled on the Co-occurring Disorders criteria Matrix) in a section of ASAM PPC-2R that will indicate new directions for the Adolescent Criteria More focus on mental health issues for adolescents who often have co-occurring emotional/ behavioral issues. No AOS, DDC or DDE descriptions in adolescent criteria 16 Understanding and Using ASAM PPC-2R

17 G. How to Organize Assessment Data to Focus Treatment Immediate Need Profile Assessor considers each dimension and with just sufficient data to assess immediate needs, checks yes or no for the following questions: 1. Acute Intoxication and/or Withdrawal Potential (a) Past history of serious withdrawal, life-threatening symptoms or seizures during withdrawal? e.g., need for IV therapy; hospitalization for seizure control; psychosis with DT s; medication management with close nurse monitoring and medical management? No Yes (b) Currently having similar withdrawal symptoms? No Yes 2. Biomedical Conditions/Complications Any current severe physical health problems? e.g., bleeding from mouth or rectum in past 24 hours; recent, unstable hypertension; recent, severe pain in chest, abdomen, head; significant problems in balance, gait, sensory or motor abilities not related to intoxication. No Yes 3. Emotional/Behavioral/Cognitive Conditions/ Complications (a) Imminent danger of harming self or someone else? e.g., suicidal ideation with intent, plan and means to succeed; homicidal or violent ideation, impulses and uncertainty about ability to control impulses, with means to act on. No Yes (b) Unable to function in activities of daily living, self with imminent, dangerous consequences? e.g., unable to bath, feed, groom and care for self due to psychosis, organicity or uncontrolled intoxication with threat of imminent safety to self, others as regards death or severe injury No Yes 4. Readiness to Change (a) Does client appear to need alcohol or other drug treatment/recovery and/or mental health treatment, but ambivalent or feels it unnecessary? e.g., severe addiction, but client feels controlled use still OK; psychotic, but blames a conspiracy. No Yes (b) Client has been coerced, mandated or required to have assessment and/or treatment by the criminal justice system, health or social services, work/school, or family/significant other? No Yes 5. Relapse/Continued Use/Continued Problem Potential (a) Is client currently under the influence? No Yes (b) Is client likely to continue to use or relapse in an imminently dangerous manner, without immediate care? No Yes (c) Is client s most troubling, presenting problem(s) that brings the client for assessment, dangerous to self or others? (See examples above in dimensions 1, 2 and 3) No Yes 6. Recovery Environment Are there any dangerous family, significant others, living/work/school situations threatening client s safety, immediate well-being, and/or sobriety? e.g., living with a drug dealer; physically abused by partner or significant other; homeless in freezing temperatures No Yes 17 Understanding and Using ASAM PPC-2R

18 H. How to Target and Focus Service Priorities Decision Tree to Match Assessment and Treatment/Placement Assignment What Does the Client Want? Why Now? Does client have immediate needs due to imminent risk in any of the six assessment dimensions? Conduct multidimensional assessment What are the multiaxial DSM IV diagnoses? Multidimensional Severity /LOF Profile Identify which assessment dimensions are currently most important to determine Tx priorities Choose a specific focus and target for each priority dimension What specific services are needed for each dimension? What dose or intensity of these services is needed for each dimension? Where can these services be provided, in the least intensive, but safe level of care or site of care? What is the progress of the treatment plan and placement decision; outcomes measurement? 18 Understanding and Using ASAM PPC-2R

19 Case Presentation Format Before presenting the case, please state why you chose the case and what you want to get from the discussion I. Identifying Client Background Data Name Age Ethnicity and Gender Marital Status Employment Status Referral Source Date Entered Treatment Level of Service Client Entered Treatment (if this case presentation is a treatment plan review) Current Level of Service (if this case presentation is a treatment plan review) DSM Diagnoses Stated or Identified Motivation for Treatment (What is the most important thing the clients wants you to help them with?) First state how severe you think each assessment dimension is and why (focus on brief history information and relevant here and now information): II. Current Placement Dimension Rating (See Dimensions below 1-6) (Give a brief explanation for each rating, note whether it has changed since the client entered treatment and why or why not) This last section we will talk about together: III. What problem(s) with High and Medium severity rating are of greatest concern at this time? Specificity of the problem Specificity of the strategies/interventions Efficiency of the intervention (Least intensive, but safe, level of service) 19 Understanding and Using ASAM PPC-2R

