Pennsylvania Client Placement Criteria, Third Edition PA Department of Drug and Alcohol Programs Rev. 11/15

Pennsylvania Client Placement Criteria, Third Edition

PA Department of Drug and Alcohol Programs

Rev. 11/15

DDAP’s Mission

• The Department of Drug and Alcohol’s mission is to engage, coordinate and lead the Commonwealth of Pennsylvania’s effort to prevent and reduce drug, alcohol and gambling addiction and abuse and to promote recovery, thereby reducing the human and economic impact of the disease.

Gary Tennis, First Secretary of DDAP

Goals

• To introduce the PCPC, providing basic knowledge and skill practice

• To provide the foundation training for those who will administer the PCPC

Objectives

• By the end of the training, participants will have:– Reviewed the purpose and use of the PCPC– Identified the levels of care, types of service and

dimensions of the PCPC– Gained knowledge of Admission, Continued Stay,

and Discharge criteria of the PCPC– Increased knowledge of placement considerations

for special populations– Demonstrated understanding by applying the

PCPC to case studies

Training Overview

• Background of PCPC• Highlights of Manual• Levels of Care,

Types of Service, & Dimensions

• Continuum of Care and Placement Process

• Summary Sheet• Special Populations• Do/Don’t Matrix• Case Studies• Training Principles• Principles of

Treatment

• Act 1521988• PCPC Task Force Established1993• Statewide Pilot Studies1996• PCPC First Edition1997• PCPC Second Edition1999• BDAP Becomes DDAP2012• PCPC Third Edition2014

PCPC Background…a look back in time

What is the PCPC?

• Set of guidelines designed to provide clinicians with a basis for determining the most appropriate treatment setting for individuals with Substance Use Disorders (SUD)

• PCPC is a placement tool, a methodology for Level of Care (LOC) determination– Originally based on ASAM Criteria– For use with adults– Mandated for publicly funded individual– Evidence-based placement tool

Why use the PCPC?

• Developed to provide clear guidance for placement in Pennsylvania SUD treatment system

• Reflects expertise of professionals across the state

• Created for use with the public sector• Includes placement considerations for special

populations• Creates common language and consistency in

the field

Why use the PCPC?

• Three best predictors of positive outcomes relate to fidelity to the assessment and placement process:– Level of Care– Length of Stay– Treatment continuum

• All three are managed by the PCPC

Why use the PCPC?

Required by Act 152 of 1988• Added to services covered by Medicaid (previously only

covered limited outpatient and hospital services)– non-hospital residential detoxification – non-hospital residential rehabilitation – halfway house

• Requires use of criteria developed and/or approved by DDAP for governing level of care and length of stay– PCPC for adults– ASAM for adolescents

A note about Act 106 of 1989

• Requires all commercial group health plans, HMOs, and the Children’s Health Insurance Program to provide comprehensive treatment for substance use disorders.

• Minimum benefits– 30 days residential per year/90 days lifetime– 30 sessions outpatient/partial hospitalization per year/120 days

lifetime– 30 additional outpatient/partial hospitalization sessions or 15

additional residential treatment days– Family counseling and intervention services

• Only lawful prerequisite is a certification and referral from a licensed physician or licensed psychologist

• Concurrent reviews are not required during this time

Principles of Treatment

• Individuals with Substance Use Disorder(SUD) require access to a coordinated continuum of services that are clinically appropriate in intensity, duration, and frequency.

• Foundation of Treatment Principles:– Science of SUD treatment, – Person-Centered and Community-Based paradigm of

recovery. • Principles based on the platform of recovery focus

on the strengths of the person and his or her connections within a community of recovery supports.

Principles of Treatment

• Principle 1: Treatment is optimal when provided through individualized and coordinated treatment intervention, follow up, and recovery support services that lead to each individual’s long term recovery.

• Principle 2: Beyond cessation of substance use, SUD treatment should also address the individual‘s needs through the provision of comprehensive services provided within seamlessly linked systems of care.

