February 2004
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In this issue
-- SAVVY........
-- SKILLS........
-- SOUL.........
-- STUMP the SHRINK...
-- SUGGESTIONS.........
-- SHARING SOLUTIONS.......
-- Until next time........

WELCOME!

On February 11, 2004 there was a press release from Join Together- a project of the Boston University School of Public Health- that had convened a national policy panel in the summer of 2002. Their task was to address the quality of treatment for substance use disorders. The panel's primary recommendation called for a fundamental change in the payment system for treating drug and alcohol disorders - that payment should be based on the results achieved; that purchasers of treatment services should reward results.

SAVVY........
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You can read the full report published December 2003 at www.jointogether.org/sa/files/pdf/quality.pdf
In each of the following Tips, I will outline some of the panel's key points of perspective and provide some commentary.

Tips:

• "We endorse previous efforts to improve treatment quality, but believe that they lack necessary force."
  
  The report mentioned two major federal consensus documents they believed "express many ideas that can help improve quality." (Fed Doc 1: The National Institute on Drug Abuse's (NIDA) Principles of Drug Addiction Treatment (1999); Fed Doc 2: Changing the Conversation, the Center for Substance Abuse Treatment's (CSAT) National Treatment Plan Initiative (2001).) The panel stated that the fundamental strategic weakness that these recent national treatment quality improvement efforts shared was this: "They are largely exhortations".
  
  Just like people suffering from alcohol and other drug problems, clinicians and providers usually do not respond well to exhortations to do better. (Webster's defines exhortations as strong admonitions, urgings, advice or appeals.) Often a client/ families' incentive to maintain or retain a significant relationship, freedom, children, job, place on the school football team, or health is what brings them to the treatment table. Similarly, professionals and organizations respond to incentives meaningful to them too. Exhortations to improve quality, to implement practice guidelines and the like often go unheeded without incentives.
  
  
  
• "We believe that buyers and funders of treatment should reward results."
  
  For most of our clients, especially those mandated for care, what motivates them to seek treatment is the result they want - i.e.to keep their marriage or relationship; to stay out of jail; get their kids back or keep their job. Tuning into those results and recognizing their incentives helps us engage clients and families in treatment. If we succeed in engaging them, then one day perhaps they may be open to our exhortations for sobriety, and consequently improve the quality of their physical, mental, social and spiritual life.
  
  Likewise as professionals, we must tune into the results that purchasers and funders of care want - increased work productivity, decreased absenteeism, fewer arrests, decreased healthcare utilization, increased safety for children and families. Then we can attract the loyalty, commitment and resources of employers, legislators, criminal justice and others. Those who pay for the services we render are also our customers and clients as well! We need to attract them into investing in addiction treatment, which means overcoming ignorance about recovery; stigma against substance use disorders; and skepticism about whether we clinicians really care about what they want (sounds like our clients and families too).
  
  There is much to be discussed and considered about paying for results. But it really isn't too much different from the auto industry. When US auto manufacturers started taking American customers for granted, it took the loss of revenue, closure of auto plants and migration to Japanese cars to shift the emphasis to quality and results. What buyers wanted was reliability, good gas mileage, lots of standard features and attractive quality. Notice our consumer behavior. We are reluctant to pay the Midas muffler shop for their excellent caring and certified service if the rattle and noise is not fixed. And we are ready to sue the pants off the surgeon or obstetrician if the surgical results are poor, or if the baby turns out damaged in some way.
  
  If we are to attract and retain clients and funders committed to treatment, a sincere shift to quality and results will be essential.
  
  
  
• "An emphasis on results will lead to a more stable treatment system, a system more capable of quality improvement."
  
  The report says:" Rewarding those programs with good results will mean taking patients and funds from programs with consistently poor results. The weaker programs are likely to close or consolidate with other programs". All this talk of results can be provocative and scary. But do you really want a poor quality program in your community prejudicing people about what good treatment is? Do you wnat them competing with you, taking clients and funding away from your high quality services?
  