20 I. Engaging the Client as a Participant in Treatment 1. Stages of Change and How People Change 12-Step model - surrender versus comply; accept versus admit; identify versus compare Transtheoretical Model of Change (Prochaska and DiClemente): Pre-contemplation: not yet considering the possibility of change although others are aware of a problem; active resistance to change; seldom appear for treatment without coercion; could benefit from non-threatening information to raise awareness of a possible problem and possibilities for change. Contemplation: ambivalent, undecided, vacillating between whether he/she really has a problem or needs to change; wants to change, but this desire exists simultaneously with resistance to it; may seek professional advice to get an objective assessment; motivational strategies useful at this stage, but aggressive or premature confrontation provokes strong resistance and defensive behaviors; many Contemplators have indefinite plans to take action in the next six months or so. Preparation: takes person from decisions made in Contemplation stage to the specific steps to be taken to solve the problem in the Action stage; increasing confidence in the decision to change; certain tasks that make up the first steps on the road to Action; most people planning to take action within the very next month; making final adjustments before they begin to change their behavior. Action: specific actions intended to bring about change; overt modification of behavior and surroundings; most busy stage of change requiring the greatest commitment of time and energy; care not to equate action with actual change; support and encouragement still very important to prevent drop out and regression in readiness to change. Maintenance: sustain the changes accomplished by previous action and prevent relapse; requires different set of skills than were needed to initiate change; consolidation of gains attained; not a static stage and lasts as little as six months or up to a lifetime; learn alternative coping and problem-solving strategies; replace problem behaviors with new, healthy life-style; work through emotional triggers of relapse. Relapse and Recycling: expectable, but not inevitable setbacks; avoid becoming stuck, discouraged, or demoralized; learn from relapse before committing to a new cycle of action; comprehensive, multidimensional assessment to explore all reasons for relapse. Termination: this stage is the ultimate goal for all changers; person exits the cycle of change, without fear of relapse; debate over whether certain problems can be terminated or merely kept in remission through maintenance strategies. Readiness to Change - not ready, unsure, ready, trying: Motivational interviewing (Miller and Rollnick) 20 Understanding and Using ASAM PPC-2R

21 The Transtheoretical Model of Behavior Change The Stages of Change Termination Action Maintenance Contemplation Preparation Precontemplation The Processes of Change Precontemplation Contemplation Preparation Action Maintenance Consciousness Raising Social Liberation Helping Relationships Emotional Arousal Self-Reevaluation Environmental Reevaluation Commitment Reward Countering Environment Control 21 Understanding and Using ASAM PPC-2R

22 2. Developing the Treatment Contract What Does the Client Want? Client Clinical Assessment Treatment Plan What? What does client want? What does client need? What is the Tx contract? Why? How? Where? When? Why now? What s the level of commitment? How will s/he get there? Where will s/he do this? When will this happen? How quickly? How badly does s/he want it? Why? What reasons are revealed by the assessment data? How will you get him/her to accept the plan? Where is the appropriate setting for treatment? What is indicated by the placement criteria? When? How soon? What are realistic expectations? What are milestones in the process? Is it linked to what client wants? Does client buy into the link? Referral to level of care What is the degree of urgency? What is the process? What are the expectations of the referral? J. Improving the Range and Use of Treatment Services 1. Dimension 4, Readiness to Change Assessment and Matching Stage of Change Service Track Treatment Processes Used PPC-2R Level Precontemplation Discovery Track Consciousness-Raising, Social Liberation Contemplation Discovery Track As above, plus Emotional Arousal, Self-Evaluation Preparation Mix of Discovery & Recovery Tracks Emotional Arousal, Self- Evaluation, Commitment Action Recovery Tracks Commitment, Reward, Countering, Environment Control, Helping Relationships Relapse, Recycling Relapse Track Based on assessed Stage of Change to which client has regressed or recycled Level 0.5 or I Level I Levels I - II.5 Levels I - II.5 Levels I - IV 22 Understanding and Using ASAM PPC-2R

