Building the Evidence Based Intensive OP Service Presenter: Thomas L. Moore LMSW, LLP, CAADC, CCS September 23 2014 1
# 33 Comprehensive Assessment # 30 Application of SUD Diagnosis to treatment recommendations # 34 Data analysis and interpretation to determine treatment recommendations #43 Formulation of mutual/measurable treatment goals and objectives Current validated instruments and protocols Selecting and administering appropriate assessment instruments and protocols Use of commonly accepted criteria for client placement The continuum of care and rage of treatment modalities Appropriate scoring methodology Using results to identify client needs and treatment options Translate assessment information into measurable treatment goals and objectives Use of goals and objectives to individualize treatment planning 2
Hours= 9 19 or 6 19 Evening, weekend, after school Offered in any setting meeting state licensure or certification criteria Individual, group, family, medication management, educational programs, occupational or recreational therapy Family therapy which includes family members, guardians, significant others Minimum # of hours Planned format of therapies, delivered in individual and group, adapted to developmental stage and comprehension level Use of MI, MET, and engagement strategies 3
Assessment Treatment Plan Monitoring Biopsychosocial Physical exam Can use extenders Problems, needs, strengths, skills and priority formulation Short term measureable goals and activities designed to achieve them Biomarkers Toxicology testing 4
1992 1997 2001 2013 ASAM PCC published Four (4) levels of care PPC 2 published Ten (10) levels of care Criteria for continued stay and discharge PPC 2R published ASAM Third Edition CRITERIA published 5
Multi-dimensional Clinically & outcome driven Variable length of service Clarifying goals Focusing on treatment outcomes ASAM s definition of addiction Not based on diagnosis alone Does not justify entering a certain modality or intensity Holistic Addresses multiple needs, as well as clinical and functional dimensions Addresses six (6) defined dimensions Determined in intake and assessment 6
Discharge date determined at admission Treatment plan is virtually identical to other clients Five to nine problems are listed with 3 5 objectives, interventions or strategies Treatment plan still being developed five or more days after admission Use terms like must complete the program or the full program PLAN of DAP or SOAP states Continue current course of treatment Treatment plan is preprinted Same numbers in more than one chart (14 sessions) Assessment document does not sync with treatment goals Progress notes are duplicated for group members Individualized Severity of illness Level of functioning Response to treatment, progress and outcomes 7
Identifies Includes States Lists Written problems or priorities e.g. obstacles, knowledge or skill deficits skills and resources positive social and spiritual supports e.g. coping strategies, exercise, medication goals (realistic, measurable, achievable) short term resolution of priorities or reduction of symptoms or problems methods or strategies identifying actions of client and staff provided services, staff responsible, site of services, and a timetable for follow through to facilitate measurement of progress. Length of stay linked to treatment response Trends in disease and illness management Emphasis on engagement and outcomes Real time measurement in each visit EBP 8
Addiction is a primary, chronic disease of brain reward, motivation, memory, and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social, and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors. Addiction is characterized by inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems with one s behaviors in interpersonal relationships, and a dysfunctional emotional response. Like other chronic diseases, addiction often involves cycles of relapse in remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death. Treatment follows theory Disease concept, public health perspective, behaviorist view, psychiatric theory Biopsychosocial perspective Etiology, expression and treatment Productive integration from all theories Individualized treatment Patient/ participant assessment, problems/priorities, plan, progress Treatment follows assessment 9
0.5 Early Intervention Prevention OMT IV. Medically- Managed Intensive TX LEVELS OF CARE I. OP services III. Residential II. IOS DIMENSION 1 Acute intoxication Withdrawal Potential DIMENSIONS DIMENSION 2 Biomedical Conditions Biomedical complications DIMENSION 3 Emotional Behavioral Cognitive DIMENSION 4 READINESS TO CHANGE DIMENSION 5 Relapse Continued Use Continued Problem Potential DIMENSION 6 Recovery/Living Environment 10
Meets specifications in Dimension 2 Dimension 3 at least one (1) of Dimensions 4-6 11
Meets specifications in Dimension 1 Dimension 2 at least one (1) of Dimensions 3-6 Level 2.1 ADULT Transfer Criteria Patient has met essential treatment objectives at a more intensive level of care AND requires Level 2.1 in at least one (1) Dimension 4 6 Level 1 has proved insufficient to meet patient needs OR motivational services have prepared patient for a more intensive level of service 12