  In 1995, the National Council on Alcoholism and Drug Dependence (NCADD) became alarmed at the potential for further erosion of funding and programs they had witnessed with managed care and shrinking employee benefit packages. They formed an ad hoc committee, the Committee of Treatment Benefits (COB), to devise ways to attract more substantial and stable funding from business and industry. Rewarding results was a foundational objective of that effort that has evolved into an independent 501 (c) 3 organization now called the Coalition for Outcomes-Based Benefits.
  (COBB PO Box 17305, Smithfield, RI 02917 Telephone 401.231.2993).
  
  
  
  
• "Another reason that we advocate rewarding results is the lack of public consensus as to the most effective approaches to creating durable recovery."
  We know from years of outcome research that -1.treatment works and- 2. that treatment is better than no treatment. However we have dissipated a lot of energy and resources on focusing on which treatment model(s) and methods are better than the other; what accreditation and quality standards and practices are better than the other. But over 40 years of research on what helps people change is sobering. What appears to be most important is engaging clients into treatment; the quality of the therapeutic relationship; and assertive early, ongoing and specific client feedback and measurement of outcome. Stated differently, what really counts is focusing on the results of what we do in treatment more than the process and procedures of what we do with clients and families.
  
  You can read more about this by checking out the Institute for the Study of Therapeutic Change. Here's the information.
  Scott D. Miller, Ph.D.
  Telephone: (773) 404-5130
  Postal address: P.O.B. 578264 Chicago, IL 60657- 8264
  Electronic mail General Information: info@talkingcure.com
  Internet: www.talkingcure.co m
  
  Also take a look at the Savvy section of the August- September 2003 Vol 1, No. 5 edition of TIPS and TOPICS (see the Back Issues link on my homepage: www.DMLMD.com) where I address some of the work of Scott Miller.

SKILLS........
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So.....
if this is the time to start moving towards a results- oriented approach, what does that mean in the real world of daily clinical practice? We are still a long way from the imaginings at the conclusion of a paper written by Jerry Shulman and myself six years ago:

" Imagine the day when a patient, referred by the courts for a first drinking and driving violation, completes the assessment process, is found to be Alcohol Dependent and awaits the treatment options discussion. He is presented with various treatment options and their costs and information about the various probabilities of success that he needs to make an informed decision. He could refuse all treatment, take the legal consequences, spend no money on treatment, but have a 95% chance of further alcohol-related consequences; a 50% probability of arrest for an alcohol-related offense; and a 20% probability of an alcohol-related accident in one year. For a combination of 12-Step groups and outpatient groups focused on education about addiction for 10 weeks, he could spend $1,000 with the chances of alcohol-related problems reduced to 60%. Or, for $2,900, he could have four weeks of intensive outpatient treatment; attend 12-Step groups and receive twenty continuing care sessions; weekly access to a significant others therapy group with only a 20% chance of further problems and a 5% probability of arrest.

Imagine the day when an employer decides to shift the remedial costs of all employees testing positive in random drug screens; or facing mandatory supervisory referral for declining job performance due to addiction; or involved in a drug-related, post accident incident report to the training and development budget away from the health benefits cost center. Now the employee can access any of the three company-approved providers, all of whom have met standards by presenting efficacy and performance data that demonstrate minimum results of 60% improvement in job productivity; 80% drop in absenteeism; virtual elimination of positive random drug screens; and 50% reduction in accident rates on the job over two years of monitoring. The employer will match employee expenditures at these providers on a 70%(employer) - 30%(employee) basis as long as all employee performance data is improving at a satisfactory rate as monitored by the supervised employee development plan. Imagine the day when the health plan administrator can review the outcomes from a variety of different treatment providers and determine their relative merits by cost-per-case; percentage decrease in health care utilization; and the level of patient satisfaction and well-being. Developing the provider network now becomes a data-driven survey of cost-effectiveness and return on investment data; and bonuses are awarded based on quality and performance data, not just cost reductions."

