Improving Communication and Multidisciplinary Team Work: How to Communicate and Integrate Treatment and Case information

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1 Improving Communication and Multidisciplinary Team Work: How to Communicate and Integrate Treatment and Case information NADCP Annual Training Conference June 1, 2018, 3:15 4:30 PM David Mee-Lee, M.D. Chief Editor, The ASAM Criteria DML Training and Consulting Davis, CA tipsntopics.com instituteforwellness.com

2 Why this Topic? Who is here? - judges, attorneys, child welfare professionals, Tx providers Questions to be answered include: How to communicate and function as a team What case information should be shared? Who needs what information? How can you share information appropriately? (a) Treatment providers who sometimes give too little or too much information, do not integrate safety/risk, etc. (b) Other professionals who ask too little or too much, and do not integrate treatment information, etc. What does change look like? What are words to use to describe progress and change? Concrete suggestions for professionals of different disciplines, to develop skills they can practice and apply in their careers.

3 Issues and Challenges 1. The justice system s appropriate mission of applying penalties such as fines or serving time under incarceration and placing the highest priority on assuring public safety, may at times appear to conflict with a treatment provider s mission of helping people change through collaboration on treatment goals and motivational enhancement. However high rates of incarceration for drug use, high costs of incarceration, high rates of relapse and recidivism, and the effectiveness of mandated treatment have guided many criminal justice administrators and policymakers to embrace the habilitative/rehabilitative role of addiction treatment among criminal justice populations. The ASAM Criteria (2013) Pages

4 Issues and Challenges (cont.) 2. While many drug court judges no longer do this, some judges, other court officials, and probation and parole officers still mandate specific levels of care (e.g., residential treatment) and lengths of stay (e.g., 1 year) versus focusing on mandating comprehensive assessment and ongoing treatment adherence. It is understood that judges, other court officials, and probation and parole officers, often do what they do because they perceive it as being required of them, as is the case in the context of sentencing and supervision guidelines given to those in the criminal justice system by a legislature or an executive branch authority. It is the treatment community s role, and challenge, to assist the justice system in interpreting the guidelines in a manner that offers the best match to the treatment options for this population within the guidelines they operate under. The ASAM Criteria (2013) Pages

5 Issues and Challenges (cont.) 3. While this is unlikely to be the case in drug courts, criminal justice s emphasis on criminogenic risk, need and responsivity (RNR) may place the need for addressing substance use disorders or co-occurring disorders as a secondary or tertiary focus, versus addressing these disorders concurrently. While recognizing substance use disorders as a criminogenic need, criminal justice may place higher priority and resource focus on other high-risk criminogenic factors such as antisocial values, criminal associates and antisocial personality traits. The challenge question for the treatment community in linking The ASAM Criteria to this population may be as follows: Is the behavioral healthcare provider adequately trained or equipped to address the RNR for the offender population? And if not, what should be done to improve this capability? However, the treatment of the other non-criminogenic disorders, while not the priority, are necessary for recovery and reducing criminogenic factors. The ASAM Criteria (2013) Pages

6 Issues and Challenges (cont.) 4. The individual s responsivity to a formal course of treatment and other recommended interventions at times may be in conflict with the criminal justice system s expectations of the participant. It is critical to involve all parties (e.g., judges, probation and parole officers, other court officials) as well as the justice- involved individual in the decision making process. It is also important to create learning opportunities for criminal justice personnel to understand more about substance-related and addictive disorders and also co-occurring mental health conditions. The ASAM Criteria (2013) Pages

7 Ten Aspects of Successful Drug Courts The NADCP Standards Committee identified ten key elements of successful drug courts: (1) drug courts integrate alcohol and other drug treatment services with the justice system case processing (2) drug courts use a non-adversarial approach in which prosecution and defense counsel promote public safety while protecting participants due process rights (3) eligible participants are identified and placed in the drug court program (4) drug courts provide access to a continuum of treatment and rehabilitation services (5) abstinence is frequently monitored by drug testing (6) sanctions and incentives that participants receive from the court and the treatment programs are organized as personalized contingency contracts (7) drug court participants have an ongoing judicial interaction (8) program effectiveness and goals are monitored and evaluated (9) continuing interdisciplinary education of the drug court team promotes effective drug court planning (10) drug court effectiveness partnerships among drug courts, public agencies and community based organizations are established (National Association of Drug Court Professionals, 1997)

8 1. Multidisciplinary Team Practice Standards (NADCP) A dedicated multidisciplinary team of professionals manages the day-to-day operations of the Drug Court, including reviewing participant progress during pre-court staff meetings and status hearings, contributing observations and recommendations within team members respective areas of expertise, and delivering or overseeing the delivery of legal, treatment and supervision services. A. Team Composition The Drug Court team comprises representatives from all partner agencies involved in the creation of the program, including but not limited to a judge or judicial officer, program coordinator, prosecutor, defense counsel representative, treatment representative, community supervision officer, and law enforcement officer. Source: National Association of Drug Court Professionals (NADCP), ADULT DRUG COURT BEST PRACTICE STANDARDS VOLUME II