Patient has met essential treatment objectives at a more intensive level of care AND requires Level 2.1 in at least one (1) Dimension Level 1 has proved insufficient to meet patient needs OR motivational services have prepared adolescent for a more intensive level of service Level 2.1 ADOLESCENT Transfer Criteria Dimension 1 Dimension 2 Dimension 3 Dimension 4 Dimension 5 Dimension 6 Signs and symptoms indicate continued presence of intoxication or withdrawal that required admission. A physical health problem exists (initial or new) requiring biomedical services. There exists the initial or emergent emotional, behavioral and/or cognitive problem. There remains a continued need for engagement and motivational enhancement. Initial or new problem exists requiring coping skills and strategies to prevent relapse, continued use, or continued problem potential. The initial problem or a new one exists in recovery environment requiring coping skills and support system interventions. 13
COR SYM OAT FAM SAM DEF SAT 14
SYMPTOMS SYM Notes early substance misuse Higher scores indicate negative consequences from misuse Individuals will evaluate their consumption as normal defined by family of origin and peers Clarifies amount of structure needed Obvious Attributes OAT Notes personality characteristics e.g. frustration tolerance, compulsivity, level of patience Indicates openness of individual to receive feedback Determination of internal versus external locus of control Clarifies if individual is an appropriate referral for group services 15
Subtle Attributes SAT Notes centrality of substance misuse in the individual s life Indicates capability of insight in regard to substance misuse, being able to link misuse and consequences Determination of therapeutic approach (e.g. cognitive therapy versus addressing affective issues Clarifies if responses are an attempt at impression management, or if further screening for an anxiety disorder is warranted Defensive ness DEF Notes direction of pain (externalized versus internalized) Indicates capacity of insight and need to defend as well of fear of being judged. May point to situational issues (e.g. job jeopardy, legal issues, child custody, etc.) Clarifies if therapeutic approach is one of avoiding expert trap, versus evaluating hopelessness, anhedonia, mood disorder, or suicidal tendencies 16
Supplemental Addiction Measure SAM Secondary scale for defensiveness Indicates presence of secrets (can be non substance related) Expectation of shame regarding secrets Therapeutic approach follows building trust and rapport, as well as addressing precontemplation and contemplation regarding issues of shame Family versus Control FAM Not a clinical scale Identifies self centeredness as opposed to a need to be a caretaker for others Depending on scores, use of an additional instrument (MILLON, or MMPI) may be indicated Determines direction of therapeutic approach (e.g. reading social cues, boundary issues, assertiveness training, development of empathy, etc.) 17
Corrections COR Not a clinical scale Identifies tendency to break rules, which determines level of legal supervision, and/or treatment structure Depending on score, primary services may focus on social/behavioral interventions and behavioral management strategies Determines therapeutic approach (e.g. impulse control, social skills development, addressing frustration tolerance, sensation seeking, etc.) 18
DIMENSION 3 Emotional, Behavioral, or Cognitive Conditions and Complications 4 Readiness to Change 5 Relapse, Continued Use, Continued Problem Potential 6 Recovery/Living Environment RISK LEVEL NEEDED TO LOWER RISK COMPETENCIES FOR SUCCESSFUL RECOVERY BY ASAM DIMENSIONS Dimension Indicator Competency 3 Psychiatric illness Psychological, behavioral, emotional or cognitive problems Chronic conditions Ability to manage activities of daily living Coping strategies 5 Current relapse prevention skills Severity of past relapse episodes Past periods of abstinence or controlled use Benefits from past treatment episodes Pharmacological Responsivity (+ or ) Reactivity to acute stimuli (triggers) Reactivity to chronic stress Cognitive/Behavioral strengths Cognitive/Behavioral weaknesses Locus of Control Self efficacy Coping skills (stimulus control) Impulsivity (risk taking, thrill seeking) Aggressive, passive, passive aggressive behavior 6 Threats to safety, engagement in treatment Resources increasing likelihood of successful treatment Legal, vocational, social service agency mandates that can enhance treatment engagement Transportation, childcare, housing or employment issues 19
Admission per ASAM Criteria Determine risk in each dimension Align treatment plan with skills to decrease risk Approach through SASSI indicators Client attends until risk level warrants transfer to another level of care Discharge/transfer from IOS per ASAM Criteria 20
