California’s Efforts to Develop Treatment Standards

California’s Efforts to Develop California’s Efforts to Develop Treatment StandardsTreatment Standards

dave neilsen, msw and Donna Lagarias, PhDdave neilsen, msw and Donna Lagarias, PhDProgram Services Division, TreatmentProgram Services Division, Treatment

CA Dept of Alcohol and Drug ProgramsCA Dept of Alcohol and Drug ProgramsSeptember 2009September 2009

To reshape and reposition ADP’s operations To reshape and reposition ADP’s operations for a comprehensive and integrated for a comprehensive and integrated

continuum of services, continuum of services, based on a chronic care model, based on a chronic care model, ensuring system accountability, ensuring system accountability,

efficiency, and effectivenessefficiency, and effectiveness.

Continuum of Services Continuum of Services System Re-EngineeringSystem Re-Engineering

(COSSR)(COSSR)

StandardsStandards

a yardstick by which we set expectations and measure value and performance

Why Standards Now?Why Standards Now?

To describe quality treatmentin a chronic care model

To support performance measurement and quality improvement efforts

by programs and counties

Treatment Standards CriteriaTreatment Standards Criteria

Continuum of care that includesmany different models and disciplines of

support, treatment and thereafter

Knowledge-based, evidence-based

Inclusive of all clients and providers

And…

• A maximal number of choices to meet the diverse needs and preferences of our clients

• Flexibility to allow for innovation• Flexibility to accommodate changes in

treatment as our understanding grows• Provision of quality care with scarce

resources

Knowledge-Based StandardsKnowledge-Based Standards

Incorporate our current understanding of:

• Substance use conditions, problems, and dependency (physiology and behavior)

• Barriers to engagement• Best business practices

Treatment GoalsTreatment Goals

Are clients participating in their care,reducing their substance use,

and improving their health and social functioning

during the course of treatment?

Skills for LifeSkills for Life

Are clients adequately preparedwith the skills and social supportsto sustain a prolonged recovery

outside the boundaries of the program?

Key Resources That Informed the First Key Resources That Informed the First DraftsDrafts

Primary literature, reviews and policy papers in the field ofsubstance use disorders

Standards from various contributors•NQF Consensus Treatment Standards, 2007•NASADAD Women’s Treatment Standards, 2008•Youth Treatment Guidelines, 2002•County Standards from San Mateo and Santa Clara•ADP certification standards for residential programs• advisory document from our LGBT constituency group

Technical assistance from SAMHSA / CSAT and Mady Chalk of TRI

In ProcessIn ProcessFirst drafts posted to the internet:

California’s Best System Practices (adaptation of the NQF Standards for the Treatment of Substance Use Conditions)

Core Treatment Standards

Stakeholder comments, posted with reply from ADP, ongoing until October 1, 2009

Revisions made, re-posting for comments

Best System PracticesBest System Practicesadapted from NQF Standardsadapted from NQF Standards

Screening and Brief Intervention for Substance Use Conditions Screening Brief Intervention

Initiation and Engagement in TreatmentAssessmentEngagement in TreatmentWithdrawal Management

Best System PracticesBest System Practicesadapted from NQF Standardsadapted from NQF Standards

Initiation and Engagement in TreatmentServices and Supports PlanningCare Management / Services Coordination

Therapeutic Interventions Psychosocial InterventionsAdjunct Pharmacotherapy for Opioid Dep.Adjunct Pharmacotherapy for Alcohol Dep.

Best System PracticesBest System Practices

Supplemental Sections under construction:

In Support of RecoveryBusiness Practices for Improved ServicesConsiderations for Individualized Care

Best System PracticesBest System PracticesSupplementalSupplemental

In Support of RecoveryFamily Strengthening

Transitional and Supportive LivingCrisis Intervention

Literacy, Education and Work-related Supports


Business Practices for Improved ServicesClinical SupervisionQuality ImprovementStaff Development

Child CareTele-Health


Considerations for Individualized CareYouth

PerinatalGenderTrauma

Criminal Justice Involvements

Practice Options: AssessmentPractice Options: Assessment

Addiction Severity Index (ASI)Global Appraisal of Individual Needs (GAIN)ASAM Patient Placement Criteria (PPC)Comprehensive Adolescent Severity

Inventory (CASI)Youth Competency Assessment (YCA)Alcohol Use Disorder and Associated

Disabilities Interview Schedule (AUDADIS)

Practice Options: Psychosocial Practice Options: Psychosocial InterventionsInterventions

Motivational Enhancement Therapy (MET)Cognitive Behavioral Therapy (CBT)Community Reinforcement Approach (CRA)Structured family and relationship therapies12-Step Facilitation TherapyContingency Management

Core Treatment Standards, v1Core Treatment Standards, v1

A first attempt to describe discrete components of

quality treatment for substance use disorders

Core Treatment StandardsCore Treatment StandardsAimsAims

Inform the public

Set expectations for quality programs

Provide the basis for performance measurement and continuous quality improvement

Core Treatment Standards Core Treatment Standards ContentContent

• Outreach to related agencies, FAQ sheet• Ongoing assessment and planning• Warm referrals• Relapse not a prelude to discharge• Discontinuation of prescribed medication

not a condition for entry into programs• Less reporting, more time with client

2020 Frequently Asked Questions (FAQ) Sheet

Each program should maintain a document for distribution on demand, that describes its approach to treatment and the services it offers. This document should provide information in an easy-to-understand format and should include answers to questions most often asked by clients and/or their significant others, such as:

What does your program do?

