Marc Fishman, M.D., Johns Hopkins University and Maryland Treatments Center, Baltimore, MD

1. Using the New GAIN Patient Placement Summary to Support Individual Treatment Planning, Placement and Program Evaluation Marc Fishman, M.D., Johns Hopkins University and Maryland Treatments Center, Baltimore, MD Laverne Hanes Stevens, Ph.D., Chestnut Health Systems, Atlanta, GA Michael L. Dennis, Ph.D., Chestnut Health Systems, Bloomington, IL Workshop at the Joint Meeting on Adolescent Treatment Effectiveness, Baltimore, MD, March 28, 2006. Preparation of this manuscript was supported by funding from the Center for Substance Abuse Treatment (CSAT Contract no. 270-2003-00006) and several individual grants. The content of this poster are the opinions of the author and do not reflect the views or policies of the government. Available on line at www.chestnut.org/LI/Posters or by contacting Joan Unsicker at 720 West Chestnut, Bloomington, IL 61701, phone: (309) 827-6026, fax:(309) 829-4661, e-Mail: junsicker@Chestnut.Org

2. This workshop will.. • Provide an overview of the evolution, strengths and limits of ASAM’s patient placement criteria (Fishman) • Outline the GAIN approach to integrating treatment planning and placement, including the expanded recommendations we are developing (Stevens) • Summarize Chestnut’s work to developing real time placement recommendations for line clinicians using the CSAT adolescent treatment data set (Dennis)

3. Introduction the American Society of Addiction Medicine’s (ASAM) Patient Placement Criteria (PPC) Marc Fishman MD Johns Hopkins University Maryland Treatment Centers

4. Evolution of the APC PPC-1 (1991) PPC-2 (1996) PPC-2R (2001)

5. ASAM PPC-2: Assessment Dimensions 1: Intoxication / Withdrawal Potential 2: Biomedical Conditions 3: Emotional / Behavioral / Cognitive Conditions 4: Readiness to Change 5: Relapse / Continued Use / Continued Problem Potential 6: Recovery Environment

6. ASAM PPCLevels of Care Level 0.5: Early Intervention Level I: Outpatient Level II: Intensive Outpatient and Partial Hospital Level III: Residential / Inpatient (includes therapeutic communities) Level IV: Hospital (based on services – NOT length of stay)

7. ASAM PPC-2R Adolescent Criteria • Level II • II.1: Intensive Outpatient (IOP) • II.5: Partial Hospital / Day Program • Level III • III.1: Clinically Managed Low Intensity Residential (e.g.., halfway houses) • III.5: Clinically Managed Medium Intensity Residential (moderate –long term treatment) • III.7: Medically Monitored High Intensity Residential/Inpatient (short term treatment)

8. ASAM PPC-2R Crosswalk

9. ASAM PPC: General Principles • Unidimensional --> Multidimensional assessment • Program driven --> Clinically / individually driven treatment • Fixed length --> Variable length of treatment • Fragmentation --> Integration of treatment services • Discrete Types --> Continuum of care

10. Strengths of PPC • Real time placement decisions • Justification of placement (regulatory, reimbursement) • Guide to common language for organizing assessment data • Guide to treatment needs and plan • Shift to a more chronic model of care that recognizes most people go through treatment multiple times over a period of several years before reaching sustained recovery.

11. Treatment Evaluation First and Continuous Standardized Assessment Treatment Proforma Assessment

12. Local Implementation • Local variations in • Availability of continuum of services • Availability of certain levels of care • Characteristics and services of actual local programs in each levels of care • Needs and expectations of client, referrors, payors, regulators, and others (e.g. judges) • Variation in provider programs, services, capacity, culture

13. Limitations to PPC • Inconsistency of interpretation and complex nature making training and reliable implementation difficult • Reliability of assessment data without standardized instrumentation • Operationalization of decision rules for placement • Services are NOT consistently bundled by level of care • Some services not level of care dependent • Face valid, but limited outcome research • Need to integrate with treatment planning for specific services

14. The GAIN approach to integrating treatment planning and placement Laverne Hanes Stevens, Ph.D., Chestnut Health Systems, Atlanta, GA

15. How the GAIN Views Problem Sets Recency Prevalence Breadth

16. Interpreting Problem Sets Factor #1 Recency: • Has this problem ever occurred and, if so, when did it last occur? • Things that happened in the past week or 90 days will typically play a greater role in current treatment than those that happened 4-12 months or 1+ years ago.

