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TIPS & TOPICS from David Mee-Lee, M.D.
Volume 4, No.6
October-November 2006
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In this issue
-- SAVVY
-- SKILLS
-- SOUL
-- SUGGESTIONS
-- Until Next Time

This is the late October/and now late November issue of TIPS and TOPICS. It’s a little longer, so you get your money’s worth.

Welcome to all the new subscribers. I appreciate the supportive comments and feedback of those who have taken the time to write, even if I can’t personally acknowledge every message. I’m glad that many find TNT helpful and would like your suggestions (see below in an “S” we haven’t used much - “Suggestions”)

SAVVY
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In September’s SKILLS section I created a list of “Things That Don’t Make Sense.” Here’s one item from the list: “A person is assessed to be in need of residential treatment, and then they are placed on a waiting list for anything from days to weeks.” One TNT reader raised some good points worth further discussing. So I have included his response (with permission), and I address some of the issues in the SAVVY and SKILLS section in this issue.

I was reminded of this recently as I was consulting on improving detoxification services. Not only was there an 8-10 week waiting list for residential care, but there was even a waiting list for detox services. I understand resources are limited, and that real financial, bureaucratic and systems’ issues just feel beyond our control. Let me propose, however, that there still exist a number of attitudinal, values and belief systems which underlie our tolerance of waiting lists. I’ll explore some of those and offer some solutions.

Firstly, here is what Mike Wallace (no, not the veteran TV journalist) wrote:

“Dr. Mee-Lee,

At our community based addictions treatment center we must do two things with Residential Treatment Wait Lists. We directly manage the men’s list, and we maintain our in-house women’s wait list for our women awaiting beds at the regional women’s treatment center, not in our control.

We provide interim services, including case management, group, and individual counseling.

We believe that even if clients are not “in imminent danger,” as you put it in your September TNT, they remain appropriate for residential care if they have a high relapse potential (few skills, lots of poor habits) and a poor recovery environment (perhaps including poor use of sober supports). Too, we consider other dimensions.

Now, if a client responds well to Outpatient interim care, we transfer him or her to Intensive Outpatient or even an OP level.

I find that I generally agree with everything you say, and can find a way to apply it even if it is very hard. However, the only thing I can do to make more residential beds (for men; I have no control over the women’s at all) is to hasten the treatment of those men already in care. I do this by encouraging appropriate clinical care, not by encouraging premature discharge.

Thanks from the field.”

Michael Wallace LPCC LICDC
Clinical Administrator
McKinley Hall, Inc.
1101 E. High Street
Springfield, Ohio 45505

Tips:

Here is the explanation of “unbundling” from the Preface to the American Society of Addiction Medicine’s Second Edition Revised of the Patient Placement Criteria for the Treatment of Substance- Related Disorders of the (ASAM PPC-2R, 2001, page 17)

“The Concept of “Unbundling”

While the first edition of the Patient Placement Criteria “bundled” clinical services with environmental supports in fixed levels of care, there is increasing recognition that clinical services can be, and often are, provided separately from environmental supports. Indeed, many managed care companies and public treatment systems are suggesting that treatment modality and intensity be “unbundled” from the treatment setting. Unbundling is a practice that allows any type of clinical service (such as psychiatric consultation) to be delivered in any setting (such as a therapeutic community). With unbundling, the type and intensity of treatment are based on the patient’s needs and not on limitations imposed by the treatment setting. The unbundling concept thus is designed to maximize individualized care and to encourage the delivery of necessary treatment in any clinically feasible setting. As a first step toward “unbundled” criteria, the second edition incorporated criteria for five levels of detoxification care as a clinical service separate from the environmental supports. The PPC-2R continues such “unbundled” criteria.”

--> Mike explains that they manage the men’s waiting list by providing “interim services.” By starting these interim services- “case management, group, and individual counseling” on an outpatient basis- his team is actually doing “unbundling.” They are comfortable that the clients on their waiting list for residential treatment are not in imminent danger. For example, if someone was suicidal and impulsive, they would not feel safe with these interim, outpatient services.

