Understanding patients through Screening, Assessment, and Placement John P Keppler MD Background for using WITS Assessment

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Understanding patients through Screening,
Assessment, and PlacementJohn P Keppler
MDBackground for using WITS Assessment

4/15/00
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What we will look at..

• Treatment process, treatment outcomes
• Approaches to improving treatment
• Using the medical record as a teaching tool for
  the client
• Quality
• Screening assessment placement

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We do pretty well

• But we can do better
• Identification and treatment af coocurring
  disorders - thought disorders, depressive
  disorders, anxiety disorders, ASP!
• Involving the client in treatment Lets talk
  about what that means (including the use of the
  medical record as an active part of treatment,
  meaningful treatment plans, better assessments,
  different interventions)
• Using medications judiciously
• Disease management principles
• A better understanding of transference and
  counter-transference

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Substance Abuse Treatmentis a Stage-Based Process
Outreach Referral
Clinical Assessment
Treatment Delivery
Transitional Care

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Components of Each Stage

• Referral
• Courts, CJ system
• HIV/AIDS, health
• Family, self

• Assessment
• Motivation/readiness
• Problem list/severity
• (assets/liabilities)
• Special needs

• Treatment
• Planning of interventionsTP
• Engagement
• Early recovery
• Monitoring of servicesprogress notes

• Transitional
• Relapse prevention
• Other treatments
• Support networks
• Monitoring (parole)

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Studies of community-based programs indicate
treatment outcomes are related to --

• Treatment readiness problems at Intake
• Treatment engagement participation
• Cognitive/behavioral/social interventions
• Adequate length of engagement

There are finer elements as well.

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Patients with better prognoses

• Lower severity dependence and psych problems at
  admission
• Motivation beyond pre-contemplation stage
• Being employed, having been employed, or those
  that become employed
• Having family and social supports (especially
  kids)
• First involvement with criminal justice

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Better Outcome/Best Practice

• Receiving more counseling sessions during
  treatment directed at what the client and
  therapist agree are problems (implies patient
  feels a part of his treatment) more
  satisfiedbetter outcome
• Identifying concomitant psych or substance
  induced psych problems then
• Receiving proper medications both anti-craving
  and medications for adjunctive pysch disorders
• Voucher-based behavioral reinforcements
• Receiving supplemental social services provided
  for medical, psych, and family problems
• KIDS FAMILY better outcome withoutawful
• EMPLOYMENT!
• NA/CA/AA FOLLOWING treatment

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Better outcome/ Best practice

• 25 of clients admitted leave within four to five
  days
• Early empathic bondingwith the counselor
  wherein the patient feels a part of the process
  and has an understanding of the process
• Identification of client needs/problems and THEN
  making a plan to treat those needs (what was the
  number one Dx in adol admitted last year?)
• Client participation extremely important (in
  understanding problems and formulation of
  treatment plan) satisfactionsatisfactionsatisfacti
  on

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Research

• Look types of service, Intensity of service
• LTR, OPDF, MM, STI DATOS
• But Always recall

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of patients reporting weekly or more frequent
Cocaine
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Decrease in Alcohol
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using heroin
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Change Illegal-Act
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Change Less Than Full Time Work
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Change Suicide Thoughts/Attempts
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Comparison of Year 1 Outcomes by Length of Stay
in LTR
plt.001
of Sample
N342 Simpson, Joe, Brown, 1997, PAB
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Major Topics

• Program Patient Diversity
• Treatment Services
• Changes over time
• Patient access
• Treatment Process Models
• Cocaine Treatment Study
• Cost effectiveness

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Return to Treatment During 1-Year Follow-up
No differences -- by modality, tenure, or PSI
Simpson, Joe, Fletcher, Hubbard, Anglin, 1999
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Patients with Prior Treatment

• Treatment repeaters
• more problems at intake
• need more services
• higher relapse rates
• Outcomes improved by
• longer retention
• more individual sessions

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Longer Length of Stay Improves Outcomes of
Treatment Repeaters
(n317)
(n190)
Using Any Cocaine in Follow-up
N507 Hser, Joshi, Anglin, Fletcher, 1999, AJPH
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Any Drug Use or Trt in Year 1 Follow Up,by
Length of Stay in DATOS
Threshold of minimum stay for effectiveness!
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Weekly Cocaine Use in Year 1 Follow Up,by Length
of Stay in DATOS
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Types of Problems at Admission
With Problems in Year Before Admission