17. Interpreting Problem Sets Factor #2 Breadth: • How widespread/diverse is the presentation of clinical symptoms or pattern of service utilization? • Typically more diverse presentations are associated with higher severity. • For clinical problems, the focus is on the past year (or since the last interview in follow-up assessments). • For services, the focus is on the lifetime pattern of service utilization.

18. Interpreting Problem Sets Factor #3 Current Prevalence: • How often has this happened in the past 90 days? • Typically things that happen more frequently (particularly if they interfere with responsibilities at home, work/school or socially) are going to be more important than those that happened only once or twice.

19. GAIN Approach to ASAM Level of Care Placement • Rate the “Problem Recency” and “Treatment History” • Three time perspectives: None, past or current • First -- Determine treatment planning and service needs based on the above rating. • Then --Identify the level of care and/or local program that best matches the cluster of service needs that are identified. • Lastly -- Use information from average performance of different levels of care with similar populations to make choices where there is more than one possibility or trade-off.

20. Conceptualization of Treatment Need and Placement * Past week for B1. Detox/Withdrawal

21. Conceptualization of Treatment Need and Placement * Past week for B1. Detox/Withdrawal

22. Conceptualization of Treatment Need and Placement * Past week for B1. Detox/Withdrawal

23. Conceptualization of Treatment Need and Placement * Past week for B1. Detox/Withdrawal

24. Conceptualization of Treatment Need and Placement * Past week for B1. Detox/Withdrawal

25. Conceptualization of Treatment Need and Placement * Past week for B1. Detox/Withdrawal

26. Conceptualization of Treatment Need and Placement * Past week for B1. Detox/Withdrawal

27. Conceptualization of Treatment Need and Placement * Past week for B1. Detox/Withdrawal

28. Supplemental ASAMWorksheet (GAIN I page 100) Can document impression here so it prints out in GRRS SA treatment used for A, B4, B5, and (if IOP/residential) B6 Can record problem recency by treatment history rating Can record comment to help with treatment planning Record preliminary placement recommendations and any comments about placement to include at the end of the GRRS

29. The GAIN Recommendation and Referral Summary (GRRS) A text-based narrative in MS Word designed to be edited and shared with specialists, clinical staff from other agencies, insurers and lay people.

30. G-RRS Organization & Content(See Appendix F) • Presenting Concerns and Identifying Information • DSM-IV/ICD-9 Diagnoses  • Evaluation Procedure • Substance Use Diagnoses and Treatment History (ASAM criteria A) • Level of Care and Service Needs (ASAM Six Dimensional Criteria B) • Summary Recommendation • Staff Notes from Assessment (should be used and removed during editing)

31. G-RRS Organization & Content(See Appendix F) • Presenting Concerns and Identifying Information • DSM-IV/ICD-9 Diagnoses  • Evaluation Procedure • Substance Use Diagnoses and Treatment History (ASAM criteria A) • Level of Care and Service Needs (ASAM Six Dimensional Criteria B) • Summary Recommendation • Staff Notes from Assessment (should be used and removed during editing)

32. Level of Care and Service Needs Arranged by six dimensions of ASAM Criteria B: • Acute Alcohol/Drug Intoxication and Withdrawal Potential • Biomedical Conditions and Complications • Emotional, Behavioral, or Cognitive Conditions and Complications • Readiness to Change • Relapse, Continued Use, or Continued Problem Potential • Recovery Environment