Rachel Connor-Synopsis of SASSI Scales FVA, FVOD The client self-reported a high (12) number of experiences of misuse of alcohol, and a moderately low (4) number of experiences of misuse of drugs other than alcohol. Drug-Of-Choice What the client self-reported indicates that the client s drug of choice has been alcohol. SYM The client also self-reported a high (8) number of symptoms of substance abuse. Individuals who score this high on the self-report scales usually have experienced the use of substances to cope, negative experiences of their use, and loss of control. This client s profile indicates that the client probably is (or was) part of a social system that promotes substance use. Such enabling social systems frequently are dominated by someone s substance use (a parent s, spouse s, friend s, or the client s own use). Members of such social systems often become so accustomed to such a lifestyle that the substance abuse and associated behaviors are considered to be normal. This client might benefit by a discussion of what is normal and a program which helps the client believe that life without substance use is possible and preferable. High COR The client s profile is predictive of risk of getting into trouble. The client might have a tendency to offend others, defy authorities and rules, lack social skills, have problems with anger, or be impulsive. Combined High SYM and High COR The client might benefit from a program which helps the client clarify long-term goals, and modify daily/weekly/monthly routines in light of those goals (increase ability to delay immediate gratification in order to obtain greater payoff later). The client is likely to need program structure clear contracts, monitoring, and accountability. Low FAM This client is apt to be so self-absorbed that the client gives little consideration to the needs of others. The client might be assertive to an extreme - quick to stand up for self, impatient and intolerant with others. The client might benefit from treatment which includes opportunities for others (family members, for example) to share their feelings and grievances, development of victim empathy, and opportunities to give to others (including restitution and apologies).
External ID # Initial Plan of Service/Assessment Name: Rachel Connor Intake/IPS Date: 8/5/2005 Time In: 4:30 PM Time Out: 5:30 PM 1. Presenting Problem/Expectations for Counseling (use client s own words): I have been sentenced to you from the court. They state that I need counseling because of my prior drinking and driving offense. I am uncertain of what type of counseling that I actually need. I don't want to focus on past issues. 2. Symptom Patterns Symptom Cluster Specific Symptoms Disturbances in Thinking: Confusion, irritability, difficulty with problem solving Date of Onset: Age 19 Somatic Symptoms: An exploratory surgery occurred in 1989 resultant to bleeding from her kidneys. Rachel also states gastrointestinal problems as well as heart disease which she calls COPD. This was diagnosed in 1999 Date of Onset: 1989 Disturbances in Behavior: There are a number of behavioral issues. Client states she obtained a drinking driving charge in 1996. In addition, Rachel noted that she was hospitalized at Pine Rest when she was approximately 19 years of age. Apparently there are behavioral problems that stem back to adolescence Date of Onset: 1976 Depressive Disturbances: Client admits to feeling hopeless, despondent, displaying sleep disturbances. Although she would admit only to severe anxiety problems, there are depressive features to her presentation. Date of Onset: 1999 Anxiety-related Disturbances: Rachel reports her first panic attack at age 18. She describes her symptoms as that she could not breathe and felt insecure all the time. She stated prior to been prescribed medication her panic attacks would last all day long. She also experienced agoraphobia at age 19 state that she did not want to leave the house Date of Onset: 1973 Harm to Self/Others: Rachel denies
Name: Rachel Connor External ID# 05787134 Page 2 Date of Onset: Not applicable Substance Use (Including Caffeine and Nicotine). Use Substance Use Chart if present: Date of Onset: 1996. Defined use of alcohol, nicotine and Xanax. States abstinence for more than two years with alcohol. Last use of Xanax and nicotine were today. 3. Current Legal or Court Involvement: Rachel is currently on probation with Karen Kuiper, 61st District Court as result of a prior drinking driving violation in which she fled. Client stated did not comply with probation requirements. 4. Occupational/Educational Concerns: She completed general education diploma (GED) age 32. She has no history of advanced vocational training. Client is currently employed part-time in a restaurant, however is uncertain as to the stability of the company. She is significantly hampered by transportation problems. 5. Financial Concerns: Rachel is significantly concerned about financial problems 6. Military Experience: YES NO Not Applicable 7. Community, Social, and Spiritual Natural Supports and/or Concerns Including Cultural Diversity Concerns: Although she lives with her family and has a current boyfriend, this area is noticeably void. Client is Caucasian, identified WASP values. Parents were first-generation Americans from Eastern European origin. Attempts will be made to encourage her to attend support groups. 