1 / 88

UCLA Integrated Substance Abuse Programs David Geffen School of Medicine at UCLA

Using The American Society of Addiction Medicine (ASAM) Criteria to Re-Assess Clients within the Context of the California Treatment System. UCLA Integrated Substance Abuse Programs David Geffen School of Medicine at UCLA Pacific Southwest Addiction Technology Transfer Center. Disclosures.

josies
Télécharger la présentation

UCLA Integrated Substance Abuse Programs David Geffen School of Medicine at UCLA

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Using The American Society of Addiction Medicine (ASAM) Criteria to Re-Assess Clients within the Context of the California Treatment System UCLA Integrated Substance Abuse Programs David Geffen School of Medicine at UCLA Pacific Southwest Addiction Technology Transfer Center

  2. Disclosures • The following planners and faculty disclosed no relevant financial relationships with commercial interests: • Gary Tsai, MD, Larissa Mooney, MD, Thomas E. Freese, PhD, Christine Oh, PhD, Richard Rawson, PhD, Darren Urada, PhD, Beth Rutkowski, MPH, Holly McCravey, MA, Lydia Becerra, and Donna K. Lee-Liu • There was no commercial support provided for this activity.

  3. The ASAM Criteria ASAM's criteria is a national set of criteria for providing outcome-oriented and results-based care in the treatment of addiction. It is an indispensable resource that addiction medicine professionals rely on to provide a nomenclature for describing the continuum of addiction services.  http://www.asam.org/quality-practice/guidelines-and-consensus-documents/the-asam-criteria/about

  4. The Mission of the ASAM Criteria • To help clinicians, counselors, and care managers develop patient-centered service plans and make objective decisions about patient admission, and transfer/discharge for individuals with substance-use disorders and co-occurring conditions, • To implement and apply the criteria effectively to a variety of patient populations in a wide range of care settings, • To encourage the development of comprehensive continuum of care,  • To help improve patient outcomes through their multidimensional assessment and the continuum of care. The ASAM criteria offer a system for improving the “level of care match” through the use of multidimensional assessment and treatment planning that permits more objective, and uniform evaluation of patient outcomes.

  5. Guiding Principles of the ASAM Criteria • Moving from one-dimensional to multidimensional assessment • Clarifying the goals of treatment, and “Medical Necessity” • Focusing on treatment outcomes while moving away from using previous “treatment failure” as an admission prerequisite • Moving toward an interdisciplinary, team approach to care and clarifying the role of the physician • Engaging with “informed consent” • Incorporating ASAM’s definition of addiction • Identifying adolescence specific needs

  6. Medical Necessity • Medical Necessity Determination can performed through a face-to-face or telehealth review by a Licensed Practitioner of the Healing Arts (LPHA). • “Face-to-face review” is a face-to-face review between the counselor who conducted the assessment and the LPHA, and the face-to-face review may include the client.

  7. Provider Qualifications LPHAs include: • Physician • Nurse Practitioner • Physician Assistant • Registered Nurses • Registered Pharmacists • Licensed Clinical Psychologist (LCP) • Licensed Clinical Social Worker (LCSW) • Licensed Professional Clinical Counselor (LPCC) • Licensed Marriage and Family Therapist (LMFT) • Licensed-eligible practitioners working under the supervision of licensed clinicians.

  8. Introduction to Medical Necessity • Medicare generally defines medically necessary services as those that are “reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.” • “…medical necessity is doing the right thing for the right patient at the right time and place.” Emily Hill, PA-C Fam PractManag. 2011 Mar-Apr;18(2):31-37.

  9. Establishing Medical Necessity • Two Steps in Establishing Medical Necessity 1. To be eligible for Drug Medi-Cal services • (e.g., to qualify for insurance) 2. To be eligible for a specific service • (e.g., to qualify for a specific service)

  10. Establishing Medical Necessity (continued) • 1. Medical Necessity for Drug Medi-Cal (DMC) Eligibility • Medi-Cal status* + Diagnostic and Statistical Manual of Mental Health Disorders, 5th Edition (DSM-5) diagnosis + appropriate ASAM level of care assessment • *Providers must determine Medi-Cal status • Must be renewed: • Every 6 months for all non-Opioid Treatment Program (OTP) services • Every 12 months for all OTP services • 2. Medical Necessity for Specific Services • DSM-5 diagnosis + appropriate ASAM level of care assessment • Renewal periods vary depending on the service • (refer to the County of Los Angeles, Quality Improvement and Utilization Management Manual for full details) • http://publichealth.lacounty.gov/sapc/HeathCare/HCRWorkGroup/Meeting/040716/1QIUMManual021617.pdf

