Descriptive Analysis of Characteristics of Monitoring Programs. Kathleen Russell, JD, MN, RN Associate Director, Nursing Regulation, NCSBN

Transcription

1 Descriptive Analysis of Characteristics of Monitoring Programs Kathleen Russell, JD, MN, RN Associate Director, Nursing Regulation, NCSBN

2 Categories of characteristics

3 Characteristics included in review 1.Intake evaluation 2.Responsibility for payment of program fees and testing costs 3. Minimum monitoring contract length 4.Requirement of abstinence from drugs/alcohol 5.Use of mood altering medications for psychiatric/medical conditions while participating in a program 6. Medication assisted treatment 7. Drug test check in frequency 8. Drug screen frequency 9.Approval of group meetings 10.Types of group meetings 11.Frequency of group attendance 12.Frequency of reports of group attendance 13.Requirement of a sponsor 14.Self-report frequency 15.Workplace restrictions 16.Regular work performance evaluator 17.Frequency of reports from evaluator 18.Definition of relapse 19.Response to relapse 20.Program noncompliance 21.Response to noncompliance Intake evaluations All sets of program materials mention intake evaluations Most (n=15) using an outside evaluator Others (n=4) identify someone internal to program as evaluator, a multidisciplinary team or a case-bycase determination Table 1. Intake Evaluation (N=27) Intake Evaluators Jurisdictions Program Director, Investigator or Consultant 2 A, F Multidisciplinary team 1 C Outside Evaluator 15 B, E, G, J, L, M, R, S, T, U, V, X, Y, Z, AA Case-by-case 1 Q Program materials do not specifically mention the type of evaluator 8 D, H, I, K, O, N, P, W

4 Responsibility for cost of testing and/or fees for the program Almost 70% indicate responsibility for cost of testing and/or program fees Most (n=12) participant pays all costs A few (n=4) participant pays only testing fees 2 payment on case-by-case basis Table 2. Responsibility for payment of program fees and testing costs Responsibility for payment Program Materials Participant pays all costs 12 A, C, D, G, I, J, T, U, X, Y, Z, AA Participant pays only testing fees 4 E, Q, H, Q Participant or BON depending on circumstances 2 K, N Program materials do not specifically mention 9 B, F, L, M, O, P, Q, R, S Minimum length of monitoring program Varies from 6 months to 5+ years Most frequent minimum length 3-years (n=7) Those which indicate less than 3-years as a minimum also have monitoring contracts that vary in length i.e. 1-year, 2-years, 5+ years on a case-by-case determination

5 Table 3. Minimum monitoring contract length Minimum contract length Jurisdiction 6 months 3 D, U, AA 1 year 2 B, R 2 years 3 C, H, V 3 years 7 A, E, J, L, S, Q, Y 4 years 1 I 5 years + 4 G, M, P, X Abstinence Abstinence as a requirement Mentioned directly in 23 4 do not specifically mention abstinence, implied in program materials Mood altering medication for psychiatric or medical conditions While participating in a monitoring program 18 allowed use 1 indicates some medications may require consultation with addictionologist before approval to use 1 indicates participant may not work while using mood altering medications

6 Table 4. Use of mood altering medications for psychiatric/medical conditions while participating in a program Allowed Number of sets of program materials Yes 18 Yes, however may require consultation with addictionologist Programs A, B, C, D, E, G, I, J, K, N, O, P, R, Q, T, U, Y, Z 1 H No, if working as a nurse 1 AA Program materials do not specifically mention 7 F, L, M, S, V, W, X Medication Assisted Treatment Use of Buprenorphine, Suboxone, Methadone, Vivitrol, Naltrexone or more general MAT can be found in several sets of the program materials 7 include information regarding Naltrexone/Vivitrol 10 include information regarding buprenorphine Some vary on whether any MAT can be allowed if the nurse is practicing Medication Assisted Treatment Others note specifically which types of medications are allowed Programs which allow use of any MAT often require approval by the program, as well as additional program monitoring and other program requirements 2 programs require use of Naltrexone or Vivitrol if the participant is determined to be a high-risk participant

7 Table 5. Medication Assisted Therapy (MAT) MAT Use of Suboxone, Methadone, Buprenorphine, Naltrexone, or MAT allowed with additional program requirements General mention allowing use of Suboxone or Methadone with program approval High risk program participants are required to take Vivitrol or Naltrexone; with additional program requirements Only rare cases will meet program determination for allowing use of Suboxone, Methadone, Buprenorphine Case-by-case determination for use of Naltrexone, Suboxone, Antabuse; will cause a practice limitation Verified in program materials (n) Jurisdiction 5 D, E, F*, M, K** 3 C***, U, V 2 B, AA 1 AA 1 W No nursing practice allowed if using Buprenorphine 1 Z No nursing practice allowed if using MAT 1 X *only mentioned Naltrexone, **did not mention Naltrexone, ***only mentioned Methadone Frequency of check in for drug testing Varies among programs 1/3 (n=9) daily check in Approximately 20% (n= 6) weekday-only check in 2 weekday plus Saturday check ins Most some allowance to skip a check in on a major holiday One specifies if participant lives >25 miles from collection site, everyday requirement adjusted Table 6. Drug test check in frequency Frequency of Check in* Jurisdiction Everyday 9 C, E, G, H, J, K, L, X, AA Weekdays 6 B, D, N, R, Q, U Weekdays + Saturdays 2 I, V Everyday, unless participant lives >25 miles from collection site 1 S *Frequently holidays are excluded from check in

