May 2021

Overdoses are up, but do we really need just more residential beds?; How to determine initial length of stay and authorization periods; Freddy enters my world.

In SAVVY & STUMP THE SHRINK, is residential care the first priority in responding to the increase in opioid overdoses?  Some States mandate certain periods of time that ban managed care authorizations and requirements for individualized treatment.  I suggest that what we really need in addiction treatment is not just more residential beds and time.

In SKILLS & SYSTEMS, treatment providers and Managed Care Organizations should not be “lined up on different sides of the aisle”.  To determine initial length of stay and authorization periods for an addiction client, think about what you would do for other health conditions.

In SOUL, Fred IV enters my world and joins Siri, Google and my Toyota Prius to help me navigate my cleaning, driving and knowledge worlds.

savvy & stump the shrink

The Centers for Disease Control and Prevention (CDC) recently published a Vital Statistics Rapid Release document that showed overdose deaths during the pandemic rose to the highest levels since the opioid epidemic began:

  • “at least 87,000 people died of a drug overdose in America” in the 12-month period ending last September, “an increase of 27% from the previous 12 months and a record for the most such deaths in a single year.” 
  • In that same period, “deaths attributed to synthetic opioids, mainly fentanyl, increased 53% nationwide.”

Tip 1

What do you believe should be the priorities for treatment of Opioid Use Disorder? Are more residential beds the answer?

With the overdose rates up, there is a push for more funding for addiction services. There should be, but often this is a call for more residential beds as if that is the first treatment of choice. Many still think of addiction treatment as:

  • Sending the person “off to rehab” 
  • for some fixed length of stay (weeks or months) from which 
  • the person graduates, completes the program, and 
  • hopefully goes to Aftercare.

The ASAM Criteria (American Society of Addiction Medicine) articulates a continuum of care for addiction that includes but is not limited to residential treatment (See Table below).

Treatment Levels of Service  (The ASAM Criteria 2013, pp 106-107)

      1  Outpatient Services

     2  Intensive Outpatient/Partial Hospitalization Services

     3  Residential/Inpatient Services

     4  Medically-Managed Intensive Inpatient Services


Tip 2 
Some States have embraced longer lengths of stay in residential treatment as a priority in the opioid crisis. They limit Managed Care Organizations’ ability to require individualized treatment

Colette Croze, Principal of Croze Consulting asked me about residential levels of care and managed care authorization processes. Here, in part, is her question:
 
For the past five years I ….worked with many states as they developed their Centers for Medicare and Medicaid Services (CMS) 1115 Substance Use Disorders (SUD) waivers.  Now I’m working with several on a variety of issues (residential utilization, expanding access to Medication for Opioid Use Disorder (MOUD), etc.)  

A couple of the states are having difficulties with their Managed Care Organizations (MCOs) in terms of the length of authorization periods for residential treatment.  I’m sure you’ve seen the tussle between MCOs who don’t really yet understand the purpose of residential treatment and providers who define it more often as a length of stay rather than a clinical regimen.  While I totally embrace the principle that residential stays are individually based, it seems like there could be some “rules of thumb” as guidance for MCOs so that they’re not using the standard 3-day periods for initial and continuing authorizations.  I’ve put some formative thoughts on paper and wondered if you’d be so kind as to give me feedback.


SUD RESIDENTIAL TREATMENT LEVELS OF CARE
EXPECTED LENGTH OF STAY, INITIAL AUTHORIZATION PERIOD AND CONTINUED STAY PERIOD
 
Reference Points from Other States

Massachusetts Medicaid Requirements of MCOs          

o   Level 3.1      No authorization for 90 days                      
o   Level 3.5      No authorization for 14 days                      
o   Level 3.7      No authorization for 14 days
 
New York State Statute

o   2017 law: no authorization for 14 days 
o   2020 revision: no authorization for 28 days 




Proposal: Use these as benchmarks for recommendations on Medicaid requirements for MCOs around authorization periods, both initial and continued stay. (Also need to evaluate them in the context of the 1115 waiver cap of average residential use of 30 days/year.)


