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–David Mee-Lee, M.D., Castle Medical Center, Honolulu, Hawaii. Dr.Mee-Lee is the co-author of two patient placement criteria, including the ASAM Criteria, and is co-chair of CSAT's TIP on Patient Placement Criteria, now being developed.

Healthcare costs can no longer support inefficient care born out of programs with one level of care and one treatment protocol for all patients, regardless of the clinical heterogeneity assessed or – too often – not assessed. Today, patients who present for treatment are becoming increasingly diverse; they are often polydrug users, younger than in the past, representing a greater gender and ethnic mix and with more serious problems, such as dual diagnosis and a history of being psychologically and socially impoverished. To successfully help these patients, staff and treatment options must also become more diverse.

The Urgent Need to " Re-tool "

There is an urgent need for the addiction treatment field to " re-tool " and find more efficient ways to provide care, to protect the quality of and access to addiction treatment, and truly begin to integrate research findings into everyday practice and programs. When addiction treatment is program based rather than clinically driven, one shoe fits all. But to protect access to quality treatment and conserve healthcare resources, there must be more focus on matching patients to levels of care and treatment modalities – providing a range of shoes to fit all sizes.

Now, in addition to diagnosis, the severity of the addiction is what must determine treatment. Addiction treatment today involves placement in a level of care; movement through a continuum, as seamless as possible; and specific matching to a variety of treatment modalities in all the levels of care. Diagnosis is a necessary, but not sufficient, determinant of treatment. What would constitute a " sufficient " determinant of treatment? The answer would be:

• Criteria to guide proper patient placement

• Practice guidelines to promote effective individualized treatment modalities

• Outcomes data to continuously improve both the criteria and guidelines

Current Status of Patient Placement Criteria

For some time, the field has recognized the need for criteria to guide individualized placement of patients and a continuum of care. Over the last 10 years, a number of expert task forces and advisory committees have spent considerable effort on developing patient placement criteria. As a result, several nationally recognized models are now available and are being increasingly used and adapted by States and treatment providers. The most widely used models are described in the box below titled "Patient Placement Criteria".

The criteria being most widely used and adapted are the patient placement criteria drafted by the American Society of Addiction Medicine (ASAM), which were originally designed to ensure a voice for substance abuse clinicians in defining a continuum of care. The ASAM Criteria, a consensus document, has become the starting point for the current effort to establish universally accepted guidelines. These criteria are expected to be used as a key model in the process aimed at developing national clinical standards and are the basis for the modified criteria developed by several States, such as Massachusetts, Montana, and Iowa.

The box down below shows the main elements of the ASAM Criteria– the six assessment dimensions used to define biopsychosocial severity and to guide placement, and the four levels of care that describe the intensity of service provided. While the ASAM Criteria provide specific guidelines on what kinds of setting, services, staff, assessments, and documentation pertain to each level of care, there is not a mandate on where the level has to be located; e.g., that Level III must be in a freestanding residential facility. Level III might well be provided in a hospital in conjunction with a Level IV program, thus allowing flexible movement of patients through the continuum more efficiently.

Steps Toward National Clinical Standards

It is widely believed that, when we place patients in services and programs that best meet their specific needs, we improve treatment outcomes as well as use funds more efficiently. Yet, there has not been consensus on which patient placement criteria to use as a national standard, despite the integration of two national sets into the ASAM Criteria. In November of 1991, recognizing that a broader consensus must be developed by all significant stakeholders, ASAM convened a roundtable discussion conference. The aim was to see whether there was support for national patient placement criteria and, if not the ASAM Criteria, then how might the field gain consensus on a universal standard?

This conference led to the establishment of the Coalition for National Clinical Criteria in November 1992, which has held two subsequent meetings. The coalition, which includes providers, business leaders, and managed care professionals, is working to create a process that will lead to national clinical standards.

One significant outcome is the development of a new guide for States and providers sponsored by the Center for Substance Abuse Treatment (CSAT). CSAT, involved in this consensus process from the beginning, recognized that it could play a useful catalytic role in reaching consensus on patient placement criteria. Aware that State AOD abuse treatment organizations and others were recognizing the need to develop more efficient, effective, and comprehensive systems of care in a managed care and healthcare reform environment, CSAT sponsored a Treatment Improvement Protocol (TIP). The contents of this TIP, and how States and treatment providers can use these guidelines to develop or adapt patient placement criteria for their own needs, are described in the box at the end of the page.

Importance of Criteria in the Managed Care Environment

Increasingly, managed care is becoming a fact of life for those of us who have traditionally treated patients in the publicly funded system. In this new environment, clinicians must now continually protect patients' access to quality care, while balancing the demands of cost containment and managed care.

Managed care has often been associated with private sector treatment. But with the push for national healthcare reform and the States ' move towards managed care for public assistance patients, the boundary between " public " and " private " is increasingly becoming blurred. Health- care costs have alarmed many employers and payers for care, including the Federal Government. Concern over costs, coupled with the perception that much care is unnecessary or provided inefficiently, has given rise to increasingly widespread techniques for managing health benefits and holding clinicians more accountable for services provided.

Within the managed care environment, as providers struggle with the pressures of cost-containment, accountability, and documentation, it often seems there is no time to focus on the patient. Yet, if we are to protect access to quality care, we have no alternative but to transition to new cost-conscious systems of care that truly incorporate careful assessment and individualized treatment. Patient placement criteria play an important part in promoting a broad continuum of care and in placing patients in a setting that not only is the least intrusive for the patient, but that provides the best opportunity to utilize health care resources most efficiently.

Implications for Patients, Clinicians, Programs, Payers, and Policy

The "r e-tooling " of the addictions treatment system necessary to promote individualized treatment requires a paradigm shift that has broad implications for patients, personnel, programs, payment systems, and the public and private sectors.

• For patients– Patients will receive care that is not only more cost efficient, but potentially more cost effective. As patients receive treat- ment in the least intensive– but safe – setting, they can test out recovery skills in as close to " real world " situations as possible and minimize re-entry problems.

• For clinicians– To provide better patient-treatment matching, clinicians will need to become more skilled at comprehensive assessment and to have a broader knowledge of placement criteria and treatment modalities.

• For treatment programs – Programs will need to expand their continuum of care to provide multiple levels of care with flexible lengths-of-stay.

• For payers– Payers will need to reimburse and fund all levels of care to allow patients to be placed in the most efficient and effective setting.

As the public-private sector boundary blurs and one quality and system of care develops, we need a uniform set of placement criteria that are clinically based, not program driven.

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