23 2. Example Policy and Procedure to Deal with Recovery and Psychosocial Crises Recovery and Psychosocial Crises cover a variety of situations that can arise while a patient is in treatment. Examples include, but are not limited to, as follows: 1. Slip/ using alcohol or other drugs while in treatment. 2. Suicidal, and the individual is feeling impulsive or wanting to use alcohol or other drugs. 3. Loss or death, disrupting the person s recovery and precipitating cravings to use or other impulsive behavior. 4. Disagreements, anger, frustration with fellow patients or therapist. The following procedures provide steps to assist in implementing the principle of re-assessment and modification of the treatment plan: 1. Set up a face to face appointment as soon as possible. If not possible in a timely fashion, follow the next steps via telephone. 2. Convey an attitude of acceptance; listen and seek to understand the patient s point of view rather than lecture, enforce program rules, or dismiss the patient s perspective. 3. Assess the patient s safety for intoxication/withdrawal and imminent risk of impulsive behavior and harm to self, others, or property. Use the six ASAM assessment dimensions to screen for severe problems and identify new issues in all biopsychosocial areas. Acute intoxication and/or withdrawal potential Biomedical conditions and complications Emotional/behavioral/cognitive conditions and complications Readiness to Change Relapse/Continued Use/Continued Problem potential Recovery environment 4. Discuss the circumstances surrounding the crisis, developing a sequence of events and precipitants leading up to the crisis. If the crisis is a slip, use the 6 dimensions as a guide to assess causes. If the crisis appears to be willful, defiant, non-compliance with the treatment plan, explore the patient s understanding of the treatment plan; level of agreement on the strategies in the treatment plan; and reasons s/he did not follow through. 5. Modify the treatment plan with patient input, to address any new or updated problems that arose from your multidimensional assessment in steps 3 and 4 above. 6. Reassess the treatment contract and what the patient wants, if there appears to be resistance to developing a modified treatment plan in step 5 above. 7. Determine if the modified strategies can be accomplished in the current level of care; or need a more or less intensive level of care in the continuum of services. 8. If, on completion of step 6, the patient recognizes the problem/s; understands the need to change the treatment plan to learn and apply new strategies to deal with the newly-identified issues; but still chooses not to accept treatment, then discharge is appropriate. 9. Document the crisis and modified treatment plan or discharge in the medical record. 23 Understanding and Using ASAM PPC-2R

24 3. The Coerced Client and Working with Referral Sources The mandated client can often present as hostile and resistant because they are at action for staying out of jail; keeping their driver s license; saving their job or marriage; or getting their children back. In working with referral agencies whether that be a judge, probation officer, child protective services, a spouse, employer or employee assistance professional, the goal is to use the leverage of the referral source to hold the client accountable to an assessment and follow through with the treatment plan. Criminal justice professionals such as judges, probation and parole officers untrained in addiction and mental health run the risk of thinking that mental health and addiction issues can be addressed from a criminal justice model. They can see mandated treatment for addiction and mental health problems as a criminal justice intervention e.g., mandate the client to a particular level of care of addiction treatment for a fixed length of stay as if ordering an offender to jail for a jail term of three months. Unfortunately, clinicians and programs often enable such criminal justice thinking by blurring the boundaries between doing time and doing treatment. Clinicians say that they cannot provide individualized treatment since they have to comply with court orders for a particular program and level of care and length of stay. For everyone involved with mandated clients and think this way, the 3 C s are important: 3 C s Consequences It is within criminal justice s mission to ensure that offenders take the consequences of their illegal behavior. If the court agrees that the behavior was largely caused by addiction and/or mental illness, and that the offender and the public is best served by providing treatment rather than punishment, then clinicians provide treatment not custody and incarceration. The obligation of clinicians is to ensure a person adheres to treatment; not to enforce consequences and compliance with court orders. Compliance The offender is required to act in accordance with the court s orders; rules and regulations. Criminal justice personnel should expect compliance. But clinicians are providing treatment where the focus is not on compliance to court orders. The focus is on whether there is a disorder needing treatment; and if there is, the expectation is for adherence to treatment, not compliance with doing time in a treatment place. Control The criminal justice system aims to control, if not eliminate, illegal acts that threaten the public. While control is appropriate for the courts, clinicians and treatment programs are focused on collaborative treatment and attracting people into recovery. The only time clinicians are required to control a client is if they are in imminent danger of harm to self or others. Otherwise, as soon as that imminent danger is stabilized, treatment resumes collaboration and client empowerment, not consequences, compliance and control. 24 Understanding and Using ASAM PPC-2R