Tip 3

Recommending expected lengths of stay, and set authorization periods for initial and continued stay reviews works against individualized, outcomes-driven care.
Here is my response to Collette:
I understand the dilemma and your attempt to give some guidelines to MCOs. But such length of stay (LOS) guidelines perpetuate a program-driven, fixed LOS mentality.  New York State, Massachusetts and maybe other states have instituted such LOS guidelines as a result, in my opinion of: 

  • Being concerned about the Opioid Crisis and that MCOs and money will drive people out of treatment. 
  • Being lobbied by residential treatment providers and a fixed LOS philosophy to give people more time in residential treatment free from “harassment” of MCOs. 
  • People (including legislators) are still not understanding that addiction treatment needs a continuum of care as in any chronic disease. Good outcomes require a long LOS in a continuum of addiction disease management, not a long LOS in “rehab” (residential). 
  • People are still focused on using residential treatment to do a ‘makeover’ of the person suffering from addiction in program-driven treatment for several weeks/months and then graduating.

What we need is:

  • Not longer lengths of stay in residential, but more focus on using the full continuum of care.
  • To move from program-driven care to person-centered, individualized treatment based on outcomes, not based on the program design, phases and “completion and graduation”.  
  • More community-based services to hang in with people for months and years just as we do for people with severe mental illness, not more residential beds and LOS.  
  • Assertive Community Treatment and Intensive Case Management teams to proactively engage and support people with severe, life-threatening addiction.
  • More low barrier living supports (wet, damp and dry housing).
  • More “Housing First” projects to engage people in treatment who are in Precontemplation about addiction treatment and recovery.

Unintended consequences When there are recommended LOS guidelines and set authorization review periods:

  • I see these turn into fixed ceiling LOS and programs keep clients for the maximum allowable days and then 
  • Providers apply for an allowable extension LOS because they are still focused on the program mentality. 
  • For example, if the initial allowable LOS is 30 days in residential with an allowable extension of 30 day increments up to 90 days, most clients stay 30 days and then get extensions for another one or two 30 day period.
  • This keeps the field locked into a residential treatment mentality and not a chronic disease, continuum of care mentality.

Collette’s response: Thanks for the thoughts.  I couldn’t agree with you more about the over-reliance on residential treatment and the lack of patient-driven outpatient options.  This current phase where providers and MCOs are lined up on different sides of the aisle is just so difficult. 

skills & systems

With treatment providers and Managed Care Organizations (MCOs) “lined up on different sides of the aisle”, how can we change SKILLS and SYSTEMS to work together to promote lasting recovery? What can we do together rather than lock in expected lengths of stay, and set authorization periods for initial and continued stay reviews?

Tip 1

If in doubt about addiction and what to do, think about what would you do for other health care conditions.

There are no recommended LOS guidelines for:

  • A patient with unstable diabetes in a medical unit of the hospital or 
  • A person suffering from a sudden stroke in the Intensive Care Unit (ICU) or 
  • A suicidal or psychotic person in an inpatient psychiatric unit.

The LOS all depends on the severity of the patient’s illness, their improved level of function, their progress and outcomes, and what services they need. 

  • The Level of Care or the setting in which care is given is not the defining determinant of LOS.
  • The patient with diabetes receives their care in a medical unit, but that ‘place’ of care doesn’t define the LOS.
  • The stroke victim receives their care in the ICU, but that ‘place’ of care doesn’t define the LOS.
  • The suicidal or psychotic person receives their care in an inpatient psychiatric unit, but that ‘place’ of care doesn’t define the LOS.
  • Similarly, being in residential treatment as a level of care, doesn’t tell you how long they need to stay.
  • It is the person’s severity, functioning, stability and progress that determines the LOS and if and when continued authorization of care is needed.

Tip 2

How to determine an initial length of stay and authorization period

With competent clinical SKILLS and a SYSTEM of ethical managed care, there is no “aisle”.  In other words, treatment providers and MCOs should all have the same goals: 

  • Lasting change, long-term recovery and good outcomes for all people in treatment.
  • Care that preserves and stretches healthcare resources to provide as long a length of stay as is needed, even if that is years or a lifetime, like we do with schizophrenia, bipolar disorder, diabetes.
  • Intensity of services that match a person’s severity of illness and level of function in the least intensive but safe level of care (setting).
  • Communication that is clinically-focused, not game-playing bargaining over days, sessions and money.