8 Frequency of drug testing Varies from 1 to 4 times/month with no frequency achieving more than 15% of those sampled Several (n=5) note a case-by-case determination of frequency of drug testing Others do not indicate frequency in program materials Many programs indicate the testing frequency may decrease after the first year or so, depending on program compliance Table 7. Drug screen frequency Minimum Tests Per Month Jurisdiction One 3 C, F, K Two 2 A, H Three 1 I Four 4 G, J, O, W Case-by-case 5 D, N, R, S, V Group meetings approval process A component of each monitoring program, however the approval process for an acceptable group meeting is not often delineated in program materials Approval process can vary Monitoring program employee (n=5) Treatment provider (n=1) BON (n=1)

9 Type of group meeting Program materials often will allow or require attendance at more than one type of group meeting Most frequently specified type of program is a 12-step program (n=17) such as AA, NA, or abstinence program An approved peer group program (non AA or NA) is second most frequent type of approved program (n=10) Frequency of group meetings Almost 40% (n=10) use case-by-case determination Others (n=8) indicate group meetings required 3/week differ in the type of meetings required some include AA/NA and peer group others indicate all AA/NA type meetings 2/week (n=4) 1/week (n=1) Table 8. Frequency of group meeting attendance Frequency of Group Attendance* Programs 1 group meeting per week 1 H 2 AA/NA per week 2 N, W 2 group meetings per week 2 S, Y 2 AA/NA + 1 peer support group per week 4 A, E, G, V 3 group meeting per week 4 D, Q, T, W Case-by-case determination 10 B, F, G, I, J, K, L, M, R, Z Program materials do not include information on frequency of group meetings 4 C, M, U, AA *If program materials indicate a monthly frequency those are adjusted to a weekly basis

10 Table 9. Frequency of reports of group attendance Frequency of Reports from Group Meeting Facilitators Programs Monthly 5 D, R, W, X, Y Initially, bimonthly, then reduced to quarterly Every 3 Months 7 B, E, G, H, J, O, S Case-by-case determination 1 Q 3 F, I, T Program materials do not include information 11 A, C, K, L, M, N, P, U, V, Z, AA Sponsor as a requirement Just over 50% (n=14) indicate a sponsor is required Requirement on a case-by-case determination (n=4) Self-reports Required in varying frequency Some note weekly, monthly, every 2 months or quarterly reports, as well as a case-by-case determination Monthly most common frequency (n=9)

11 Table 10. Self-report frequency Frequency of Self Reports Weekly contact with Program via , voice or voic Programs 1 I Monthly 9 F, H, P, ED, S, T, U, X, Y Every 2 months 1 A Every 3 months 5 B, E, G, O, V Case-by-case determination 2 K, L Program materials do not include information 9 C, D, M, N, Q, J, W, Z, AA Workplace restrictions 93% indicated several workplace restrictions per participant Prohibition from working at a staffing or registry agency (n=14) working in a home or community based setting (n=14) floating away from regular unit (n=13) Restriction on work hours/days/shifts (n=16) Access to controlled substances (n=16) Work performance evaluation Work performance evaluation noted in 45% (n=12) Individual to perform the evaluation workplace supervisor (n=5) worksite monitor (n=5) others included case manager or employer Work performance evaluation reports vary from quarterly to case-by-case determination

12 Table 11. Frequency of Reports from Worksite Evaluator Frequency of Reports from Evaluator Programs Every month 2 S, X Every 2 months 1 Q Every 3 months 7 B, E, G, T, V, Y, AA Case-by-case determination 3 H, K, L Program materials do not include information 13 A, C, D, F, I, J, M, N, O, P, R, U, Z Relapse defined Many define relapse (n=17) At least 7 relapse definitions are indicated across the program materials Table 12. Definition of Relapse Relapse is: Jurisdictions Positive Screen for Any Unauthorized Substance 5 A, O, R, Z, AA Use of Unauthorized Substance 6 A, D, P, S, I, AA Return to Drug/Alcohol After Abstinence 3 E, L, H Admitted Use After Abstinence 1 I Return to Use of Substances that Impedes Safe Practice Return of Signs and Symptoms After Apparent Recovery 1 F 6 B, L, M, R, S, X Failure to Submit Fluid Under Suspicion 1 H Relapse Determined by Evaluation 2 Q, Z Relapse mentioned but not specifically defined in program materials 10 C, G, J, K, N, T, U, V, W, Y

