Substance abuse treatment evolves: A follow-up
Assess need for continued care
By Patrice Spath, ART
Consultant in Health Care Quality and Resource Management
Forest Grove, OR
(Editor’s note: This month’s Quality-Cost Connection is the second of a two-part series addressing issues surrounding case management in alcohol and chemical dependency treatment. Last month’s column covered initial placement, continued stay, and discharge planning; this month we examine methods of concurrent review.)
Case management in alcohol and chemical dependency treatment services does not stop with the initial assessment of patient level of care needs. A process must be established to periodically evaluate the patient’s continued need for treatment and the appropriate level of care. Con cur rent review requires analysis of information in the patient’s record and input from the treatment team to determine the patient’s current status.
It is helpful to objectively define what the case managers should look for as they perform concurrent review. This will minimize unnecessary chart review and provide a training tool for new case managers. Examples of the type of information that should be considered during the concurrent review process are listed below:
• How is the patient doing in treatment?
• Is he or she motivated?
• What Alcoholics Anonymous (AA) step is the patient on?
• In what areas is the patient doing well? What barriers to continued progress exist, if any?
• Are goals established by the treatment team being achieved in a reasonable time frame? Are changes in the treatment plan necessary?
• What is going on now with the patient that makes continued treatment at the same level of care necessary?
• Can patient care be more effectively provided at a lower level of care?
Several care options exist for alcohol/drug abuse treatment. From the least to the greatest intensity, the levels of care choices include:
• Outpatient treatment.
Within this level of care are services that vary greatly in structure and intensity. They include weekly to daily individual or group counseling, often in combination with additional treatment services such as detoxification, education, medical services, and specially focused groups. A multidisciplinary treatment team that includes assertive and intensive case management services may be needed for patients with the dual disorders of mental illness and substance abuse.
• Intensive outpatient treatment.
This level of care includes treatment models such as partial hospitalization (which includes day treatment, evening, and weekend programs). For example, patients in day treatment generally participate in a full day of treatment for five or more days per week. Intensive outpatient treatment represents a range of treatment intensities. The level of intensity of a given program is based primarily on the number of treatment services offered. Generally, intensive outpatient treatment programs offer several treatment components, such as group therapy, educational sessions, and social support services.
• Halfway houses.
These are settings that serve as safe alcohol/ drug-free homes for people who can manage independent daily activities and can benefit from a structured and recovery-oriented group living arrangement. They vary widely in style and purpose.
• Residential rehabilitation setting.
Participation can vary from 30 days to three months or more. In residential settings, patients receive education and learn important recovery skills such as utilizing groups, building trust, and talking about feelings. Therapy and support groups provide socialization and support, and are the core of treatment. They prepare the patient for increased reliance on group support systems after discharge.
• Therapeutic communities.
Long-term therapeutic communities often require patient participation lasting from six months to two years. They are generally considered appropriate for patients with severe alcohol/drug dependence disorders who have significant social and vocational deficits and who require long-term and intensive support, skill building, interpersonal abilities refinement, and trauma resolution.
• Hospitals.
Hospitalization may be required for acute and subacute stabilization, especially when the patient has conditions requiring close observation and medical management.
The patient’s status should be reviewed 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 (see forms and related article, Hospital Peer Review, August 1997, pp. 116-122) are used to evaluate whether the patient should be transferred to a higher or lower level of care or to a self-directed recovery program.
Case management helps the facility demonstrate appropriate and effective allocation of its resources to payers. By assessing and enhancing the efficient and cost-effective use of health care resources, an effective institutional case management program can ensure that a patient’s limited health insurance benefits are wisely spent.
Case managers also must interact with insurers to provide the information necessary for insurance coverage certification. These liaison activities protect the facility, its staff, and its clients from the threat of nonpayment or even worse, cancellation of a managed care contract. To be effective, the case management program in alcohol and substance abuse treatment facilities must identify and resolve utilization-related problems before they come to the attention of an external organization that might take unwelcome actions.
Ideally, individualized case management does not stop once the patient has left the acute environment. By providing a continuum of case management, ranging from treatment plan coordination while the patient is in treatment to coordinating services within the community, case managers can have a positive influence on patient outcomes.
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