Principles of Treatment• Principle 6: Within the continuum of treatment services,

treatment placement recommendations need to be based on a comprehensive assessment that includes a review of the severity and biopsychosocial impact of the individual’s substance use as well as the individual’s clinical, social, and recovery status.

• Principle 7: Remaining in treatment for an appropriate period of time is critical to positive outcomes.

• Principle 18: Treatment and recovery systems can and should continually evolve to serve individuals and communities appropriately.

Continuum of Care

PreventionEarly

InterventionOP IOP

PartialHalfway House

Med Mon Detox

Med MonST

Residential

Med Mon

LT Residential

Med Managed

Detox

Med Managed Inpatient

What is assessment?• Definition: A face-to-face interview with the client to

ascertain treatment needs based on the degree and severity of alcohol and other drug use/abuse through the development of a comprehensive, confidential personal history, including significant medical, emotional, social, occupational, education and family information.

• Conducted by qualified professional• Vital element in placement process

– Assessment is NOT placement– Assessment is the foundation for determining PCPC placement

• Assessment is NOT required for emergent care placement

PCPC Dimensions

1) Acute Intoxication and Withdrawal

2) Biomedical Conditions and Complications

3) Emotional/Behavioral Conditions and Complications

4) Treatment Acceptance/Resistance

5) Relapse Potential

6) Recovery Environment

PCPC Levels of Care and Types of Service

• Five Levels of Care– Broad Description of Services to meet the client’s

needs in three areas:• Medical Needs• Therapeutic Contact (Counseling and Medical)• Structure and/or Restrictions

• Ten types of service organized under the five broad levels of care– Nine types of D&A services are licensed in PA– Early Intervention is not licensed in PA

PCPC Levels of Care *based on service descriptions

Types of Service Tx Contact/ Staff Ratio Structure* Medical* Setting

Level .5 Early Intervention None Low None Community

Level IOutpatient 1A

Low (<5hr/35:1)

Low None Community

Intensive Outpatient 1BMedium

Low None Community(5-10 hr./15:1)

Level IIPartial Hospitalization 2A

MediumMedium None Community

(10+ hr./10:1)

Halfway House 2BLow (<5 hr./8:1)

High (24 hr.) Low (phys. exam)Community/ Residential

Level III

Med Monitored Detox 3A High (7:1) High (24 hr.) Medium (exam in 24h) Residential

Short Term Residential 3B High (8:1) High (24 hr.)Medium (physical exam)

Residential

Long Term Residential 3C High (8:1)High (24 hr.) Medium(phys. exam

48h)Residential

(Longer tx)

Level IVMed Managed Detox 4A Very High (5:1) High (24 hr.) Very High (24h Doc) Hospital

Med Managed Tx 4B High (7:1) High (24 hr.) High (24h Nurs.) Hospital

Tips & Tricks for Placement• Question 1: Is the individual’s life/health in danger

because of the amount of drugs or type of drugs they have taken? (Dimension 1)– If YES, see 4A or 3A

• 4A if they will possibly need emergency care/life is in danger/crash cart & emergency on stand-by

• 3A if the symptoms aren’t extreme– If NO, move on (you’ve just eliminated 3A & 4A)

• Question 2: Does the individual’s medical or mental condition need frequent care or 24 hour nursing? (Dimension 2 & 3)– If YES, placement is 4B– If NO, move on (now you have eliminated ALL of LEVEL 4)

Tips & Tricks for Placement

• Question 3: How much structure and contact does the person need? (Dimension 3)

• A lot? (Level 3)• A little? (Level 1)• In between? (Level 2)

– Start reviewing criteria in that level of care – look at the Dimensional Scoring Specification

– Hint: you only need to look at dimensions 3, 4, 5, & 6

• Question 4: Are you sure?– To check, look at the criteria in the services that are the next

most intensive and the next least intensive

• The Next Step: Anything special about this individual?

Initial Placement Determination

What type of help (medical, structure, contact) does the client need?

