Substance abuse treatment evolves
Case manager assumes new responsibilities
By Patrice Spath, ART
Consultant in Health Care Quality and Resource Management
Forest Grove, OR
The treatment options for alcohol and drug abuse have changed considerably over the past decade, creating new challenges for the health care quality professional. Whereas patients used to remain hospitalized for an extended treatment period, today there are a wide range of treatment choices for patient detoxification and for long-term recovery and maintenance.
In this age of managed care, hospitalization episodes have become much shorter and more acute than a few years ago. This puts more responsibility on case managers, who must assist caregivers in selecting the most effective and least costly treatment alternatives for their clients. Chemical dependency case managers play an important role by identifying the client’s limitations, deficits, and strengths and designing treatment plans that give patients what they need.
When a patient rejects professional assistance, the case manager may assume responsibility for finding a different way to get the person to accept assistance. Case managers in alcohol/drug treatment programs can help to engage, link, and support patients in needed community services. Such long-term case management helps reduce the negative consequences to the individual from lack of follow-up and participation in treatment. Without case management, many severely ill patients would decompensate, need to be hospitalized, or become homeless.
Effective case management in alcohol and chemical dependency treatment services is a team approach that includes comprehensive initial assessment, treatment engagement, treatment planning, and follow-up.
What makes case management challenging in alcohol and substance abuse treatment is that individual clients differ significantly in their treatment needs, making a standard set of utilization review criteria difficult to apply. (See story in July Hospital Peer Review, p. 96, for an article on assessing the incoming alcohol-dependent patient.) The type of treatment, the setting, the intensity, and the duration must relate to the client’s status at the time of first assessment and throughout treatment. When clients are initially placed in the most appropriate level of care they are more likely to have cost-effective, positive outcomes.
A comprehensive diagnostic assessment is the first step in selecting the least restrictive level of care appropriate to the client’s needs. In order to establish a substance use disorder diagnosis, ascertain the appropriate level of care, and formulate an individualized treatment plan, the medical practitioner must assess the following areas:1
• substance use history;
• risk of withdrawal syndrome;
• potential danger to self or others;
• medical history and current conditions;
• psychological history and current signs of psychological disorders and current mental status;
• external support systems and recovery environment, including housing;
• resistance/acceptance to treatment;
• previous treatment experience;
• historical and current data regarding family and interpersonal relationships, vocation, legal issues, social systems, education, learning disabilities, school-related problems, and military experience;
• external pressures or mandates (i.e., employer, spouse, housing authority, legal).
Enticing patients
Treatment engagement refers to the process of initiating and sustaining the patient’s participation in the ongoing treatment process. The case manager can assist in the engagement process by offering the patient enticements such as providing help with the procurement of food, shelter, and medical services. Engagement can also involve removing barriers to treatment and making treatment more accessible and acceptable, such as by providing day and evening treatment services. Engagement can be enhanced by providing adjunctive services that may appear to be indirectly related to the patient’s disorder, such as child care services, job skills counseling, and recreational activities.
Engagement begins with efforts that are designed to enlist people into treatment, but it is a long-term process with the goals of keeping patients in treatment and helping them manage ongoing problems and crises.
Once addiction severity has been determined and the patient agrees to proceed with professional help, the treatment intensity, structure, and level of care required must be decided. A number of organizations and provider groups have developed criteria for chemical dependency placement, continued stay, and discharge. Case managers and caregivers can use these criteria to select the least intrusive, most effective treatment plan. The criteria used by chemical dependency case managers involved in treatment planning for Oregon Health Plan recipients are shown on pp. 117-119. The Oregon Health Plan is the state of Oregon’s managed care plan for Medicaid clients. The criteria were developed by the state’s Office of Alcohol and Drug Abuse Programs, with input from the provider community. The case manager or another member of the multidisciplinary care team uses the three-page list of criteria to evaluate a patient’s access to and length of stay in chemical dependency treatment.
Decisions on initial patient placement, continued stay, and discharge are based on patient factors in the following six dimensions:
• detoxification and/or withdrawal potential;
• physical health conditions and complications;
• emotional/behavioral conditions or complications;
• treatment acceptance/resistance;
• relapse potential;
• recovery environment.
Severity-of-illness indicators are used to judge the appropriate level of care and formulate an individualized treatment plan within each of these six dimensions. The information necessary to apply these criteria is obtained during the initial patient assessment process. The form shown on pp. 120-121 is used by case managers to document the discharge decision.
[Editor’s note: Next month’s Quality-Cost Connection column will address the follow-up phase of case management, in which case managers review the patient’s status on a regularly scheduled basis and when appropriate (e.g., when a crisis occurs that may indicate an immediate change in level of care). Criteria similar to the initial placement criteria are used to evaluate whether the patient should be transferred to a different level of care.]
Reference
1. American Society of Addiction Medicine. Patient Placement Criteria for the Treatment of Substance-Related Disorders. 2nd ed. Chevy Chase, MD: ASAM; 1996.
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