Vol. #14, No. 11
In this issue
David Mee-Lee M.D.
From January 29 to February 1, I participated in C4 Recovery Solutions’ Addiction Executives Industry Summit (AXIS) conference in Naples, Florida. AXIS is designed as an intensive 3-day strategic planning event where there is as much peer-to-peer collaborative learning and roundtable discussions as there are didactic learning presentations.
At one roundtable discussion we were focusing on where addiction services are headed; and how the continuum of care should/will be designed, delivered and paid for. It was interesting to note how our terminology and descriptions of services reflected, not so surprisingly, our underlying concepts about what addiction is and what treatment should look like.
Longtime readers of Tips & Topics (TNT) will note that I have touched on these issues for many years (we are in our 14th year of publishing TNT). But I thought it would be useful to make a table out of it.
Discern what your norms and beliefs are about treatment as you listen to the words you use to describe the design and delivery of services
|Old terms||New terms||So what?|
|Transition from the current level of care||Graduate and complete the program||1. Program-driven care vs. continuum of levels of care|
|Graduated||Achieved treatment goals for this level of care||2. When does a person “graduate” from treatment for diabetes, schizophrenia, hypertension, asthma, bipolar disorder?|
|Graduation ceremony||RCA ceremony||3. See Tips & Topics, March 2011RCA Ceremony|
|Discharge||Transfer||4. Treatment continues in the next level of care, thus “transfer”|
|Refer||Link||5. Break down silos of care & “link” to assure continuity of care|
|Least restrictive||Least intensive||6. Treatment is about “intensity” of services, not “restrictiveness” of services|
|Higher or lower level of care||More or less intensive level||7. Treatment is about “intensity” of services, not “higher or lower” services|
|Pre and post-treatment||Treatment||8. Disease management is continuous services not a program level for which there is “pre-treatment” before a person gets to the program; and “post-treatment as if real treatment has ended.” services|
|Primary treatment program||Acute care stabilization||9. The initial treatment experience is not an intensive residential or intensive outpatient program followed by aftercare. It may involve acute care stabilization in withdrawal management or a short length of time to prepare a person for ongoing care in the level of care needed.|
|Prolonged or extended care||Continuing care||10. The length of stay for each person is based on severity, function, service needs and progress. There is no fixed length that needs to be “prolonged” or “extended”, just “continuing care”|
|Aftercare||Continuing care||11. Addiction treatment is not a “primary treatment program” followed by “aftercare” but just “care” or “continuing care”|
|Fee for Service||Capitated, case rates or per member per month payment (PMPM)||12. Payment is shifting from paying for a service, a slot or a bed to paying for outcomes, effectiveness and efficiency. Payment for the health of a designated population, not payment for individual services|
|Case closed if not seen within 60 days||Case remains open if patient stable for 60 days, not needing an appointment||13. In chronic disease management, a stable, well-managed person may need to be seen only every 3 or 6 months, needing the case record to remain active. In program-driven services, no patient visits for 60 days requires the case to be closed|
For more explanation about numbers 1-13 above, see TIP 2.
Dig more deeply into the “So what?” for why we need new terms and new concepts.
Here is some more detail on Column 3- So What?
1) Program-driven care vs. continuum of levels of care and
2) When does a person “graduate” from treatment for diabetes, schizophrenia, hypertension, asthma, bipolar disorder?
3) See Tips & Topics, March 2011 Tips & Topics March 2011
- Addiction treatment is often viewed as a person entering a program, often for a fixed length of stay, and then “completing” and “graduating from the program”.
- Addiction as a disease which needs ongoing disease management “transitions” people from one level of care in a flexible, seamless manner.
- In no other chronic disease do we “graduate” people from treatment’.
- You can still celebrate a client’s achieving a certain level of stability and hard work without giving the message that they are “done with”, “completed” or “graduated” from treatment.
4) Treatment continues in the next level of care, thus “transfer” is a better term.
5) Break down silos of care & “link”(rather than “refer”) to assure continuity of care.