8. Leisure Time Activities: Client could only identify staying in her room. 9. Medical/Health Concerns or Allergies, Accommodations Necessary for Disabilities or Sensory Needs: Client reports heart problems, gastrointestinal problems Physical Exam Recommended? Yes No 10. Developmental Milestones - Prenatal/Perinatal (for children under 12) Not applicable 11. Previous Psychiatric/Psychological Treatment, Including Hospitalizations Rachel was hospitalized at Pine Rest Christian hospital which he was 16 years old. She is been meeting with a physician in Battle Creek since 1994 and receives Xanax and Paxil. Her last
Name: Rachel Connor External ID# 05787134 Page 3 hospitalization was in 1997 at Marshall MI for a 24-hour period of time. She previously met with Donald Gosling, MSW in this office (2001) for five individual sessions. 12. Family and Social History Both parents are still living and married. Rachel is actually living in their home at this time. She has four sisters and describes herself as the middle child. She perceives that she has minimal contact with her siblings, citing poor and conflict-filled relationships. Client describes mother as distant and critical. Client states that she did experience sexual abuse as a child, yet was unwilling to go into detail about this event. 13. Current Living/Social Situation She is currently living with parents and one of her daughters is also living in this house. Client has been married on two occasions, the first time for 13 years. She does report having a cordial relationship with her second ex-husband. Client states she is concerned about her children because she feels that they take care of her rather than the other way around. 14. Client Strengths Insightful, verbal, sober 15. MENTAL STATUS Dress: Appropriate Motor Behavior: Increased Speech/Thought: Persevering Flow of Thought: worried Evidence of Psychosis: none Mood and Affect: Flat Orientation: Intellect: Average Insight: Above-average Impulse control: Poor Judgment: Impaired Attention: Tangential Memory: Time Oriented Place Oriented Person Oriented Recent good Remote Good Past - Good 16.High Risk Indicators: Suicidal Ideation Victim of Domestic Violence No Apparent Indicator Past Present
Name: Rachel Connor External ID# 05787134 Page 4 Perpetrator of Domestic Violence Victim of Child Abuse/Neglect Perpetrator of Child Abuse/Neglect Victim of Sexual Abuse Perpetrator of Sexual Abuse Threat to Others Eating Disorder Evidence of Psychosis Noncompliance with Treatment 17.Safety Concerns: Rachel states she experiences passive suicidal ideation, although states that she would not act upon it. She is quite dependent and vulnerable in her current situation. 18.Referrals to Community Resources Due to her agoraphobia, it's difficult to state what resources can be realistically accessed. Ideally, she would attend AA as a support group as well as become involved in transitional housing. 19. In Addition to Client, Who Else May be Involved in Treatment No one else will be involved at this time due to client request for privacy. 20. Recommended Treatment Modality and Frequency Individual counseling on a twice per month basis 21. Diagnostic Formulation Rachel presents with an extreme panic disorder, as well as numerous environmental issues. She has a dependent personality disorder, which renders render her vulnerable to living in her parents home and continuing to use. Client struggles with transportation issues, employment issues, and financial issues. She needs an advocate in order to make necessary changes. There may be issues in regard to childhood sexual abuse, need to monitor for PTSD as well as determine whether current anxiety disturbances are related to childhood abuse. Relapse history needs to be explored in regard to correlation between anxiety, potential PTSD and trauma responses as well as lack of support system. Xanax dependence needs to be monitored.
Name: Rachel Connor External ID# 05787134 Page 5 22. Diagnostic Impression: Axis I: 300.02 Generalized Anxiety Disorder, 300.900 Alcohol Dependence without Physiological Dependence in Sustained Full Remission; 304.10 Anxiolytic Dependence with Physiological Dependence, Moderate; RULE/OUT Panic Disorder with Agoraphobia Axis II: 301.60 Dependent Personality Disorder; RULE OUT Borderline Personality Disorder Axis III: Cardiac problems Axis IV: Financial problems, transportation problems, job problems, problems with primary support group Axis V Current GAF: 49 Highest GAF during past year: 55
Competency 9: Understand the established diagnostic criteria for substance use disorders, and describe treatment modalities and placement criteria and within the continuum of care. Knowledge: Established placement criteria developed by various states and professional organizations. Continuum of treatment services and activities. Attitudes: Openness to a variety of treatment services based on client needs.