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Chapter 1—Introduction

In recent years, the alcohol and other drug (AOD) abuse treatment field has begun the process of standardizing patient placement criteria (PPC). The goal is to establish uniform patient placement criteria (UPPC), accepted by all providers in the field, that can be used to accurately assess the severity of a client's problems in three areas: medical, psychological, and social. Carefully developed UPPC will lead to effective placement of clients in appropriate levels of care. Such criteria can also be used as a basis for making decisions about moving clients through the continuum of treatment services as treatment progresses or relapses occur.

The Development of UPPC

In developing this Treatment Improvement Protocol (TIP), Federal officials and national professional association representatives met with the chairs of the consensus panel to advise them about its content. There was considerable discussion regarding the role of the panel in developing "the definitive set" of patient placement criteria. Ultimately, it was decided that the nature of the TIP development process, as well as time constraints, would not allow for analysis and discussion of all the input that would be necessary to develop UPPC. Before UPPC could be developed, existing criteria and the experiences of those who have implemented them would have to be assembled and examined.

The purpose of the consensus panel and of this TIP, therefore, is not to write these uniform patient placement criteria, but to lay the groundwork for developing them. A wide variety of people are interested in the current use of PPC and their evolution; these "stakeholders" and their interests are enumerated in this TIP. It was written also to inform readers of the sets of criteria and issues in the development, adoption, implementation, and ongoing improvement of patient placement criteria. States just beginning to consider patient placement criteria can use this TIP to learn from the experiences of others and avoid pitfalls. For those further along, the TIP can provide a vision of future directions in the challenging but necessary move toward national uniform patient placement criteria.

Assuming UPPC are developed with the broadest possible input and are based on research and evaluation findings, they can be used to help ensure that:

• The client's specific needs will be identified and a level of care will be chosen to fully address those needs
• A method is in place for continually improving the effectiveness of assessment, placement, and treatment.

Advantages of UPPC

The many advantages of adopting UPPC will be discussed in detail throughout this TIP and are summarized here.

• A common lexicon describing the dimensions of assessment and the components of the continuum of care can enable clinicians to consult about clients or program characteristics without confusion.
• Uniform criteria can provide a common basis for study and continual improvement, not only of the criteria themselves, but also of the services provided in response to particular criteria.
• UPPC can help alleviate the high cost of undertreatment by ensuring that patients get all the treatment they need, based on continued stay criteria rather than arbitrary monetary or time limitations.
• UPPC can alleviate the high cost of overtreatment by ensuring that patients get only the treatment they need, based on assessed needs and established criteria.
• Common definitions of levels of care, common standards of assessment, and common standards for continued stay and discharge can establish the same framework for public and private programs.

Nearly all AOD abuse treatment is influenced by some form of managed care in its broadest sense. Virtually no payment system-public or private-is free from eligibility, admission, or discharge criteria. Private payment systems sometimes limit the duration of treatment or number of admissions, which leads to inadequate treatment of severely impaired consumers. Public payment systems may limit treatment to only severely impaired consumers, prohibiting access to service for individuals when their problems are less complex. Lack of a single, consistently applied set of criteria has led to gaps in service in both public and private systems.

The need for patient placement criteria arises from the desire of professionals involved in the provision of AOD treatment services to improve the quality and appropriateness of services. This desire manifests itself in efforts to align the duration of treatment and level of care with the client's identified needs.

Various assessment instruments and interview guides have been developed to assist clinicians in assessing the broad range of client needs. The information gathered through this process helps determine the level of care appropriate for the client. Continued assessment dictates changes in the level of care. Patient placement criteria provide a link between assessment data and placement decisions. Any guidelines that provide this link or start with a specific level of care can be considered patient placement criteria. Perhaps the most recognized are those used by private managed care firms, but certainly individual treatment programs have guidelines that place clients in a level of care, identify the need for transition to another level, and define completion of treatment. Moving from a proliferation of varying sets of patient placement criteria to uniform criteria would have some major advantages, which are discussed in this TIP.

Challenges

As the advantages of adopting UPPC become apparent, the question may be asked: Why hasn't some form of patient placement criteria been adopted by every funder, every treatment provider, and every State? What are the barriers to development?

Bringing consistency to placement decisions has a number of advantages, but the development of the criteria presents challenges. In some situations, the advantages are not recognized. In other situations, the task of implementation is daunting because of limited resources, geography, multiple funding systems, or separate treatment systems for public and private clients. The tasks of writing new criteria or sorting through the proliferation of existing criteria are overwhelming. This TIP addresses these and other barriers, so that movement toward an accepted set of placement criteria is furthered.

The Role of the States

The discussion of UPPC for AOD abuse treatment has largely taken place among clinicians and treatment providers, with limited attention given to the implementation of UPPC as public policy. In contrast, this TIP is intended to be useful to a variety of audiences:

However, this TIP is addressed primarily to the SSAs, which are key to the standardized implementation of patient placement criteria because:

Therefore, this TIP broadens the discussion to include the implementation of patient placement criteria and related public policy issues at State and national levels.