- While a patient may be “discharged” from a certain level of care to home or to another level, it is more productive to conceptualize as a “transfer” to the next level of care.
- “Transfer” emphasizes a smooth continuum of care versus silos of treatment from which one is “discharged”.
- When levels of care are siloed, there is a tendency to “refer” a person to the next level of care hoping the person follows through.
- We need to “link” people to the next level by literally or figuratively walking them to engage in the next level, much as a good hotel or even a drugstore, walks you to the restaurant or the shopping aisle to make sure you get what you want.
- Instead of giving a client a number to call (“refer); we could overlap levels of care. We could have a person in residential treatment attend and bond with the outpatient group they will be attending before being transferred to outpatient treatment.
6) Treatment is about “intensity” of services, not “restrictiveness” of services.
7) Treatment is about “intensity” of services, not “higher or lower” services.
- When treatment is conceptualized as matching the severity of illness (SI) and level of function (LOF) with the needed intensity of services (IS), then treatment levels are described in terms of “intensity” not “restrictiveness”, which is a disempowering and stigmatizing concept; nor “higher” or “lower”, which can connote one level is better than the other.
- Levels of care are simply different benchmarks of intensity of services. In a hospital it is called the “intensive care unit” not the “restrictive or higher care unit”
- In mental health it is called a “secure intensive psychiatric unit”, not the “higher restrictive psychiatric unit”.
- The penthouse and expensive cabins are on the “higher” floors and decks whereas the cheaper and less desirable units or cabins are on the “lower” or basement levels.
8) Disease management involves continuous services not a program level for which there is “pre-treatment” before a person gets to the program; and “post-treatment as if real treatment has ended.
9) The initial treatment experience is not an intensive residential or intensive outpatient program followed by aftercare. It may involve acute care stabilization in withdrawal management or a short length of time to prepare a person for ongoing care in the level of care needed and
10) The length of stay for each person is based on severity, function, service needs and progress. There is no fixed length that needs to be “prolonged” or “extended”, just “continuing care”.
11) Addiction treatment is not a “primary treatment program” followed by “aftercare” but just “care” or “continuing care”.
- Sometimes people are placed on a waiting list while they wait to get into “real” treatment thus “pre-treatment”. Programs have experimented with a “pre-treatment” group to keep the person engaged while waiting for a treatment slot or bed.”
- Some of those clients actually do well in the so-called “pre-treatment” group and then don’t need the “real” treatment group or bed because they are doing well already. In other words the “pre-treatment” group is just “treatment”.
- “Post-treatment” does not exist in disease management of chronic disease. There is no “real primary treatment” to come first before the “post-treatment”. When a client needs ongoing care from whatever level of care they started in, then they are just receiving “treatment”.
- If there is no program in which a person usually stays a certain predetermined length of time, then there is no concept of “prolonged” or “extended” stay. The patient simply stays for whatever time is needed in that intensity of service.
12) Payment is shifting from paying for a service, a slot or a bed to paying for outcomes, effectiveness and efficiency. Payment for the health of a designated population, not payment for individual services.
- We are moving from a sick-care system, where treatment providers, hospitals and programs have been funded to treat patients and clients who were sick, and needed a residential or inpatient bed or an outpatient slot or group. A patient is stabilized, treated and discharged, but if they become sick again, or never really got into good health, then they are readmitted for acute stabilization, and the provider gets paid regardless of the outcome.
- A true health care system focuses on positive results in health and well-being. They are paid for keeping clients and populations well, not just for providing a treatment service.
13) In chronic disease management, a stable, a well-managed person may need to be seen only every 3 or 6 months, needing the case record to remain active. In program-driven services, no patient visits for 60 days requires the case to be closed.
- Policies and procedures still require programs to close a case if the client has not been seen, for example, for 60 days. This is inconsistent with disease management that continues even if a patient is stable but still needs to be monitored.
- As the person stabilizes, the frequency of visits can and should be decreased even to 3, 6, 9 or 12 monthly visits. Just because a patient is not seen, doesn’t mean their case should be closed. That belongs to the idea that if the client is not in the “program” then the case should be closed.