You’d have to tell me about the patient’s unique severity of illness and level of function; and what the diagnoses and multidimensional problems are to determine a reasonable period for review of the stay.  

Vignette #1

A person with alcohol use disorder in long term recovery has a tragic loss of a loved one and relapses for a week.  The mild withdrawal symptoms do not need medically monitored withdrawal management. He has great recovery supports but has gotten acutely depressed from the loss and started drinking to drown his sorrow.  He needs to be stabilized and to get back on track.  After 3- 4 days in Level 3.5 (for intense cravings) or Level 3.7 (drinking flared up physical health problems), he is back on track, ready to get back to his support groups and start grief counseling in Level 1, Outpatient treatment.  

Vignette #2

A person with opioid use disorder and chronic pain addicted to narcotic medication is having strong cravings to use and has been impulsively using whatever he can find on the street. Just revived from an overdose, he needs to be engaged into treatment to prevent immediate return to the street with life-threatening overdose potential. In addition, while in the 24 hour treatment setting of Level 3.5, he needs close collaboration with a pain specialist.  Using motivational enhancement and care management between addiction treatment and pain management, the goal is to try to prevent immediate return to impulsive opioid use. 

The clinician and MCO collaborate and estimate that at least 12 -14 days will be needed to work together with the pain specialist. The plan is to transfer the client to Level 3.1 if stable in cravings and impulses to use, but if he is still needing 24 hour living support to continue pain management and engagement in recovery.

Vignette #3

A person with methamphetamine use disorder and co-occurring Major Depression and Posttraumatic Stress Disorders (PTSD) is depressed, partially from withdrawal off methamphetamine and partially as part of ongoing mental health problems. She has been feeling suicidal and overwhelmed after an argument with her male partner and was admitted to Level 3.5 after superficially cutting her wrists. They have been arguing over money but there has been no intimate partner physical abuse. She does have a therapist she trusts and the partner is willing to participate in couples counseling. 

The clinician and MCO collaborate and estimate that at least 5 days will be needed to stabilize her depression, reconnect her with her therapist, and to start couples counseling to be sure there will not be an immediate flare-up of arguments.  The plan is to transfer the client to Level 1 or 2.1 Intensive Outpatient if stable in her cutting impulses and if the relationship is less volatile.

These three vignettes are just a few of multiple other permutations and combinations of clinical presentations that could give different estimated LOS predictions based on an individualized assessment and treatment approach.

soul

My friend named him “Fred III” because her friend has already had two Freds. I’m not sure what I will call mine, though I’m leaning towards “Fred IV”.  It would continue the lineage, but I’ll probably just call him “Fred” for short.  Or maybe affectionately “Freddy”.




This week I got my very first robotic vacuum cleaner. I know they have been around for years.  Siri, my Apple iPhone assistant, told me they have been available commercially since the 1990s.  But on this innovation, I am a late adopter.  Freddy has already vacuumed the whole lower floor of my house and all I had to do was empty the dustbin catcher and filter twice.  I already love Freddy.

What’s the world coming to?  But then I remember I increasingly rely on Siri to help me out.  My Toyota Prius warns me if there is a car coming into my blindspot while driving and if I am veering out of my road lane.  It even asks me if I “want to take a break?” if I have been driving too long.  Best of all, it warns me that I am heading too fast towards impact and if I still don’t listen, it actually brakes the car suddenly for me.

What’s the world coming to?  I don’t ask that question with any hint of concern. That’s what people said when they took their first train ride, Ford Model T car ride, or plane ride; and I’m sure glad we have trains, cars and planes.  Walking is good, but not all the time. And I am so grateful that I don’t have to carry my Garmin road navigator device everytime I travel; or don’t have to follow those complicated steps to program my car’s navigation system.  Not having to pay the big bucks for the full map upgrade every year is also a bonus.

What’s the world coming to? For my world right now, it’s Fred IV, my robotic vacuum cleaner.  Thanks Freddy.