Medication-Assisted Treatment

Co-Occurring SUD and Mental Health

Women/Women with Children

Criminal Justice

Cultural/Ethnic

Sexual Orientation/ Gender Identity

Co-Occurring SUD and Gambling Disorder

Level of Care Type of ServiceSpecial

Considerations Provider

Which Type of Service is designed to meet those needs?

(TOS Placement)

Which Provider meets the needs?

LOUIS

Admission Case Study


















Low (<5hr/35:1)

Low None Community





(10+ hr./10:1)



Level III



Residential


48h)Residential

(Longer tx)



Completing the PCPC Summary Sheet• Complete clinical assessment.• Go to the Level of Care that appears most

appropriate.• Starting with the 1st dimension that must be met,

compare client symptoms with required criteria. • Fill in the level of care and criteria by alpha numeric

reference in the dimensional scoring section.• Fill in the comments section with a brief, global

statement of how the client meets the dimensional criteria.

• Summary Sheet must comply with 4 Pa Code 255.5 on confidentiality– As a provider in PA, one may not release additional information

Completing the PCPC Summary Sheet

Forms are available online at www.ddap.pa.gov. Select “DDAP Document Library” and then “Forms”.

http://www.ddap.pa.gov/

Level of Care Overview

Level 3

• Professionally directed (“monitored”)

• Does not require full resources of medical facility

Level 4

• Medically directed (“managed”)

• 24-hour medical service is needed


3A

• Admission criteria requires score of 3A in Dim. 1 and no higher than 3A for Dim. 2 & 3

• Physical exam within 24 hrs. or physical exam completed within 7 days reviewed within 24 hrs.

4A

• Admission Criteria requires score of 4A in Dim. 1 or 3A if Dim. 2 or 3 are 4A

• Physician completes comprehensive history (D&A included) and physical exam within 24 hrs.


3B

• Professionally directed• Individuals in acute

distress• May have co-existing

issues but they do not require frequent care

• Full resources of medical facility not available on-site

4B

• Medically directed• Individuals in acute

distress• Have co-existing issues

which require frequent care

• Full resources of medical facility available on-site


3B

• Professionally directed• Individuals in acute

distress• Moderate impairment of

social, occupational, of school functioning

• Rehabilitation is goal

3C

• Professionally directed• Individuals in chronic

distress• Severe impairment of

social, occupational, or school functioning

• Habilitation is the goal


3B (Dimension 3)

Must meet one of dimensional specifications e.g. :• Emotional/behavioral

symptoms sufficiently interfering with recovery

• Moderate risk of dangerous behavior

• Self-destructive behaviors related to intoxication

• Impairment requires 24-hour setting

3C (Dimension 3)

Must meet two of dimensional specifications e.g. :• Disordered living skills• Disordered social

adaptiveness• Disordered self

adaptiveness• Disordered psychological

status

Continued Stay and Discharge Criteria

• Continued Stay– A set of criteria used to review and determine clinical

necessity of a client’s status in a particular LOC and Type of Service.

– Ultimately determines appropriate length of stay until admission criteria are met for another LOC or client is discharged from the continuum.

– Once Continued Stay Criteria is no longer met, individual is referred to the next appropriate level of care.

– Timeframes for continued stay review found on page 10 in PCPC manual.

• Discharge Criteria is only appropriate for Outpatient Treatment, Level 1A.

Placement Process

STEP ONE

ASSESS and apply PCPC admission criteria

PLACE in appropriate LOC/TOS

FORWARD PCPC summary sheet to provider & authorizing agency/payer

STEP TWO

REVIEW progress and apply continued stay criteria


STEP THREE

MAKE REFERRAL to next appropriate LOC/TOS


USE strategies to maintain engagement

STEP FOUR

ASSESS and validate admission PCPC

FORWARD PCPC summary sheet to authorizing agency/payer

STEP FIVE(Outpatient

Only)

DISCHARGE from LOC

CONNECT with recovery support services

FOLLOW-UP

LOUIS

Continued Stay ReviewCase Study


















Low (<5hr/35:1)

Low None Community





(10+ hr./10:1)



Level III



Residential


48h)Residential

(Longer tx)



Special Populations/Considerations• A vital component of the decision-making process in

placement concerns the determination of the need for specialized services.