SKILLS and STUMP THE SHRINK
Here are two Stump the Shrink questions. Both illustrate the relevance of individualized treatment as well as the importance of focusing lengths of stay based on client needs, not program design or funding limits.
Remember that the treatment plan is the client’s plan, not the clinician’s plan.
This question comes from Sean Callahan, Chief Information Officer, ZenCharts™, a behavioral healthcare electronic health record (EHR).
I have a customer of our electronic health record who asked me what the procedure is in documentation in our EHR. The email read, “I wanted to ask what the protocol is when a client does not want to sign their treatment plan/does not agree with the diagnosis entered.
I had my first session with XYZ and I was reviewing his treatment plans with him in order to get his signatures. He was not willing to sign the treatment plans for Depression or Anxiety. Since this was my first session I do not yet know his history that warranted this diagnosis. I will continue to assess for these, but wanted to know the protocol in the meantime.”
What would a clinician do in that case? The client disagrees with a diagnosis and refuses to sign a treatment plan.
If a client does not want to sign the treatment plan, then it is the wrong treatment plan.
The treatment plan should be a written expression and agreement of the therapeutic alliance with the client: agreement on goals and agreement on methods and strategies within the context of a trusting working relationship between the client and counselor. Actually the therapeutic alliance, in conjunction with the skill of the counselor to foster a good alliance, predicts the outcome more than whatever evidence-based practices are used.
Therefore, if the client disagrees with the diagnosis and treatment plan, the counselor needs to understand and assess what that is about, then collaborate on a plan and direction which makes sense to the client. For example, one of the priorities in the treatment plan could be:
“John has been diagnosed with Major Depression and Anxiety Disorder, but disagrees with these diagnoses.”
Goal: John will identify why he was given these diagnoses and gather data to explain his disagreement with those conditions.
- Review his past health records to see where and why those diagnoses were given and discuss with counselor and family.
- In group, individual and family therapy, discuss why he disagrees with those diagnoses plus what data he needs to gather to document his disagreement.
- Psychiatric consultation to obtain a second opinion about any mental health issues and discuss with the psychiatrist his/her findings.
This is the kind of treatment plan that should make sense to him, if he collaborated on how to word the problem/priority, the goal and the methods and strategies. Then “John” will sign it because it his treatment plan, not the counselor’s plan. The counselor who wrote to you has already said: “Since this was my first session I do not yet know his history that warranted this diagnosis.” Yet the counselor is wanting the client to sign a plan that even the counselor is unsure about, because there has not been enough assessment to even know what the diagnoses are and what the client needs.
Here’s the parallel: Imagine a surgeon asking a patient to sign a treatment plan for abdominal surgery based on a diagnosis the patient disagrees with. In addition, the surgeon is unsure as s/he has not done an assessment; and then plans an operation using procedures and instruments not based on a diagnosis, severity and needs. What patient would sign a treatment plan like that? What surgeon would plan treatment based on a questionable diagnosis and an inadequate assessment on the first meeting with the patient? How come we ask addiction and mental health clients to comply with a plan that doesn’t make sense to them?
Hope this helps, but let me know if not.
Examine underlying assumptions about methadone and Opioid Treatment Program expectations for length of stay and success.
The second question is directed to a quality committee from Shereen Khatapoush, Ph.D., Research & Program Evaluation Associate, Santa Barbara County Department of Behavioral Wellness, Santa Barbara, California.
I work in Research and Program Evaluation for the County of Santa Barbara. We contract out all our treatment services and are working on improving our contractual expectations and outcomes. I’ve been trying to find, without success, some data re:
- Average length of stay in methadone treatment
- Percentage rates for successful discharge after 1 year, 2 years in methadone treatment
I’d welcome any suggestions you might have about other indicators/outcomes for which there may be some standards (for example, re: employment, criminal justice involvement).
Thanks very much for your help – much appreciated!