Simpson, Joe, Fletcher, Hubbard, Anglin, 1999
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Weekly Cocaine Use After Treatment, by Problem
Severity
Problem Severity in Each Treatment Modality
(plt.001)
Simpson, Joe, Fletcher, Hubbard, Anglin, 1999
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Weekly Cocaine Use
Cocaine Treatment Outcomes (in Year After
Discharge in DATOS) Tamara this is the slide!
Problem Severity at Intake (plt.001)
Length of Treatment (plt.001)
Simpson, Joe, Fletcher, Hubbard, Anglin, 1999,
Arch Gen Psy
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Sequence of Recovery Stages ??
Program Participation
Behavioral Change
Sufficient Retention
Drug Use
Crime
Therapeutic Relationship
Psycho-Social Change
Social Relations
Posttreatment
How can interventions impact this process ?
Simpson Joe, 1993 (Pt) Joe, Simpson,
Dansereau, Rowan-Szal (2001, PS)
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Motivation Retention in LTR
Patient Predictors
Stages
Problem Recognition
Motivation
Desire for Help
Older
Treatment Readiness
Never married
90 Days
Alcohol problem
Employed
Legally involved
Fewer arrests
Treatment Engagement ?
Intake
N2,265 Simpson, Joe, Broome, 1998, Addiction
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Motivation Engagement in LTR
Each based on 5-item composites
Treatment Readiness
Commitment
Confidence
Similar in ODF OMT
Rapport
Therapeutic Involvement in Months 13
Integrative modeling of process components?
N2,265 Simpson, Joe, Broome, 1998, Addiction
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TCU Motivation ScalesStages of Treatment
Readiness
r .43 (b .05)
Problem Recognition
Treatment Readiness
r .69 (b .58)
r .74 (b .53)
Desire For Help
Drug use is ... - more trouble than worth -
causing trouble with . law, work, health .
family friends alpha for PR .88
- need help - tired of problems - life out of
control - will give up friends alpha for DH
.77
- want treatment - trt can really help - trt may
be last chance - plan to stay awhile alpha for
TR .72
Simpson Joe, 1993 (Psychotherapy)
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TCU Treatment Process Model
Most experienced staff
Early Engagement
Early Recovery
Therapeutic Relationship
Behavioral Compliance
Sufficient Retention
Screening and Assessment Process
and Instruments!
Program Participation
Psychological Improvement
Months 1-3
Posttreatment
How can interventions impact this process ?

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Predictors of Year 1 Outcomes(Odds Ratios from
Logistic Regressions)
2.1
Career Stage (Over 35)
Favorable Follow-up Outcomes
1.8
Resources/Drugs (White)
2.2
Severity of Use (Lower IDU)
1.8
5.1
Higher Motivation (Patient Rating)
Longer Tenure (1 Yr. or More)
Factors related to retention??
Simpson, Joe, Rowan-Szal, 1997 (DAD)
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Predictors of Longer Tenure
Opioid Use
Career
Favorable Follow-up Outcomes
Cocaine Use
Resources
Inject Freq
Severity
Alcohol Use
Criminality
Higher Motivation (Patient Rating)
Odds Ratios
1.7
Longer Tenure (1 Yr. or More)
2.3
High Attendance (Sessions in Mo 1-3)
2.1
High Engagement (Counselor Rating)
Simpson, Joe, Rowan-Szal, 1997 (DAD)
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Process Model for Time in OMT Treatment
(Structural equation modeling)
Motivation for Treatment
Low Drug Use
Session Attendance
Therapeutic Relationship
Ratings from Counselors
Time in Treatment
Pretreatment
Month 3
Months 1-2
Simpson, Joe, Rowan-Szal, Greener, 1997 (J SAT)
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Correlates of Therapeutic Rapport
Low Drug Use
Session Attendance
Session Attendance
Low Drug Use
Low Crime
Low Peer Crime

Rapport
Therapeutic Relationship

Ratings from Counselors
5 Items ? .80
Replicated withindependentOMT samples

Ratings from Patients
Counselor Skills
Treatment Satisfaction
Social Relationships
Joe, Simpson, Dansereau, Rowan-Szal, 2001
(Psych Services)
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Process Model for Time in LTR Treatment
(Structural equation modeling)
Session Attributes
Previous Trt
Depression
Retention (90 days)
Cocaine Prob
-
Therapeutic Involvement
Motivation (Trt Readiness)
-
Hostility
Ratings from Patients
Pretreatment
Months 1-2
Joe, Simpson, Broome, 1999 (DAD)
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Conclusions