Mike and the team still recognize the clients have “a high relapse potential (few skills, lots of poor habits) and a poor recovery environment (perhaps including poor use of sober supports.”) The usual clinical impulse is to bundle (join) the relapse and recovery environment dimensions together, and recommend residential treatment first.

However a residential bed is not available for the client. What to do?

The team commences treatment immediately with case management, group, and individual counseling on an outpatient basis. Some of those clients respond and make good progress so that they don’t even need to be admitted to residential treatment and are transferred to ASAM Level II.1 (Intensive outpatient) or Level I (Outpatient services).

Actually as soon as the interim services begin, the clients are already in Level I or II.1. Mike says: “Now, if a client responds well to Outpatient interim care, we transfer him or her to Intensive Outpatient or even an OP level.” There really is no need to think of this as a “transfer.” The clients are continuing to receive the same outpatient services that were started when originally placed on the waiting list. The treatment is working, so the same level of care is appropriate.

--> If you start outpatient services and things are not improving, don’t reflexively move back to bundled care, and wait for the residential bed to open up. Reassess. You may be able to add some services to the current set of services. For example, add another outpatient group or individual session. Or recommend more self/mutual help meetings.

-->Example 1:
A medical student client was doing well in Level II.1 Intensive Outpatient with his methamphetamine dependence. He was so excited about his recovery that he visited his still-using friends to invite them to join him in treatment. However he ended up using with them. His slip is not a failure of outpatient treatment now indicating the need for residential treatment. He was simply doing outreach calls to actively-using friends much too early in his recovery. He can change his treatment by attending more self- help groups and help clean up the coffee mugs, rather than try to help clean up his friends. That does not require a change in level of care.

-->Example 2:
A man is in alcohol withdrawal. He needs detox, but lives with unsupportive family members. Again the impulse is to bundle together his living situation with his detox needs. This type of person typically gets admitted to a $500-$1000 a day hospital detox bed. However his needs might still be addressed safely and efficiently through “unbundling.” He is better placed in a supportive living setting for $50/night; and during the day he is detoxed in an outpatient partial hospital detox setting for $100/day. This uses limited resources wisely for those who don’t need a hospital level of detox service.

--> Example 3:
Then there’s the adolescent who is arguing with her parents and throws a chair while intoxicated. She does not need separation from her family in a locked psychiatric unit, even if just for overnight. There is no withdrawal, medical, or even psychiatric severity that needs to be bundled together for treatment in an intensive setting like that. A crisis worker should arrange “unbundled” services: overnight stay with a relative or trusted friend; a family meeting first thing in the morning; support and guidance for both the adolescent and parents in their frustration with each other.

The Bottom Line
The treatment field does not need more residential and detox beds and waiting lists!
It needs:
-> more case management;
->crisis intervention;
->outreach teams as in Assertive Community Treatment teams;
->a wider variety and range of housing supports.

There are a wide range of needed housing supports. There are low intensity shelters and respite beds. There needs to be a greater variety of supportive living environments. Some could be peer-led or supervised 24 hours by non-clinical staff. More intensive settings are 24 hour clinically managed by treatment professionals as in a social detox. Further, there is a need for more Recovery homes, apartments, Oxford Houses, and sober living. At the beginning end of the spectrum the field needs “Discovery” homes, for those not yet ready to commit to lifelong sobriety and wellness.

Access to care can increase dramatically by unbundling the full range of services from the need for housing and safe living surroundings. Bundle all that together and waiting lists will continue to limit access to care and waste limited resources on revolving door detox and acute care admissions in psychiatric units and emergency rooms.

Reference and Resources for ASAM Patient Placement Criteria

Mee-Lee D, Shulman GD, Fishman M, Gastfriend DR, and Griffith JH, eds. (2001). ASAM Patient Placement Criteria for the Treatment of Substance-Related Disorders, Second Edition-Revised (ASAM PPC-2R). Chevy Chase, MD: American Society of Addiction Medicine, Inc. ISBN 1-880425-06-8

American Society of Addiction Medicine - 4601 Nth. Park Ave., Arcade Suite 101, Chevy Chase, MD 20815. (301) 656-3920; Fax: (301) 656-3815; www.asam.org; (800) 844-8948. This is where you can order ASAM PPC-2R online; or call the toll-free (800) 844-8948.