13 Response to relapse Varies widely across programs; many programs having more than 1 response to relapse Most frequent responses to relapse evaluation (n=10) cease practice (n=9) Reporting to BON (n=6) Increasing drug screen frequency (n=5) Increasing contract length (n=5) Just over 40% (n=12) indicate case-by-case determination of the response Table 13. Response to Relapse Relapse consequences Programs Cease Practice 9 A, B, D, E, H, M, S, X, AA Report to Employer 1 AA Evaluation for SUD 10 A, B, D, E, F, H, M, Q, T, Z Increase Drug Screen Frequency 5 A, F, H, I, T Increase Contract Length 5 D, E, F, Q, X Increase Support Meetings 2 A, F Impose Access Restrictions 2 A, F Establish a recovery plan 1 AA Report to BON 6 D, P, Q, W, X, Z Enter Treatment 1 X Case-by-case determination 12 D, E, F, H, J, K, L, P, S, Q, T, W Response to relapse mentioned not specified 7 C, G, N, O, U, V, Y Noncompliance definition Defined by various violations of program contract or policies Almost 40% (n=10) drug test violation is noncompliance Further defined as failure to submit/missed test (n=10) positive test (n=7) substituted/dilute/altered test (n=7) Other drug violations, only noted in a few (n<5) ingestion/failed abstinence, diversion, possession, failure to obey access restrictions, prescription forgery, drug/alcohol arrest or failure to take prescribed medications

14 Noncompliance definition Certain participant conduct also noncompliance (n=9) Refusal or failure to respond, a pattern of behavior, unable to practice safely, accepting a position without approval, late/missing/poor reporting, failure to pay fees, lapse of license and failure to notify No consistency across program materials related to the participant conduct Violations of attendance (n=5) Violations of law or contract (n=8) Implied by program materials when there are references to consequences for noncompliance Table 14. Program Noncompliance Program Violation Admitted/Confirmed/Diagnosed Relapse Verified in program Programs 3* B, K, O Drug Test Violation 10 A**, B, D, E**, I, J, O, S, Q, T Other Drug Violation 5 B, D, I, K, T Attendance Violation 5 B, D, I, O, T Other Conduct Violation 9 B, D, H, I, J, O, S, C, T Violation of Law or Contract 8 C, D, H, J, M, O, P, T Program materials do not include information on definition, but list consequences for noncompliance 5 F, G, L, N, R * One of these three Programs does not define Relapse ** Programs where this violation is the only consideration for noncompliance Response to noncompliance At least 16 different types of responses indicated, some programs use multiple types of responses for a particular instance of noncompliance At least 40% of program materials indicate response as cease practice (n=12) discharge or terminate from program (n=12) or report to BON (n=14)

15 Table 15. Response to noncompliance Response to noncompliance Programs Cease Practice 12 D, E, F, H, I, K, L, S, U, X, Z, AA Report to Worksite Monitor 3 D, V, AA Impose/Change Narcotic Access Restrictions 1 F Increase Drug Screen Frequency 13 B, D, E, F, I, K, N, O, R, Q, T, V, W Increase Support/Sponsor/Case Manager Meetings 2 E, F Independent Evaluation/Evaluation for SUD/Fitness to Practice Evaluation 10 B, D, E, F, I, R, S, V, W, Z Return to Treatment 4 D, F, X, Z Education Program/Relapse Prevention Program 3 E, F, V Message/Written Notice of Noncompliance 6 D, O, R, S, Q, T Review by Medical Director 4 B, R, T, V Establish a recovery plan 1 AA Increase Contract Length/Revision to Contract 5 D, E, H, V, X Review for Termination of Program 4 B, L, T, W Discharge/Termination of Program 12 A, B, D, E, H, J, M, R, Q, T, V, X Report/Referral to Board of Nursing Disciplinary Action by the Board of Nursing 14 D, E, H, I, K, M, U, V, W, X, Y, Z, Q, P Consequences mentioned but not specifically indicated 2 C, G Program information included in materials Wide variance in characteristics included in program materials Most consistently included information response to program noncompliance (92%) workplace restrictions (85%) requirement of abstinence (85%) Drug check in & drug testing frequency only included in program materials 67% and 56% of the time respectively Response to a relapse included in 70% of program materials Program information included in materials Just over a majority of program materials included definition of relapse (59%) program non-compliance (56%) whether use of mood altering medications for psychiatric/medical conditions while participating in a program is allowed (74%) responsibility for cost (63%) requirement of a sponsor (66%)

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17 Thank you for your attention Questions