9 Practice Standards (NADCP) (cont.) B. Pre-Court Staff Meetings Team members consistently attend pre-court staff meetings to review participant progress, determine appropriate actions to improve outcomes, and prepare for status hearings in court. Pre-court staff meetings are presumptively closed to participants and the public unless the court has a good reason for a participant to attend discussions related to that participant s case. C. Sharing Information Team members share information as necessary to appraise participants progress in treatment and compliance with the conditions of the Drug Court. Partner agencies execute memoranda of understanding (MOUs) specifying what information will be shared among team members. Participants provide voluntary and informed consent permitting team members to share specified data elements relating to participants progress in treatment and compliance with program requirements. Defense attorneys make it clear to participants and other team members whether they will share communications from participants with the Drug Court team. Source: National Association of Drug Court Professionals (NADCP), ADULT DRUG COURT BEST PRACTICE STANDARDS VOLUME II

10 Data Elements to Appraise Progress At a minimum, following data elements are required by all treatment court team members to appraise participant progress and compliance or noncompliance with the conditions of Drug Court: 1. Assessment results pertaining to a participant s eligibility for Drug/Treatment Court and treatment and supervision needs 2. Attendance at scheduled appointments and level of active participation based on the individualized treatment plan versus passive attendance 3. Drug and alcohol test results, including efforts to defraud or invalidate said tests 4. Attainment of treatment plan goals that are focusing on attitudes, thoughts and behaviors assessed as affecting public safety and legal recidivism. 5. Evidence of symptom resolution, such as reductions in drug cravings or withdrawal symptoms. 6. Evidence of treatment-related attitudinal improvements, such as increased insight or motivation for change; behavioral and functional improvements in all assessed areas affecting public safety and legal recidivism. Source: National Association of Drug Court Professionals (NADCP), ADULT DRUG COURT BEST PRACTICE STANDARDS VOLUME II

11 Data Elements to Appraise Progress (cont.) 7. Attainment of Drug/treatment Court phase requirements that should be based on functional change not time based phases, such as obtaining and maintaining employment or enrolling in an educational program, ability to cope with cravings to use, level of impulse control etc. 8. Compliance with electronic monitoring, home curfews, travel limitations, and geographic or associated restrictions. Non-compliance should trigger a clinical assessment and change in the treatment plan not automatic sanctions. 9. Adherence to legally prescribed and authorized medically assisted treatments. 10. Procurement of unauthorized prescriptions for addictive or intoxicating medications. 11. Commission of or arrests for new offenses. 12. Menacing, threatening, or disruptive behavior directed at staff members, participants or other persons. Source: National Association of Drug Court Professionals (NADCP), ADULT DRUG COURT BEST PRACTICE STANDARDS VOLUME II

12 Team Communication Decision Making D. Team Communication and Decision Making Team members contribute relevant insights, observations, and recommendations based on their professional knowledge, training, and experience. The judge considers the perspectives of all team members before making decisions that affect participants welfare or liberty interests and explains the rationale for such decisions to team members and participants. (National Association of Drug Court Professionals (NADCP), ADULT DRUG COURT BEST PRACTICE STANDARDS VOLUME II. Pages 38-39, 43 -modified)

13 Increase Team Functioning To increase team functioning, the following issues are best addressed: 1. Recognition that all team members have the same common purpose and mission public safety; safety for children; decreased legal recidivism and crime. 2. All members could benefit from a common language of assessment of stage of change models of stages of change. 3. Develop a consensus philosophy of addressing readiness to change solution-focused; motivational enhancement. 4. Develop consensus on how to combine resources and leverage to effect change, responsibility and accountability coordinated efforts to create and provide incentives and supports for change. 5. Improve communication and conflict resolution - committed to common goals of public safety; responsibility, accountability, decreased legal recidivism and lasting change ; keep our collective eyes on the prize No one succeeds unless we all succeed!