I am not sure about the assumptions behind your question for such data as you improve contractual expectations and outcomes. From a holistic clinical perspective focused on individualized treatment and outcomes, average length of stay and “successful discharge” are tricky.
- If a person stays on methadone for 2 years, doesn’t grow in recovery, doesn’t become self-sufficient, nor embraces wellness, but doesn’t share needles, nor spreads HIV and Hepatitis C, is that a successful client outcome?
- If another person is on methadone for 3 months, stabilizes and for them, is attracted into abstinence, non-medication recovery, is that a successful client outcome?
- If another person is on methadone for 10 years, grows in recovery becoming a fully independent, employed person blossoming physically, mentally, socially and spiritually, is that a successful client? And why would you want to “discharge” him/her off methadone?
I know this more nuanced array of varying clinical presentations isn’t a very satisfying answer when you were asking for a concrete average length of stay number. Are other assumptions behind your question the following?:
- How long should we fund methadone treatment? – for 1 year or 2 years or what?
- When should we expect our contract providers to have discharged a client off methadone – after 1 year or 2 years?
If these are behind your question, then I would ask: Do we search for data about how long to fund insulin and anti-hypertensive medication for diabetes and hypertension; or anti-psychotic or antidepressant medication in mental health?
I suggest the focus to improve contractual expectations and outcomes be on:
- How well are providers engaging their methadone clients into a full recovery process?
- Are there clients for whom methadone treatment is a public health intervention regardless of whether they are interested or successful in achieving robust recovery?
- What is the success of the methadone clients in blossoming physically, mentally, socially and spiritually and are the providers working on that?
- Are some providers just handing out medication, doing cursory counseling to comply with Federal regulations, and not doing full addiction treatment and recovery?
In other words, contractual expectations and outcomes depend on the population served; the goals of the methadone treatment (recovery and/or public health safety); and the quality of holistic biopsychosocial-spiritual services versus just “bio” medication.
Over the course of a year, I rent scores of cars from airports. It’s always a bit of game to see what brand of care is available. (You have to see some fun in all the travel I do). I am not so particular about the brand as long as it is reliable and good value. However there are a couple of preferences I would lock in if I could ,when I make the care rental reservation. This week I was pleasantly surprised when I hopped in the car at the airport:
- I like to track the number of miles I actually travel. So the first thing I do is set the Trip mileage monitor to zero. Older style odometers have an actual button you just have to press to reset the Trip odometer to zero. It is right there in front of you in the speed and mileage window.
- The new fangled, digital touchscreen, computerized models don’t have a physical button to press. You have to find the screen to locate the virtual touchscreen “button”. There are different screens on the dashboard for the speedometer, the radio, the tachometer, temperature gauge etc. It’s anybody’s guess where to locate the right “button”.
Joy #1: My car had an actual physical button I could press. I could see exactly where it was and should be.
Joy #2 had to do with the radio station settings:
- I like to tune into the local National Public Radio (NPR) station for the latest news and balanced analysis. With the older technology, when the right station was found, you just held down the radio Preset button. That station would be locked in.
- Again, the new fangled, digital touchscreen, computerized models don’t have a physical button right under the radio stations. It’s not easy to figure out where and how to digitally touchscreen a radio station to lock it in.
At this point, if you are still reading SOUL, you might be thinking I am a bit old fashioned. Anyway, what has this got to do with anything, except someone’s trivial travel preferences?
Here is the point: It really is pretty common for people to like the familiar, easy to navigate and predictable methods that don’t make you feel confused, lost and incompetent. That is true for rental cars. It is also true for many treatment providers.
The changes discussed this month in SAVVY, SKILLS and STUMP THE SHRINK can easily feel unfamiliar, difficult to navigate and leave you feeling confused, lost and incompetent. Yet quality improvement and cost-effectiveness will increasingly demand that treatment providers and systems of care stretch their level of familiarity and comfort zone.
I better learn how to reset odometers and lock in radio stations without pushing buttons in rental cars. These days there are less and less cars with physical buttons.
Fortunately my shirts still have buttons!