SKILLS
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Let’s look at another point in Mike’s message. “We maintain our in-house women’s wait list for our women awaiting beds at the regional women’s treatment center, not in our control.”

Providers often feel stuck with little control over referral sources, resources and regulations. For example, you might like to be more flexible with criminal justice clients, but feel the courts will not allow that. Or perhaps you can’t move people on through your program because there is a waiting list for the next level of care.

Tips:

Things that do make sense – No. 1
Do you face waiting lists? Do the best you can by creatively piecing together resources that will provide the intensity of care needed. This is where unbundling and mixing and matching services is important. Or take a look at this link- http://www.chess.chsra.wisc.edu/NIATx/Content/ ContentPage.aspx?NID=44
Discover what a number of programs have done to eliminate or trim waiting lists. Read case studies about their successes and solutions.

What else to do
Take 30 seconds to document the level or kind of service which would be ideal for your client; note down what service the client actually received; and record the reason for the difference as below:

PLACEMENT SUMMARY

Level of Care/Service Indicated- - Insert the ASAM Level number that offers the most appropriate level of care/service that can provide the service intensity needed to address the client's current functioning/severity.	Write level in here
Level of Care/Service Received - -Insert the ASAM Level number -- If the most appropriate level is not utilized, insert the most appropriate placement available.	Write level in here
Reason for Difference- -Circle the Reason for Difference between Indicated and Received Level. Circle only one number. --1. Service not available --2. Provider judgment --3. Client preference --4. Client is on waiting list for appropriate level --5. Service available, but no payment source --6. Geographic accessibility --7. Family responsibility --8. Language --9. Not applicable --10. Not listed.

 

Make this frustrating situation into a positive: turn it into a data-gathering opportunity to help change the system. Accumulated data will tell you:
-> how many services or patient days were unnecessarily provided
-> how many services or patient days withheld from people.
-> what are the biggest gaps in the continuum of care- especially if inadequate services resulted in readmissions or early departure from treatment.

Things that do make sense – No. 2
Think less about programs, and more about meeting peoples’ needs from a menu of services. Think less about plugging a person into a program, and more about a holistic, multidimensional assessment of needs and their resources. You probably know the mix of services needed for this client right now, and could start treatment immediately. Not everyone needs to be on a waiting list for some other magical program.

What else to do
With some creative collaboration, empowerment of the individual and their family; and heavy reliance on natural community supports, self/mutual help groups and consumer alumni groups you just may actually develop the most effective and efficient plan anyway. Shift your thinking away from “interim plans for people on waiting lists” to “here-and-now services for people who need help now”. We may be able to help more people, more appropriately, more efficiently and more effectively than you dreamed of. Many of you do this already anyway, even though you think of it as second class, interim “pretreatment”. It is not marking time. It doesn’t have to be anything less than the real thing.

Things that do make sense – No. 3
It’s easy to stay stuck in the victim helpless position of “they won’t let me do more flexible care” or some version of that whining conclusion. Empower yourself and speak up. Since all policies and procedures are person-made, they can be person-changed. Develop coalitions with fellow providers. Brainstorm about better systems solutions. Use the data you collect on No. 1 above – initiate consciousness-raising meetings with accreditation, funding and licensing organizations.

What else to do
Track the costs (in human, financial, criminal justice and health care systems) of inflexible funding, contracting, licensing or accreditation methodologies. Bring these to the ‘consciousness-raising table’ with administrators, managed care, State contracting and benefits managers etc. Don’t forget to include the costs of fatigued staff members burdened with onerous paperwork, large caseloads and procedures which are more paperwork-centered than peoplework- centered.