• Issues which must be considered prior to placement include (but are not limited to):– Medication-Assisted Treatment– Co-Occurring Substance Use and Mental Health Disorders– Women & Women with Children– Criminal Justice– Culture and Ethnicity– Sexual Orientation and Gender Identity– Co-Occurring Substance Use and Gambling Disorder

Special Populations/Considerations

• Medication-Assisted Treatment– MAT is the use of medication, in combination with counseling

and behavioral therapies, to provide an integrated, person-centered approach to the treatment of SUD.

– Ensure coordination of care and medication reconciliation to prevent medical errors and duplication of services.

• Co-Occurring Substance Use and Mental health Disorders– Where possible, treatment should be integrated or coordinated

between SUD and MH providers.– Since each illness affects the course and severity of the other,

both disorders are considered primary.– The Four-Quadrant Model provides a basis for placing

individuals based on their specific needs.

Four-Quadrant Model (Ries, 1993)

More severe SUDLess severe MH

Type: Co-Occurring Capable

More severe SUDMore severe MH

Type: Co-Occurring Integrated

Less severe SUDLess severe MH


Less severe SUDMore severe MH


Lowseverity

High severity

High severity


• Women & Women With Children– Medical, psychiatric, trauma and violence, childcare, and

legal considerations must be understood to assure access and continued treatment.

• Criminal Justice– Since offenders are expected to be abstinent from the use

of substances while incarcerated, the evaluation should examine substance use patterns in the 6 months prior to incarceration for the purpose of assessment.

– Criminality and addiction often coexist, but each can be distinct and function independently of the other.

– Treatment behind the walls followed by a community-based continuum of care leads to the best outcomes.


• Cultural & Ethnic Considerations– The strengths of a culture can be used to reinforce

prevention and treatment programs.– Certain behaviors have different meanings depending on

the cultural context; failure to recognize the appropriate cultural context could result in misinformation or incorrect placement.

• Sexual Orientation– Not all individuals may feel safe revealing their non-

heterosexual identity.– Some individuals, especially those who have experienced

negative consequences related to their sexual orientation, might have better results in a program with targeted services.


• Co-Occurring Substance Use and Gambling Disorder– Assessing for a co-occurring gambling disorder

should be part of the process for every individual.– Because each individual’s case is extremely variable,

treatment needs to be person-centered and highly individualized.

– Where possible, treatment should be integrated or coordinated between SUD and gambling providers.

– Many individuals are in denial of their gambling disorder, instead identifying it as “money problem”.

Special Considerations and Do/Don’t Matrix

• General– Detailed guidelines for how to and how not to

address common placement considerations.– These do’s and don’ts are integrated in each level of

care.

• Examples– Individual Declines Assessed LOC– Role of Funding Availability– Individuals in Controlled Environment– Knowledge of Resources– Co-Occurring SUD and MH Disorder Individuals

TONIA

Admission Case Study


















Low (<5hr/35:1)

Low None Community





(10+ hr./10:1)



Level III



Residential


48h)Residential

(Longer tx)



TONIA

Continued Stay Review Case Study


















Low (<5hr/35:1)

Low None Community





(10+ hr./10:1)



Level III



Residential


48h)Residential

(Longer tx)



PCPC Training Principles

• These principles represent guidelines for the PCPC training, for becoming trained and for having knowledge about the PCPC.

• This document outlines training principles for trainees who will administer the PCPC as well as for those who will not administer the PCPC but wish to understand the instrument.

• These principles ensure PCPC fidelity.

Documents

Pennsylvania Client Placement Criteria, Third Edition PA Department of Drug and Alcohol Programs Rev. 11/15