Are We Ready for ASAM? Does the ASAM Level of Care Designa:ons Correspond to Clinical Judgment?

Transcription

1 Are We Ready for ASAM? Does the ASAM Level of Care Designa:ons Correspond to Clinical Judgment? Desirée A. Crevecoeur-MacPhail, PhD UCLA Integrated Substance Abuse Programs Semel for Neuroscience and Human Behavior David Geffen School of Medicine at UCLA AHSR 2016, SeaLle WA

2 Disclosures No disclosures to report No relevant financial with commercial interests exist between the author of this PPP and the creators of the ASAM This project was funded solely by the Los Angeles County Department of Public Health Substance Abuse and Control

3 Select the Best Answer The best treatment system for addic:on is: a. A 28 day stay in inpa@ent with educa@on b. A broad con@nuum 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 con@nuity of care e. Short stay inpa@ent hospitaliza@on for psychoeduca@on

4 How do professionals working with pa:ents diagnosed with substance use disorders determine the appropriate level of care they need?

5 The Crystal Ball Method

6 The Magic Eight-Ball Method

7 Different Parameters to Determine Level of Care Court mandated What is available at site where client presents for treatment What the client wants to do Determined by counselor judgment Subject to biases (MAT, own tx program, own recovery) Recent experiences

8 How Did We Get Here? No standard assessment for substance use disorders - intui@ve Addic@on Severity Index (ASI) and other tools Changes in SUD tx system require EBPs, use of DSM criteria, and demonstra@on of medical necessity ASAM s Solu@on: ASAM Criteria (1991, 2001, 2013)

9 Paradigm ShiN ASAM criteria have evolved to reflect current research One dimension to Program-driven to clinically driven treatment Fixed length of stay to variable length Limited number of discrete levels of care to a con@nuum of care

10 A LiOle About Los Angeles County 10+ Million Residents 50 65K Treatment Admissions ~ 200 Agencies Centralized assessments (Community Assessment Service Centers) Most operated by treatment agencies Favori@sm regarding referrals

11 Training on ASAM Criteria UCLA conducted 13, day-long training sessions in FY with 562 alendees Sessions included case and other processes to give providers experience with the ASAM criteria addressed during sessions and included on forms collected aler the training

12 Understanding and the ASAM Criteria

13 Six dimensions ASAM Criteria Refer to numerous levels of care (OP, IOP, RS, WM, OTP) Used to help determine level of care for SUD and MH Assist clinician in determining the appropriate level of care for both SUD and MH Suggested level of care clinician may override

14 ASAM PLACEMENT CRITERIA LEVELS OF 1. OUTPT 2. INTENSIVE 3. MED 4. MED OF CARE OUTPT MON INPT MGD INPT CRITERIA Intoxication/ Withdrawal no risk minimal some risk severe risk medical 24-hr acute monitoring med. care required required Medical Complications no risk manageable Psych/Behav Complications no risk mild severity moderate cooperative high resist., Readiness but requires needs 24-hr For Change cooperative structure motivating Relapse Potential Recovery Environment maintains abstinence supportive more symptoms, needs close monitoring less support, w/ structure can cope unable to control use in outpt care danger to recovery, logistical incapacity for outpt 24-hr psych. & addiction Tx required

15 ASAM Dimensions Acute and/or Withdrawal Biomedical and Behavioral, or and Readiness to Change Relapse, Use, or Problems Recovery and Living Environment ASI Domains Alcohol, Drugs Medical Psychiatric Alcohol, Drugs Employment support, Legal, Family social

16 Is there disagreement? YES! But why?

17 Some Sources of Disagreement Fear of change Lack of interest in doing something different Slow adopters

18 Other Sources of Disagreement 1. Counselor recognizes signs that are not reported by the client A. Symptoms of withdrawal B. Dishonest report of substance use palerns 2. Lacking familiarity with ASAM criteria A. Focus on both SUD and MH (and some medical) B. Sugges+ons for level of care 3. Training issues

19 Addressing Areas of Disagreement Encourage clinician to make notes made on assessment form, progress notes, or elsewhere in file Did report significant MH issues / or limited substance use Remind clinician that, in some cases, overrides of LOC suggested by ASAM are ok Addi@onal training or more prac@ce needed?

20 Conclusions Some engage/make changes immediately, some resist, others are simply confused Significant changes to implement Do not assume that resistance is the only reason for slow of new tools Encourage discussion of problems, areas of disagreement

21 Acknowledgements For allowing the use of their slides, thanks to Tom Freese, PhD, UCLA ISAP PSATTC Albert Hasson, MSW, UCLA ISAP Lynn Posze, MA, LPCC Kentucky Division of Behavioral Health

22 Questions?

23 THANK YOU! Desiree A. Crevecoeur-MacPhail, Ph.D. Principal Investigator/Research Psychologist UCLA Integrated Substance Abuse Programs (310)