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16 Individualized Clinically-driven Treatment Patient/Participant Assessment BIOPSYCHOSOCIAL Dimensions Progress Treatment Response Severity of Illness/Level of Function Problems/Priorities Severity of Illness/Level of Function Mee-Lee, David (2001): Persons with Addictive Disorders, System Failures, and Managed Care Chapter 9, pp in Managed Behavioral Health Care Handbook Plan INTENSITY OF SERVICE - Modalities and Levels of Service

17 The ASAM Criteria Multidimensional Assessment 1. Acute Intoxication and/or Withdrawal Potential 2. Biomedical Conditions and Complications 3. Emotional, Behavioral or Cognitive Conditions and Complications 4. Readiness to Change 5. Relapse/Continued Use, Continued Problem Potential 6. Recovery Environment The ASAM Criteria (2013) Pages 43-53

18 Criminogenic Factors and ASAM Criteria Dimensions Criminogenic Factors ASAM Criteria Dimensions Antisocial values, attitudes, Dimensions 3, 4, and 6 behavior, personality Criminal/deviant peer association Substance Abuse Dysfunctional family relations Dimension 6 Dimensions 1, 4, 5, 6 Dimension 6

19 Biopsychosocial Treatment Treatment Matching - Modalities Motivate - Dimension 4 Manage All Six Dimensions Medication Dimensions 1, 2, 3, 5 - MAT Meetings Dimensions 2, 3, 4, 5, 6 Monitor- All Six Dimensions

20 Treatment Levels of Service 0.5 Early Intervention 1 Outpatient Treatment 2 Intensive Outpatient and Partial Hospitalization 3 Residential/Inpatient Treatment 4 Medically-Managed Intensive Inpatient Treatment

21 ASAM Criteria Levels of Care

22 Focus Assessment and Treatment What Does the Client Want? Does client have immediate needs due to imminent risk in any of six dimensions? Conduct multidimensional assessment The ASAM Criteria p 124

23 Focus Assessment and Treatment (cont.) DSM/ICD diagnoses? Multidimensional Severity/LOF Profile Which assessment dimensions are most important to determine Tx priorities The ASAM Criteria p 124

24 Focus Assessment and Treatment (cont.) Specific focus/target for each priority dimension What specific services needed for each dimension What dose or intensity of these services needed (The ASAM Criteria, 2013, p124)

25 Focus Assessment and Treatment (cont.) Where can these services be provided in least intensive, but safe level of care? What is progress of treatment plan and placement decision; outcomes measurement? The ASAM Criteria p 124

26 DSM/ICD diagnoses? Multidimensional Severity/LOF Profile Which assessment dimensions are most important to determine Tx priorities Specific focus/target for each priority dimension What specific services needed for each dimension What dose or intensity of these services needed Where can these services be provided in least intensive, but safe level of care? What is progress of treatment plan and placement decision; outcomes measurement? The ASAM Criteria p 124

27 Continued Service Criteria (ASAM Criteria) Retain at the present level of care if: 1. Making progress, but not yet achieved goals articulated in individualized treatment plan. Continued treatment at present level of care necessary to permit patient to continue to work toward his or her treatment goals; or (The ASAM Criteria, 2013, p.300)

28 Continued Service Criteria (ASAM Criteria) (cont.) 2. Not yet making progress but has capacity to resolve his or her problems. Actively working on goals articulated in individualized treatment plan. Continued treatment at present level of care necessary to permit patient to continue to work toward his or her treatment goals; and/or (The ASAM Criteria, 2013, p.300)

29 Continued Service Criteria (ASAM Criteria) (cont.) 3. New problems identified that appropriately treated at present level of care. This level is least intensive at which patient s new problems can be addressed effectively. (The ASAM Criteria, 2013, p.300)

30 Discharge/Transfer Service Criteria (ASAM Criteria) Transfer or discharge from present level of care if he or she meets the following criteria: 1. Has achieved goals articulated in his or her individualized treatment plan, thus resolving problem(s) that justified admission to current level of care; or (The ASAM Criteria, 2013, p.303)

31 Discharge/Transfer Service Criteria (ASAM Criteria) (cont.) 2. Has been unable to resolve problem(s) that justified admission to present level of care, despite amendments to treatment plan. Treatment at another level of care or type of service therefore is indicated; or (The ASAM Criteria, 2013, p.303)

32 Discharge/Transfer Service Criteria (ASAM Criteria) (cont.) 3. Has demonstrated lack of capacity to resolve his or her problem(s). Treatment at another level of care or type of service therefore is indicated; or (The ASAM Criteria, 2013, p.303)

33 Discharge/Transfer Service Criteria (ASAM Criteria) (cont.) 4. Has experienced intensification of his or her problem(s), or has developed new problem(s), and can be treated effectively only at a more intensive level of care (The ASAM Criteria, 2013, p.303)

34 Resources A Technical Assistance Guide For Drug Court Judges on Drug Court Treatment Services - Bureau of Justice Assistance Drug Court Technical Assistance Project. American University, School of Public Affairs, Justice Programs Office. Lead Authors: Jeffrey N. Kushner, MHRA, State Drug Court Coordinator, Montana Supreme Court; Roger H. Peters, Ph.D., University of South Florida; Caroline S. Cooper BJA Drug Court Technical Assistance Project. School of Public Affairs, American University. May 1, Bureau of Justice Assistance (BJA) training video on The ASAM Criteria that can be viewed by creating an account and going to the Adult Drug Court Lessons. The system can be found at and this video was initiated by Dennis Reilly at the Center for Court innovation. Critical Treatment Issues Webinar Series, Bureau of Justice (BJA) Drug Court Technical Assistance Project at American University Feb. 10, 2016 May 3, DiClemente CC (2006): Natural Change and the Troublesome Use of Substances A Life-Course Perspective in Rethinking Substance Abuse: What the Science Shows, and What We Should Do about It. Ed. William R Miller and Kathleen M. Carroll. Guildford Press, New York, NY. pp 91; 95.