33. Prior Treatment Options Built into the GAIN Recommendation & Referral Summary B1 Intoxication/Withdrawal: Need for Detox Services • Monitoring for change in intoxication or withdrawal symptoms • Ambulatory detoxification services related to withdrawal • Inpatient detoxification services related to current intoxication and withdrawal B2 – Biomedical: Need for Medical Services • Monitoring for change in physical health (and medication compliance) • The following specific accommodations for medical conditions required to participate in treatment: List out • A more detailed medical assessment (including nutritional guidance) • Referral for the following specific medical services: List out B3 Emotional/Behavioral: Need for Psychological Services • Monitoring for change in mental health (and medication compliance) • The following specific accommodations for psychological conditions required to participate in treatment: List out • A more detailed psychological assessment • Referral for the following specific psychological services: List out

34. Prior Treatment Options… (Continued) B4 Readiness to Change: Need for Motivational Services, Coordination of Pressure and/or Access/Resistance Issues • Monitoring for change in readiness for change • The following assistance to help address treatment resistance: list out • Individual motivational enhancement sessions • The following specific services to help maintain motivation to stay in recovery: list out B5 Relapse/Continued Use Potential: Need for Risk Management • Monitoring for change in relapse potential • Relapse prevention skills groups • Increased structure to reduce environmental risks of relapse • The following specific steps to reduce continued use/relapse potential: list out B6 Recovery Environment: Need for Environmental Interventions and Risk management • Monitoring for change in recovery environment • A residential or more structured treatment setting to temporarily control environmental risks • the following specific steps to reduce recovery environment risks: list out • The following specific steps to take further advantages of sources of support/personal strengths: list out

35. NEW Recommendation Summary for Supporting Clinical Decisions

36. Problem No Problem No past / current Past Problems Lifetime history of withdrawal symptoms and no current problems Current - Low/Mod Problems Any past week symptoms of withdrawal and no current high severity problems Current High Severity High on Current Withdrawal Scale in the past week Any past week withdrawal symptoms with daily opioid use or physiological symptoms of withdrawal Treatment No Treatment History No past / current treatment Past (Lifetime) Treatment History Lifetime history of detoxification services and no current treatment Currently in Treatment 1 or more of the past 90 days in detoxification Dimension B-1: Intoxication / Withdrawal

37. Conceptualization of Treatment Need and Placement * Past week for B1. Detox/Withdrawal

38. Example: Dimension B-1 / Cell 6 Text The GRRS will print: [NAME] has received detoxification services in the past 90 days but is still using at a low frequency or having some withdrawal symptoms in the past week. Based on the information provided, the evaluator recommends: <<PROMPT: REVIEW, DELETE OR EDIT ACCORDING T0 SPECIFIC NEEDS AND CLINICAL INDICATIONS>> • Discussing the current and/or prior detoxification episodes with [NAME] to review the experience (e.g., Did [he/she/name] complete the prior detoxification program? follow-up recommendation to go to treatment? achieve a period of initial abstinence (at least 90 days)? Are there things that might be adjusted to make it work as well or better this time? What is [he/she/name] willing/able to do differently this time?)

39. Requesting records from most recent detoxification episode and reviewing those records to determine the services previously provided, recommendations and outcomes. • Discuss [NAME]’s progress with current treatment team to discuss areas of responsiveness and unresponsiveness; compliance and noncompliance; and possible impact of any physical or emotional problems that may be posing challenges for detoxification. • A review to determine whether to continue with current detoxification services, re-admit or step-up to next level of care. • Restart or continue ambulatory or residential/inpatient detoxification services

40. Problem No Problem No past / current Past Problems Past year mod/high on Health Distress Scale; any disabilities; female w/history of pregnancy; history of infectious diseases; or any lifetime report of health problems/issues Current - Low/Mod Problems Any disabilities; female who became pregnant in past 90 days (regardless of outcome) or is currently pregnant, past 90 day infectious diseases or health problems or need medical attention to attend treatment Current High Severity Had any health problems daily (45+/90) or functional impairment weekly (13+/90) Treatment No Treatment History No past / current treatment Past (Lifetime) Treatment History Any physical health treatment, or current medication, or ever having seen a doctor) Currently in Treatment Any physical health treatment in the past 90 days or currently being treated Dimension B-2: Biomedical Conditions

41. Conceptualization of Treatment Need and Placement * Past week for B1. Detox/Withdrawal

42. Example: Dimension B-2 / Cell 2 Text The GRRS will print: [NAME] reported a history of prior health problems, but not having problems or treatment in the past 90 days. Based on the information provided, the evaluator recommends: <<PROMPT: REVIEW, DELETE OR EDIT ACCORDING T0 SPECIFIC NEEDS AND CLINICAL INDICATIONS>> • Discussing prior health problems and any prior medical care with [NAME] to review the problem, the care received, and potential impact upon treatment (e.g., Is there a relationship between [NAME]’s medical issues and [his/her/Name’s] substance use? To what extent might these health issues pose challenges for the treatment of the substance use disorder? Are there special needs that must be considered in order to participate in substance use treatment?)