  11. Establishing Medical Necessity for Specific Services • Medical necessity criteria: • DSM-5 diagnosis for Substance-Related and Addictive Disorders with the exception of Tobacco-Related Disorders and Non-Substance Related Disorders; OR Be assessed to be at-risk for developing substance use disorder (for youth under age 21) • ASAM treatment criteria to ensure that services are appropriate and provided in the appropriate level of care DSM-5 Diagnosis of Substance Use Disorders: What has Changed? Freese, Thomas https://vimeo.com/178256186

  12. Appropriateness of Care • “Substance use, addictive and mental health disorders are biopsychosocial in etiology and expression, treatment and care management are most effective if they, too are biopsychosocial.” • “Medical necessity should pertain to necessary care for biopsychosocial severity and is defined by the extent and severity of problems in all six multidimensional assessment areas of the patient.” The ASAM Criteria; American Society of Addiction Medicine, Third Edition, 2013

  13. Individualized TreatmentRequires Comprehensive Assessment • What are the patient’s immediate needs and is there imminent danger? • What risk is associated with intoxication and/or withdrawal? • How are they functioning across multiple domains? • Where are their greatest risks, and what does this indicate about treatment needs?

  14. Assessing “Immediate Needs” and “Imminent Danger” • Immediate needs and imminent danger can be assessed in person or over the phone. • Should address each of the six dimensions, • Includes three components: • The strong probability that certain behaviors will occur (i.e., continued alcohol or drug use, etc.), AND • That such behaviors will present a significant risk of serious adverse consequences to individual and/or others (i.e., driving while intoxicated, neglect of child, etc.), AND • The likelihood these events will occur in the very near future (within hours or days, notweeks or months).

  15. Six Dimensions of Multidimensional Assessment • Acute Intoxication and/or Withdrawal Potential • Biomedical Conditions and Complications • Emotional, Behavioral, or Cognitive Conditions and Complications • Readiness to Change • Relapse, Continued Use, or Continued Problems Potential • Recovery and Living Environment

  16. What guides placement? • “… the highest severity problem, with specific attention to Dimensions 1, 2, and 3 should determine the patient’s entry point into the treatment continuum.” • Resolution of any acute problem(s) provides an opportunity to shift the patient down to a less intensive level of care. • The ASAM Criteria, Third Edition, Page 112

  17. What guides placement? • “… the highest severity problem, with specific attention to Dimensions 1, 2, and 3 should determine the patient’s entry point into the treatment continuum.” • Exacerbation of any acute problem(s) provides an opportunity to shift the patient up to a more intensive level of care. • The ASAM Criteria, Third Edition, Page 112

  18. What is Regular Assessment? • Includes assessment across all six dimensions • Acute care facilities-daily or multiple times per day; • Residential settings-once weekly or more often if the patient is unstable; • In Outpatient settings-every six sessions. • The ASAM Criteria, Third Edition, Page 110

  19. Why is a Continuum of Care Important? • Levels of care provide a terminology for describing the Continuum of “recovery-oriented” addiction services; • Designed to create a seamless continuum of flexible services; • Improved efficiency and effectiveness of services; • Through regular assessment, patients can be shifted to the appropriate level of care, thereby effectively extending the care they receive.

  20. All Levels of Care include, where appropriate, • Medication Management and Addiction Pharmacotherapy • Support for families

  21. Levels of Withdrawal Management

  22. Continuum of Care-1 *DHCS – California Department of Health Care Services

  23. Continuum of Care-2

  24. Continuum of Care-3

  25. Decisional Flow to Match Assessment and Treatment Placement • What does the patient want and why now? • What are the patient’s immediate needs or imminent danger in each of the dimensions? • What is the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, diagnosis (DSM-5)? • Intake, Assessment and Re-Assessment

  26. Decisional Flow to Match Assessment and Treatment Placement • Multidimensional severity/Level of function • Prioritize which dimensions are most important • Specify a target for each priority • What services are needed • Service Planning and Placement

  27. Decisional Flow to Match Assessment and Treatment Placement • What intensity of services is needed? • Where are these services located (least intensive, but appropriate level of care)? • What is the patient’s progress regarding the established treatment plan and placement decision? • Level of Care Placement including: • Withdrawal management • Level of Care Placement • Special Populations

  28. Assessing Risk for Each Dimension • Serious issue or difficulty coping. High risk or near imminent danger • Utmost severity. Critical impairments/symptoms indicating imminent danger 4 • Moderate difficulty in functioning with some persistent chronic Issues 3 • Mild difficulty, signs, or symptoms. Any chronic issue likely to resolve soon • Non-issue, or very low-risk issue. No current risk and any chronic issues likely to be mostly or entirely resolved 2 1 0