For example, I visited a program which was contracted to provide one level of detox for all clients in a Medically Monitored Inpatient Detox level of care - for one flat daily rate. However many of the 30 or so clients did not need that intensity of detox service for all the time of their treatment (See ASAM PPC-2R’s five levels of detoxification pp 145-175). They were required to meet documentation and staff standards as if every client required that intensity of nursing and medical monitoring. Instead of being able to be flexible in how they staffed and documented, the funding and contracting arrangement perpetuated the “one size fits all” mentality and service structure.

This would just be an interesting academic observation were it not for the fact that this is all too common. It decreases access to care for clients needing services. It uses valuable staff resources inefficiently. It prevents a flexible use of team members who could give more care to those who need it, and less to those already stable.

SOUL
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George Carlin is that irreverent but thought-provoking comedian who points out our slick use of words to hide all kinds of attitudes and foibles. Like saying “vertically challenged” instead of “short”. I heard another variant the other day. A reporter was discussing new packaging on meat; the packaging now declares: “Animal compassionate”. This is meant to up the ante I suppose on cows and chickens that are “free-range”, hormone-free or “range-fed” in no “feed-lot” living.
But I was wondering if the poor cow cared much about how compassionate you were when you barbecued their rump not long after someone else slit their throat or shocked them to death. But it is good to know that the mouthful you just chewed up came from a place that is “animal compassionate”. If you are going to kill and eat someone, at least be compassionate about it.

I am poking fun at myself as much as at anyone else, because I am no vegetarian either. But it got me thinking about something else that happened recently with my office telephone headset. I bought a not inexpensive set from Hello Direct over 18 months ago. Unknown to me, a power failure had triggered a malfunction; but I was unaware of that until I received a customer service call. By chance I received a routine call of theirs, inquiring if I was still using the headset and how it was working for me. As it so happened, I had been quite frustrated of late- the volume was all messed up. I literally had the instruction manual open on my desk at that moment, searching through the Trouble Shooting pages.

The friendly voice said she would connect me with the technical department, who immediately walked me through the problem until it was solved and fully functioning. And to top it all, the customer service person called me back just the other day to verify that the technical person did indeed help me; and she promised to check back with me in a month. I was waiting for the sales pitch on some new wireless product she wanted to sell me. But no such “catch”! This level of service is all about a telephone headset I bought 18 months ago. It’s not like I am a big office promising them big sales. We have probably spent a few hundred dollars with them in the past ten years.

Then my mind drifted to how we treat people in the healthcare field. Sometimes we confront people, disempower them and chew them up with less compassion than the animals we eat. And can you imagine how effective it might be to call up someone 6, 12 or 18 months later? See how they are doing? Are they still using any of the ideas or skills we generated together in treatment? Are they helping? No sales pitch, no judging, just interested about whether life is better for this person---and then to remain available to them. What a concept of illness management and recovery monitoring!

It’s a good thing that our healthcare system is more compassionate and service oriented than the meat packaging and telephone headset industries.

SUGGESTIONS
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For over 3 years TIPS and TOPICS has been sent out to thousands of people. The feedback I receive tells me TNT has helped fill a niche for useable information for many readers. (Of course those of you who think it stinks, don’t usually write me.) But now I would like to ask you to do something - if you wish.

I am collating some of the TIPS and TOPICS into a series of books – maybe the Top Ten Tips in Treatment Planning; or TTT in Co-Occurring Disorders; or TTT in Engaging People into Collaborative Treatment; or TTT in Understanding the ASAM Criteria etc.

If you are willing, I would like to ask you to do the following, and email me:

If your list comes closest to what I actually end up publishing first (e.g., your top ten tips are mostly or all chosen), I will send you 10 books free when published; plus 3 hours of free telephone consultation on tough cases, program change, systems change, or anything else you want to talk about.

Deal or No Deal?!

Until Next Time
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Happy Thanksgiving to all USA readers. All the best to the rest.
David

 

Contact Information
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email: info@dmlmd.com
phone: 530-753-4300
web: http://www.dmlmd.com
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