Excerpted from:
(Mee-Lee, David, Shulman Gerald D (1998): "Towards Clinically Effective, Cost Efficient, Outcomes-Driven Treatment". NCADD Amethyst. Vol.6, No.3, pp.1-2.)

Tips:

• Ask clients and families what was helpful and what was not helpful in the session?
  
  Even before you or your program is ready to commit to an outcomes, results-oriented approach, you can start informally by seeking direct, honest and immediate feedback. Before asking for feedback however, check whether you really are interested in the feedback, and whether you would actually discuss and use the feedback to change the next session.
  
  > "How much did you feel that I heard, understood or respected you or not?"
  > "Did we, or did we not, work on or talk about what you wanted to work on or talk about?"
  > "Is my approach to treatment a good fit for you not?"
  > "Was there anything at all that was missing in the session today?"
  
  These questions are drawn from Scott Miller and his colleagues' Session Rating Scale (SRS).
  
  
  
• Use "low tech" data to alert you to problems with client engagement.
  
  You don't need high-powered computers and fancy software to start tracking data that helps you become increasingly results-oriented. Start collecting and using simple data like client "no- show" and "premature treatment departure" rates. (I'm still mulling a language switch from "drop out" rates, which some have suggested is judgmental and negative-sounding). If you would like to see improvements in client engagement and outcomes, a reduction in no show or premature treatment departure rates is a good place to start.
  
  Clients and families can certainly achieve the results they want, and terminate treatment sooner than what we might have deemed necessary. On the other hand, we may have failed to create a welcoming, hopeful, empathic and engaging therapeutic environment. Such data collection and analysis gives us the chance to check that we have done all that we can to create the most conducive environment for change.

SOUL.........
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I just returned from a conference on Pain Management and End of Life care. It wouldn't have been my first choice, but California requires all physicians to complete 12 hours of continuing education on these topics to keep their medical license. It's mandated education, just like our clients. The conference provoked much thought. Here is but one piece rich in its content and implications:

Dale Borglum, Ph.D., Executive Director of the Living/Dying Project in Fairfax, California (www.livingdying.org) suggested there are three reactions we can have when confronted with pain:
(1) Separation - we don't want to see or be that; and so deal with pain in a detached clinical and intellectual manner. It keeps us shielded from experiencing the pain and keeps us separated from the person.
(2) Identification - realization and startled alarm that there I am. While we have a better chance to understand and join with the client, this reaction can actually keep us more focused on ourselves and what worked for us - this too can separate us from this person and their pain and path to recovery. (This can be an occupational hazard for recovered addiction counselors).
(3) Compassion - joining and feeling with the person, allowing the painful to be bearable. Compassion isn't about changing the other person; it is about changing us and allowing us to meet that person as an equal. How to stay present with the other person - not pity them, judge them, or condescendingly educate them about their deficits.

In our field, we are constantly confronted with pain and suffering. With big caseloads, time pressures, and paperwork, compassion is a fine idea and ideal. But, excuse me, I have to get my charting done. Practicing compassion is like practicing progressive relaxation exercises - it doesn't come quickly or naturally. But it is worth it in the end - for you and for those we serve.

STUMP the SHRINK...
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Question:
Dear Dr. Mee-Lee:

I work as an Assessment Specialist for a chemical dependency treatment agency that has both outpatient and residential levels of care.

I have recently encountered conflicts regarding the appropriateness of documenting highly sensitive information in patients' charts and/or ASAM PPC Assessment Summaries. Specifically, whether it is considered best practice to include HIV or HCV diagnoses in Dimension 2, or admissions of serious crimes (such as those without statute of limitations) in Dimension 3. Such disclosures have serious ramifications for patients' privacy and legal status, and nondisclosure has potential consequences regarding the proper care of the patient.

I understand that these questions may not be definitively answered, but I appreciate your input or, alternatively, direction to good sources for information on these ethical/legal questions. At present I am only able to access the somewhat uninformed opinions of colleagues and would like a better source.

