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The Challenges of Improving Addictions Treatment

Daniel Rhodes, MA, LCAS
Clinical Reviewer Lead

Ben Ryden, MSW, LCSW
Clinical Review Supervisor

Bennett Garner, MD, MHA
Medical Director, Behavioral Health

John Sparks, MD
National Medical Director


What Are ASAM and The ASAM Criteria?

Over the last 15 years or so, the landscape in addiction treatment has changed significantly. Treatment has evolved from abstinence-only (without medications) philosophies to more comprehensive program designs that incorporate medications and other evidence-based practices. Standards of care developed by the American Society of Addiction Medicine (ASAM) have been instrumental in driving this evolution and have become the gold standard for substance use disorder (SUD) treatment. In designing a new framework for the assessment and treatment of patients with SUDs, ASAM developed The ASAM Criteria, a comprehensive set of guidelines that helps clinicians determine what level of care is most appropriate for a given patient at a given time. The levels of care include early intervention, outpatient, intensive outpatient/partial hospitalization, residential and medically monitored intensive inpatient services. Residential levels of care include clinically managed high-intensity and low-intensity residential treatment. Each level represents a key part of the ASAM continuum of care.


ASAM as a National Standard

Regulatory bodies nationwide have decided to incorporate ASAM’s standards of care in their efforts to drive better care in their states. Implementation of ASAM standards can have very positive effects on the quality of treatment that patients receive. For example, ASAM’s research shows that patient retention in treatment at 90 days improves by 30% when the patient is treated at the appropriate level at the appropriate time.


Challenges With Implementing ASAM

While ASAM has become the national standard, and more and more systems of care are implementing its criteria, decisionmakers often incorporate ASAM through utilization review (UR). The idea is that regulators can drive adoption of ASAM’s standards by making payment for services contingent on agencies’ adherence to ASAM standards of care. We have found, however, that in most cases, systems of care that are nominally adherent to ASAM standards miss major pieces that are essential to realizing the full benefits of alignment with ASAM.

Significant issues arise when states attempt ASAM integration through UR with a system of care that is not already based on ASAM standards. There are many ways that established systems do not align with ASAM, but perhaps the most easily understood is when the system lacks levels of care that are part of the ASAM continuum of care. If the appropriate level of care is not available, it is impossible to place patients in the level of treatment they need. There are many factors that drive these gaps in treatment availability. Some are driven by culture. Others are driven by history, agency policies, regulatory policy or law/administrative code. For example, when a state’s reimbursement rates favor one level of care over another, naturally, the agencies in that state tend to have more capacity devoted to the better-compensated level of care. Sometimes, whole levels of care are missing from a state system because the reimbursement structure is so misaligned that it simply isn’t possible to provide the ASAM-specified care given the rate of compensation.


An Assessment of the SUD System of Care Is Necessary

When payment is contingent on treatment alignment with ASAM standards, but the appropriate level of care does not exist in the state’s continuum of care, the state and the agencies are confronted with a major problem where patients are getting inappropriate care, and sometimes unnecessary denials, leading to problems with agency reimbursement. The solution is to roll out ASAM in a planned and collaborative way. It is necessary to fully assess the existing system of care in order to thoroughly understand the extent to which it aligns with ASAM. The results of such an assessment will inform the specific planning needed to prepare the system for implementing an ASAM-based framework for care. ASAM’s standards can then be implemented fully, including the UR component. However, implementation of ASAM standards without thorough assessment and planning can cause at least as many problems as it solves. For this reason, it is essential to take a measured approach to implementation.


UM Can Support Adherence to ASAM if Initiated After System Alignment

Once system alignment is underway, it can be further supported by informed utilization management (UM) that promotes fidelity to The ASAM Criteria. A major challenge is that utilizing The ASAM Criteria to assign levels of care requires a multidimensional analysis of six functional areas of the patient’s life. Assessment of many of these dimensions is subjective and the clinician must use clinical judgment in rating each dimension and then weigh each of those ratings in order to recommend a level of care. Because the inter-rater reliability of this method is low, the Substance Abuse and Mental Health Services Administration (SAMSHA) asked ASAM to develop a software product, the ASAM CONTINUUM, to assist in this process.

CONTINUUM consists of a structured interview that yields automated level of care recommendations. ASAM reports the inter-rater reliability is 0.77 and that the time it takes to do an assessment is about 10 minutes shorter than usual methods. For these reasons, Comagine Health decided to incorporate the CONTINUUM decision support software into our UM activities. However, CONTINUUM software alone is not sufficient to assign the appropriate level of care because sometimes its recommendations do not align with clinical information obtained from other sources, including patient-centered treatment plans and clinical summaries of progress.

Despite these limitations, CONTINUUM provides a standardized assessment, a problem list and level of care recommendations. This information means that clinicians and utilization managers are beginning their discussion using the same standardized information set regarding the appropriate level of care. It also provides information essential to the development of person-centered treatment plans. All this information supports ongoing review and training activities.

Comagine Health’s experience has shown that one-off trainings such as those available from ASAM’s e-learning site, while necessary, are not nearly sufficient to effect change. Rather, we have seen that frequent, targeted, ongoing, case-based training for clinicians can produce major improvements in patient care. As noted above, CONTINUUM provides essential information that supports this process. As a result of pairing residential SUD UM with intensive training, we have seen major improvements in the ability of programs to assess patients properly, develop person-centered treatment plans and address the needs of individuals with co-existing SUD and mental health problems. It is only after each of the steps outlined above have been completed that implementing UM guided by The ASAM Criteria can succeed.


Conclusion

Aligning a system with ASAM requirements is a lengthy and complex process; however, the rewards of success promise enhanced patient outcomes. These improved outcomes will be realized by more appropriate matching of patient needs with the level of care delivered. Not only will appropriate placement result in greater retention in treatment, but it will also deliver increased efficiency as individuals receive what they need rather than whatever happens to be available at that particular time and place. An aligned system with evidence-based utilization management such as that provided when incorporating decision support tools like CONTINUUM will also allow ongoing systemwide quality improvement because of the data generated by such activities. Such data will provide information about the need for different levels of care so appropriate adjustments can be made. It can also help to identify best practices and high performing clinicians and programs that can be shared in ongoing learning collaboratives.

Despite the complexity and apparent cost of the effort, given the human, economic and social costs of addictions, undertaking an alignment with ASAM requirements will reap substantial benefits.

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