It is widely believed that placing patients in levels of care appropriate to their needs will improve treatment outcomes and lead to more efficient use of funds. Yet full consensus has not been reached on which criteria to use, despite the integration of two national sets of criteria into the American Society of Addiction Medicine's (ASAM) criteria, which were published in 1991. Recognizing that a broader consensus must be developed by all significant stakeholders, ASAM convened a roundtable discussion conference in November 1991. The goal was to assess support for national patient placement criteria and to determine methods for gaining consensus in the field.

This conference led to the establishment in November 1992 of the Coalition for National Clinical Criteria, which held two subsequent meetings. The Center for Substance Abuse Treatment (CSAT) recognizes that it can play a useful catalytic role in the effort to reach consensus on UPPC. Aware that State alcohol and other drug abuse treatment organizations (and others) saw the need to develop more effective and comprehensive systems of care in a managed care and healthcare reform environment, CSAT sponsored the development of this TIP.

The ASAM criteria have become the most widely distributed, implemented, discussed, and reviewed criteria available. Several States have adapted the ASAM PPC for use with public providers. For these and other reasons, the ASAM PPC are referenced in this TIP as a basis of comparison. They are not perfect, nor are they universally accepted. However, no other set of criteria reviewed for this TIP demonstrated significant advantages over the ASAM criteria.

The UPPC discussed throughout this TIP do not yet exist. While the ASAM PPC provide an important starting point, they do not represent the UPPC envisioned by this consensus panel. Much work is needed to develop criteria that adequately address the needs of all populations within a complete range of treatment programs. The UPPC that are ultimately developed may be a significantly revised version of the ASAM criteria. On the other hand, the developed criteria may be entirely new, sharing with the ASAM PPC only the essential principles of development by consensus, multidimensional assessment, continuity of care, and a common language.

Chapter 2-The Role of PPC in a Managed Care Environment. This chapter, initially written by David Mee-Lee, M.D., and revised for this TIP, describes the challenge of transitioning to new cost-conscious systems of care. While UPPC alone cannot produce this transition, this chapter puts in perspective the role of UPPC in diagnosis, placement, matching to specific modalities and strategies, and efficient utilization of healthcare resources.

Chapter 3-Critique of Existing Criteria. This chapter provides a detailed analysis of the ASAM criteria and examines other public and private criteria currently in use. With strengths and weaknesses of the criteria identified, recommendations are then made for interim steps to be taken until a redesigned set of uniform criteria can be developed. Recognizing that placement criteria alone do not efficiently match patients to treatment, directions are discussed that would allow an increased assessment-based match to individualized treatment components.

Chapter 4—Building Support for Adopting UPPC. Chapter 4 describes how the implementation of UPPC can provide a framework that will enhance patient access to the full range of treatment services. Once established, UPPC will have the potential to improve assessments and individual treatment plans; provide economic benefits; and establish a common language for multidisciplinary service providers, payers, policymakers, and other interested parties.

Chapter 5—Implementation Strategies. This chapter addresses the basic decisions necessary for implementation of UPPC. Important considerations include the issue of tying UPPC to licensing requirements and treatment funding, the relationship between UPPC and the actual availability of treatment resources, and the way in which wraparound services broaden the concept of "medical necessity." Factors to consider when making placement decisions for special populations are explored. This chapter also informs the reader of the relationship between eligibility criteria and patient placement criteria. Elements and goals of assessment are delineated and staff and training needs are identified. There is a detailed discussion of the strengths and weaknesses of the settings in which assessment takes place. Finally, several useful assessment instruments and tools are identified.

Chapter 6—Future Directions: National Implementation and New Research Opportunities. This chapter discusses the process of developing widespread support for UPPC on a national level and suggests strategies for implementing them. Several immediate tasks are outlined that are necessary to overcome the barriers to acceptance of UPPC by the alcohol and other drug abuse treatment system and by stakeholder groups. Recommendations are presented for the formation of a national advisory panel to guide the consensus-building, implementation, and research process and to play a continuing role in the refinement of UPPC. The future impact of UPPC on assessment, treatment, and outcomes monitoring is described here, as UPPC may improve research and lead to quality improvement. Finally, the role of UPPC in healthcare reform is discussed.

Chapter 7—Ethical and Legal Issues. In Chapter 7, the basic ethical principles that relate to AOD abuse treatment are discussed, as well as legal issues that may arise. Once UPPC are in place, there will be strong supportive documentation confirming the treatment provider's clinical judgment and defining clearly what is meant by medical necessity. Uniform patient placement criteria, if they are developed according to the consensus-building process outlined in this document, will represent the opinions of AOD abuse treatment providers from many disciplines. The case is made that these criteria may be viewed by courts as reflecting generally accepted medical practice, especially if the criteria are widely used.

Appendix A is a list of references cited in the TIP.

Appendix B lists resources that might be useful to programs or systems seeking to create or adapt patient placement criteria. Assessment instruments are described, as well as software packages to aid clinical management of patients. For readers who wish to examine existing criteria in more detail, Appendix B provides information on obtaining criteria sets from various States and private organizations. The final section is a brief annotated bibliography of materials related to managed care and healthcare reform.

Appendix C is a glossary of terms used in the TIP.

Appendix D lists the names of persons who attended the Federal resource panel in the early stages of development of the TIP, and Appendix E lists the names of experts from across the country who participated in the field review of the TIP.

Last Updated 11-7-02