  29. So, what do we do with all of this information? Dimension 1 Risk 0 Levels of Withdrawal Management (Level 1-4-WM) What is working? What is not working? What does the patient want? Dimension 2 Risk 1 Dimension 3 Levels of Care Placement (Level 0.5 – 4) Risk 2 Dimension 4 Risk 3 Dimension 5 Risk 4 Dimension 6

  30. ASAM Levels of Care 0.5 Early Intervention • Outpatient Treatment • Intensive Outpatient and Partial Hospitalization • Residential/Inpatient Treatment • Medically-Managed Intensive Inpatient Treatment

  31. Engage the person in their own care! What? • Why? • How? • When? • Where?

  32. Six Dimensions of Multidimensional Assessment • Acute Intoxication and/or Withdrawal Potential • Biomedical Conditions and Complications • Emotional, Behavioral, or Cognitive Conditions and Complications • Readiness to Change • Relapse, Continued Use, or Continued Problems Potential • Recovery and Living Environment 4 Utmost Severity Imminent Danger Serious Issue, high risk or near imminent danger 3 • Moderate difficulty,with some persistent chronic Issues 2 • Mild difficulty, Chronic issue likely to resolve soon 1 • Non-issue, or very low-risk issue. chronic issues likely to be mostly or entirely resolved 0

  33. Practice Prioritizing • Review the Case and list the problem areas: • Order the list starting with the highest priority • What is the rationale for making this priority ASAM Dimensions

  34. Your Task • Evaluate the severity of the case study, on each of the Six dimensions of the ASAM criteria using the information presented in one of the case scenarios listed above. Will the patient require additional care, remain in the same level of care, or be stepped down to a less intensive level of care? It is important to arrive at a severity level, 0-4 for each of the six dimensions, ensuring to document the rational for each.

  35. Your Task (continued) • Discuss and document the patient’s service needs appropriate to each of the 6 dimensions. Finally, use the “ASAM LEVEL of CARE DETERMINATION TOOL” to arrive at the most appropriate, least intensive level of care based upon the most current information that you have.

  36. Now it’s time to Reassess the case study • Break out into two groups, with each group taking one case scenario and evaluating your assigned case on risk/severity across each dimension. Once your group has completed the risk ratings for all 6 dimensions, using the ASAM LEVEL of CARE DETERMINATION TOOL, apply the risk ratings for the case scenario that you were assigned to determine the most appropriate placement. 2 1 3 4 0 Utmost severity Mild Non-issue Serious issue Moderate Critical impairments Very Low Risk Difficulty coping Difficulty Difficulty

  37. Assessing Risk for Each Dimension • Serious issue or difficulty coping. High risk or near imminent danger • Utmost severity. Critical impairments/symptoms indicating imminent danger 4 • Moderate difficulty in functioning with some persistent chronic Issues 3 • Mild difficulty, signs, or symptoms. Any chronic issue likely to resolve soon • Non-issue, or very low-risk issue. No current risk and any chronic issues likely to be mostly or entirely resolved 2 1 0

  38. Assessment Considerations: Dimension 1 • Acute Intoxication and/or Withdrawal Potential Exploring an individual’s past and current experiences of substance use and withdrawal • What risk is associated with current level of intoxication? • Are intoxication management services needed? • What is the risk of severe withdrawal symptoms, seizures or other medical complications? • Are there current signs of withdrawal? • What are the scores of the standardized withdrawal rating scales? • What are the patient’s vital signs? • Does the patient have support to complete an ambulatory withdrawal, if medically safe to consider? 2 1 3 4 0 Utmost severity Mild Non-issue Serious issue Moderate Critical impairments Very Low Risk Difficulty coping Difficulty Difficulty

  39. Assessment Considerations: Dimension 2 • Biomedical Conditions and Complications Exploring an individual’s health history and current physical condition • Other than withdrawal, what are the current physical illnesses that should be addressed? • What are the chronic conditions that need to be stabilized? • Is there a communicable disease present? • Is the patient pregnant? What is her pregnancy history? 2 1 3 4 0 Utmost severity Mild Non-issue Serious issue Moderate Critical impairments Very Low Risk Difficulty coping Difficulty Difficulty

  40. Assessment Considerations: Dimension 3 • Emotional, Behavioral, or Cognitive Conditions and Complications Exploring thoughts, emotions, and mental health issues • Are there psychiatric, psychological, behavioral, emotional or cognitive conditions needing to be addressed? • What if any chronic conditions need to be stabilized (e.g., bipolar disorder or chronic anxiety) • Are the behavioral or cognitive symptoms part of the addictive disorder? • Do the emotional, cognitive or behavioral conditions require mental health system care (e.g., suicidal ideation and depression) • Is the patient able to participate in daily activities • Can she/he cope with the these symptoms? 2 1 3 4 0 Utmost severity Mild Non-issue Serious issue Moderate Critical impairments Very Low Risk Difficulty coping Difficulty Difficulty

More Related