43. Monitoring for change in physical health (and medication compliance) • Review of plan for what to do if these health problems re-occur in the future

44. Problem No Problem No past / current Past Problems Reported lifetime history of being bothered by emotional, trauma or behavior problems, or diagnoses Current - Low/Mod Problems Bothered by MH problems, functional impairment, memories from the past, attention problems or self-injury, at any time in the past 90 days. Current High Severity Had any emotional, trauma or behavioral problems daily (45+ /90) or functional impairment or self-harm weekly (13+/90) or suicide plans/ means/attempts with any functional impairment or self-harm Treatment No Treatment History No past / current treatment Past (Lifetime) Treatment History Any mental health treatment, or current medication, or ever having seen a doctor Currently in Treatment Any mental health treatment in the past 90 days or currently being treated Dimension B-3: Emotional-Cognitive-Behavioral

45. Conceptualization of Treatment Need and Placement * Past week for B1. Detox/Withdrawal

46. Example: Dimension B-3 / Cell 5 Text The GRRS will print: [NAME] has received mental health treatment for emotional, behavioral or cognitive problems in the past 90 days, but reports not having problems in the past 90 days. Based on the information provided, the evaluator recommends: <<PROMPT: REVIEW, DELETE OR EDIT ACCORDING T0 SPECIFIC NEEDS AND CLINICAL INDICATIONS>> • Discussing past emotional, behavioral or cognitive problems with [NAME] to review the need for future mental health services, barriers to accessing them and any accommodations needed to participate in treatment.

47. Discussing how past emotional, behavioral or cognitive problems and substance use problems may be related • Develop follow-up plans related to mental health care (e.g. Were arrangements made for continuing care? Does [NAME] express willingness, have a plan and means, and/or taken initial steps toward adhering to the follow-up recommendations? Does [NAME] know what to do if problems re-emerge?) • Monitoring for change in emotional, behavioral or cognitive condition, linkage to treatment, and treatment/medication compliance • The following specific accommodations for emotional, behavioral or cognitive problems required to participate in treatment: <list out>

48. Problem No Problem No past / current Past Problems Lifetime substance dependence, abuse, induced disorders, weekly substance use, hiding use or substance related family problems Current - Low/Mod Problems Using in the past 90 days and one of the following (mod/high resistance, low/mod motivation, few reasons for quitting, not completely ready to stop) Current High Severity (Using in the past 48 hours, daily (45+/90) or using opioids weekly (13+/90)) and one of the following (high resistance, low motivation, no reasons for quitting, not completely ready to stop) Treatment No Treatment History No past / current treatment Past (Lifetime) Treatment History Lifetime substance use disorder treatment, current medication, any recent treatment Currently in Treatment Currently taking substance use disorder meds; in substance use disorder treatment in the past 90 days; currently in substance use disorder treatment; or others are putting on pressure to change. Dimension B-4: Readiness for Change

49. Conceptualization of Treatment Need and Placement * Past week for B1. Detox/Withdrawal

50. Example: Dimension B-4 / Cell 7 Text The GRRS will print: [NAME] has received treatment for substance use problems in the past 90 days, but is still experiencing severe problems. Based on the information provided, the evaluator recommends: <<PROMPT: REVIEW, DELETE OR EDIT ACCORDING T0 SPECIFIC NEEDS AND CLINICAL INDICATIONS>> • Discussing the current and/or prior treatment episodes with [NAME] to review the experience (e.g., Did [he/she/name] achieve a period of sustained abstinence? What is [he/she/name] willing/able to do differently?)