Thank you for your assistance.
MJ.

Response:
Dear MJ:
It is a good question and one that is sticky. I am not a legal or HIPAA expert, but knowing how medical records can be used or misused, I always have mixed feelings about how specific to be. On the one hand, an overall principle is to have the medical record be as meaningful a living document that actually guides the treatment and is a communication tool for the client, treatment team and referral sources and ongoing continuum of care.

On the other hand, we live in a litigious and adversarial environment where people's privacy can easily be violated. I don't agree with some people who make the whole record so vague that everyone's record sounds the same as another's. Nor would I recommend what some people do, which is to keep two separate records - we have enough paperwork to do without keeping "two sets of books".

My recommendation is to be as specific as possible without jeopardizing a person's privacy unnecessarily. So if there is a sensitive medical or behavioral issue, you could word it so that it is clear to the patient and team what the issue is without having all the specific details documented.

For example:
1. For a Dimension 3 (Emotional, Behavioral or Cognitive Conditions and Complications) issue, it could be documented as "Upsetting regrets and feelings about past behavior in his 20's" (some illegal act committed) Or "Flashbacks and fears about traumatic relationship problem" (an extramarital affair; or an abusive relationship)

2. For Dimension 2, (Biomedical Conditions and Complications) it could be "Worried about health problems and his energy level" (AIDS or HIV, HCV positive). Or "Stressed about ongoing well being and quality of his physical health" (a chronic illness not named).

I hope this helps, but let me know if not. You could also check with your local medical association to get their advice about legalities and also your malpractice carrier as they often have good risk management advice.

SUGGESTIONS.........
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Suggestions for Stump the Shrink:

Dear ezine readers:
Do you have a better answer than what I gave to MJ? What thoughts, experiences, advice can you offer? I invite you to contribute any further tips you have for MJ's situation.

In that same vein, below is a another comment and request from a reader. Again if you have ideas to share for this LCSW's obvious frustration, please send them to me. Do you share her experience too? How do you cope?

"Thank you Dr. Mee-Lee for your newsletter. I am a dually licensed (MH/SA) therapist who works for a rural community mental health center. I just came back from a family services team meeting for a juvenile who suffers from chemical dependency and I'm so frustrated I want to scream, cry, etc. She is a decent kid, no history of conduct disorder or other behavior problems prior to the onset of substance abuse. I was the lone voice recommending treatment. I love working with individuals with CD disorders because treated appropriately there is so much hope and improvement. However, the criminalization of addiction, the lack of compassion, understanding and punitive approaches is getting to me. Thank you for your humanistic understanding of the disorder and the men, women and kids who suffer from it. Any suggestions on increasing my coping skills with my frustration?"

LSCW

Email me your ideas at info@dmlmd.com. I will include your various responses in upcoming editions.

SHARING SOLUTIONS.......
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Over the years, I have continued to get requests to review and comment on assessment forms, tools that programs have developed to implement the ASAM Criteria, or treatment planning forms.

If you are proud of a form or tool you have created and would like to share the wisdom in it...........
If you are developing a form or tool and want input/feedback........
If you need comment/critique on an intake form? a telephone response form? outcome results form? a tracking form?.........

Then................
** Send me your forms, tools,and documents.

What I will do
.I will comment and give constructive critical review on any forms or tools you send me.
.In exchange for my review, I ask your permission to publish and sell the best ones I receive- perhaps twice a year.

What you will receive
.Feedback and suggestions to improve your tool or form.
.Ongoing feedback by email for 3 months.
.Complimentary copies of the next two editions of forms and tools published.
.You ( your program) will receive full recognition and source acknowledgement with your contact information in the publication.

If this appeals to you, I would welcome hearing from you now. Please email me at info@dmlmd.com

Until next time........
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Thanks again to all of you who send comments and questions. Email your suggestions, your solutions, your wisdom, your forms, your tools.................
See you in March.

David