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-- Darryl L. Bruno, Administrator, Alcohol and Drug Abuse Division, Montana Department of Corrections and Human Services

The purpose of patient placement criteria is to encourage the most appropriate, effective, and cost-efficient utilization of services and to promote placement of clients in the least restrictive setting. In Montana, we have recently instituted a statewide system of patient placement standards for approved chemical dependency programs.

Our experience with these standards has been a positive one. The State Alcohol and Drug Abuse Division is pleased with the implementation process, because it has ultimately led to an enhancement in the quality and appropriateness of care and cost effectiveness. Furthermore, we believe this is an essential process in the advent of health care reform.

Need for the Development of Standards

The State of Montana Department of Corrections and Human Services, Alcohol and Drug Abuse Division, developed and required patient placement in our State standards as a proactive solution to the following problems:

• Increased demand for treatment services as a result of State priorities, legislation, and funding restrictions that were requiring services be provided to greater numbers and critical populations

• Declining State revenues

• Declining revenues of community-based programs as a result of managed care by the insurance industry

• The large number of uninsured Montanans in need of services

In September 1992, the Alcohol and Drug Abuse Division adopted State standards (Administrative Rules) which would be required for all chemical dependency programs. These standards defined the level of care/component, described the patients appropriate for each level of care/component, and required that programs have criteria for admission, continued stay, and discharge, as well as a review process and corresponding documentation. Additionally, the standards asked programs to select nationally recognized criteria and to adopt a system of placement.

Adopting the New Standards

The unified support of treatment providers across the State was a crucial factor in implementing the new standards. Approved chemical dependency programs supported the adoption of patient placement criteria; third-party payers already required the use of patient placement criteria.

Training became a crucial issue in adopting the criteria. Four training events were offered. These included Managing Managed Care by Norman Hoffman, Proper Patient Placement by Mona Sumner, ASAM Patient Placement Criteria by Dr. David Mee-Lee, and ASAM Revisited by Richard Weedman. The costs of the training events were shared by Blue Cross/Blue Shield, private providers, and by the Alcohol and Drug Abuse Division.

Assessing Program Success

Programs were given 9 months from adoption of the rule to develop a system of patient placement. In July 1993, the Alcohol and Drug Abuse Division began evaluating the implementation of patient placement criteria and expanded utilization review.

The evaluation showed that most programs have selected two prototypes. The majority of approved chemical dependency programs utilize either the ASAM criteria or a Computer Placement System (CPS) that resembles a combination of the Cleveland and ASAM criteria.

We found that programs tended to encounter certain common problems in the process of implementation. These problems included:

• A failure to establish continued stay and discharge criteria as part of the assessment process

• A need to expand the biopsychosocial assessment to match the dimensions that are used to guide placement of patients into the various levels of care

• A need to integrate the treatment planning process into a qualifying framework that matches the dimensions of the criteria

• A need to incorporate discharge criteria into the discharge process and summary documentation.

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