Does what you do work, and for whom?

How will you determine what I need?

Will you help me find the right level of care, even if you cannot provide it?

Do I have a say in my care? Can I tell you when it isn’t working?

Do you employ persons that are trained to provide services for people like me?

Will you tell me all of this, and what it costs, before I enter your care?

5100 Alcohol and Drug-Free Environment

Alcohol and/or other drug programs shall provide an alcohol and drug-free environment. An alcohol and drug-free lifestyle should be the goal for program clients, and all participants shall be alcohol and drug-free while participating in program activities.

The practice of discharging clients for the same reason they were admitted (substance use) is not acceptable. Recognizing that substance use disorder is a chronic, relapsing disorder, the program shall make every effort to retain clients in treatment, and shall have written policies regarding appropriate supports to the client during a relapse episode. These policies shall be consistent with the alcohol and drug-free environment of the program.

Clients may be discharged if they engage in illegal activities or activities listed under Title 9 that compromise their safety or the safety of others, such as possessing, selling, or sharing alcohol or other drugs on-site at a program facility.

5200 Medications

Clients currently on medications will be seeking services. Clients shall not be denied services based solely on the fact that they are taking prescribed medication, regardless of the type of medication. Accordingly:

1. Programs shall not deny services to a client with current, physician-prescribed medications, including those with psychoactive characteristics. However, a program may consider whether the nature and extent of the prescribed medications requires a higher level of care than offered at that program.

2. With client consent, providers shall coordinate with the client’s physician when she/he enters treatment with prescribed medications having psychoactive characteristics. Services and Supports Plans (5500) shall be reviewed with the prescribing physician.

5400 Referral Arrangements

If, during the course of program services, the client is assessed (5300) and determined to be in need of and ready for services not provided by the program, the program shall refer the client to appropriate services and with permission of the client, facilitate the first contact.

For each client for whom a referral is made, an entry shall be made in the client's record (6700), documenting the staff member making and following up the referral, the person and agency to which the referral was made, and the date of first service received by the client from the agency to which the referral was made.

5500 Services and Supports Plan

A plan of services and supports shall be developed in collaboration with the client, with careful attention to individual needs. The plan should be developed as soon as the client is ready, using assessment (5300) as a guide.

It should include:• The client’s most important goal(s);• Measurable, time sensitive steps that the client will make toward

achieving their goal(s); and• Measurable, time sensitive steps that the program will take to

support the client in achieving his/her goal(s).

Services vital for client attendance, such as child care and transportation, shall be included in the services and supports plan.

The plan shall include Treatment and Support Services (5600) for substance use disorders and should be updated and revised when appropriate. Revisions/amendments shall occur as steps are accomplished and next steps are identified, when goals important to the client have been met or have changed significantly, or when new support needs become apparent.

In Support of ADP’s COSSR Initiative:In Support of ADP’s COSSR Initiative:an integrated package of supportsan integrated package of supports

Best System PracticesCore Treatment Standards for ProgramsCertification Standards for CounselorsSystem-wide training

NIATx and moreUser-friendly data system for:

Performance measurementContinuous quality improvement

Beyond Standards: What Next?Beyond Standards: What Next?

CalOMS Update Trim data pieces that are not used

Add encounter data, services received

Streamlined data entry and retrieval

Ultimate Goal: Performance Monitoring and Continuous Quality Improvement

(provider driven – initiated)

California Discharge DataContinuous Quality Improvement Efforts

% % Unsat, % 90dReferred Left Stays

Outpatient 2006 99,398 31.1 38.6 46.62007 103,396 32.5 38.9 50.52008 102,558 34.1 35.1 51.2

>30d Res 2006 36,011 52.0 26.4 33.42007 37,951 55.5 24.8 34.42008 37,843 60.9 20.8 34.7

Detox NH 2006 25,834 60.0 12.3 NA2007 24,523 64.6 12.0 NA2008 24,778 69.6 10.3 NA

Treatment Level Total

CALIFORNIA’sContinuous Quality Improvement Efforts Discharge Query: Use in Past 30 Days

1 Any alcohol consumption in the past 30 days, CalOMS data2 Increase / no change in drug use compared to admission, CalOMS data

Alcohol 1 Drugs 2 Responses% % n=

2006 10.8 27.4 45,0002007 9.1 19.7 53,8192008 8.5 16.8 52,935

http://www.adp.ca.gov/Treatment/standards/ts.asp



Documents

California’s Efforts to Develop Treatment Standards