35 Resources (cont.) Engel GL (1977): The need for a new medical model: a challenge for biomedicine. Science 196: Engel GL (1980): The clinical application of the biopsychosocial model. Am J Psychiatry 137: Fava, G.A. and Sonino, N. (2008):The Biopsychosocial Model Thirty Years Later. Psychother Psychosom 2008;77:1-2 Disease Model of Addiction versus Biopsychosocial Model of Addiction August 9, Donovan, DM (1988): Assessment of addictive behaviors: Implications of an emerging biopsychosocial model. In DM Donovan & GA Marlatt (eds.) Assessment of Addictive Behaviors. Griffiths, Mark (2005): A components model of addiction within a biopsychosocial framework Journal of Substance Use, 2005, Vol. 10, No. 4 : Pages Marlatt, GR and Gordon, JR (Eds) (1985). Relapse Prevention: Maintenance Strategies in the Treatment of Addictive Behaviors. New York, Guilford Press.

36 Resources (cont.) McGovern MP, Wrisley BR, Drake RE (2005): Relapse of Substance Use Disorder and Its Prevention Among Persons With Co-Occurring Disorders. Psychiatric Services 56: Mee-Lee, David (2009): "Moving Beyond Compliance to Lasting Change. Impaired Driving Update Vol XIII, No. 1. Winter Pages 7-10, 22. Mee-Lee D, Shulman GD, Fishman MJ, and Gastfriend DR, Miller MM eds. (2013). The ASAM Criteria: Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions. Third Edition. Carson City, NV: The Change Companies. Mee-Lee, David with Jennifer E. Harrison (2010). Tips and Topics: Opening the Toolbox for Transforming Services and Systems. The Change Companies, Carson City, NV National Institute on Drug Abuse. Principles of Drug Addiction Treatment for Criminal Justice Populations - A Research Based Guide April principles

37 Resources (cont.) The Definition of Addiction Adopted April 12, American Society of Addiction Medicine. Recovery Training and Self-Help: In Service Training Curriculum (1993). National Institute on Drug Abuse (NIDA) NIH Publication No Rockville, MD. Relapse Prevention: More Support for Your Clients (1993). National Institute on Drug Abuse (NIDA) NIH Publication No Rockville, MD. Volkow, Nora D (2018): What Does It Mean When We Call Addiction a Brain Disorder? Scientific American blog March 23, Wallace, J (1990): The new disease model of alcoholism Western Journal of Medicine.152: Zinberg, N. E. (1984). Drug, Set, And Setting: The Basis for Controlled Intoxicant Use. New Haven: Yale University Press. ISBN

38 Resources (cont.) RESOURCE FOR ASAM E-LEARNING AND INTERACTIVE JOURNALS E-learning module on ASAM Multidimensional Assessment and From Assessment to Service Planning and Level of Care 5 CE credits for each module. Introduction to The ASAM Criteria (2 CEU hours) Understanding the Dimensions of Change Creating an effective service plan Interactive Journaling Moving Forward Guiding individualized service planning Interactive Journaling To order: The Change Companies at ; changecompanies.net CLIENT WORKBOOKS AND INTERACTIVE JOURNALS The Change Companies MEE (Motivational, Educational and Experiential) Journal System provides Interactive journaling for clients. It provides the structure of multiple, pertinent topics from which to choose; but allows for flexible personalized choices to help this particular client at this particular stage of his or her stage of readiness and interest in change. To order: The Change Companies at The ASAM Criteria Software Decision Engine - CONTINUUM The ASAM Criteria book and The ASAM Criteria Software now branded as Continuum are companion text and application. The text delineates the dimensions, levels of care, and decision rules that comprise The ASAM Criteria. The software provides an approved structured interview to guide adult assessment and calculate the complex decision tree to yield suggested levels of care, which are verified through the text. Brendan McEntee at ASAM: bmcentee@asam.org David Gastfriend, M.D., Chief Architect of The ASAM Criteria Software: gastfriend@gmail.com

39 THANK-YOU David Mee-Lee, M.D. Chief Editor, The ASAM Criteria DML Training and Consulting Davis, CA tipsntopics.com instituteforwellness.com