• Long-term outcome studies --
• Indicate that treatment is effective
• Lead to questions about HOW
• The program and therapists role --
• Identify important therapeutic dynamics
• Define interim performance measures
• Clarify the role of interventions
• Lead to management strategies

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Recommended References

1. Bartholomew, N. G., Hiller, M. L., Knight, K.,
   Nucatola, D. C., Simpson, D. D. (2000).
   Effectiveness of communication and relationship
   skills training for men in substance abuse
   treatment. Journal of Substance Abuse Treatment,
   18, 217-225.
2. Bartholomew, N., Rowan-Szal, G. A., Chatham, L.
   R., Simpson, D. D. (1994). Effectiveness of a
   specialized intervention for women in a methadone
   program. Journal of Psychoactive Drugs, 26(3),
   249-255.
3. Blankenship, J., Dansereau, D. F., Simpson, D.
   D. (1999). Cognitive enhancements for treatment
   readiness in probationers with limited education.
   Prison Journal, 79 (4), 431-445.
4. Dansereau, D. F., Dees, S. M., Greener, J.,
   Simpson, D. D. (1995). Node-link mapping and
   the evaluation of drug abuse counseling sessions.
   Psychology of Addictive Behaviors, 9(3),
   195-203.
5. Dansereau, D. F., Joe, G. W., Simpson, D. D.
   (1993). Node-link mapping A visual
   representation strategy for enhancing drug abuse
   counseling. Journal of Counseling Psychology,
   40(4), 385-395.
6. Dees, S. M., Dansereau, D. F., Simpson, D. D.
   (in review). Implementing a readiness program
   for mandated substance abuse treatment. (IBR
   manuscript).
7. Hiller, M. L., Rowan-Szal, G. A., Bartholomew, N.
   G., Simpson, D. D. (1996). Effectiveness of a
   specialized womens intervention in a residential
   treatment program. Substance Use and Misuse,
   31(6), 771-783.
8. Joe, G. W., Dansereau, D. F., Pitre, U.,
   Simpson, D. D. (1997). Effectiveness of
   node-link mapping enhanced counseling for opiate
   addicts A 12-month posttreatment follow-up.
   Journal of Nervous and Mental Disease, 183(5),
   306-313.
9. Lehman, W. E. K., Dansereau, D. F., Chatham, L.
   R., Simpson, D. D. (in review). Structured
   treatment induction for methadone maintenance
   outpatients Initial development and assessment.
   (IBR manuscript).

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Recommended References

1. Pitre, U., Dansereau, D. F., Newbern, D.,
   Simpson, D. D. (1998). Residential drug-abuse
   treatment for probationers Use of node-link
   mapping to enhance participation and progress.
   Journal of Substance Abuse Treatment, 15(6),
   535-543.
2. Rowan-Szal, G. A., Joe, G. W., Chatham, L. R.,
   Simpson, D. D. (1994). A simple reinforcement
   system for methadone clients in a community-based
   treatment program. Journal of Substance Abuse
   Treatment, 11(3), 217-222.
3. Rowan-Szal, G. A., Joe, G. W., Hiller, M. L.,
   Simpson, D. D. (1997). Increasing early
   engagement in methadone treatment. Journal of
   Maintenance in the Addictions, 1(1), 49-61.
4. Simpson, D. D. (1997). Effectiveness of
   drug-abuse treatment A review of research from
   field settings. In J. A. Egertson, D. M. Fox,
   A. I. Leshner (Eds.), Treating drug abusers
   effectively (pp. 41-73). Cambridge, MA
   Blackwell Publishers of North America.
5. Simpson, D. D., Joe, G. W. (1993). Motivation
   as a predictor of early dropout from drug abuse
   treatment. Psychotherapy, 30(2), 357-368.
6. Simpson, D. D., Joe, G. W., Dansereau, D. F.,
   Chatham, L. R. (1997). Strategies for improving
   methadone treatment process and outcomes.
   Journal of Drug Issues, 27(2), 239-260.
7. Simpson, D. D., Joe, G. W., Greener, J. W.,
   Rowan-Szal, G. A. (in press). Modeling year 1
   outcomes with treatment process and posttreatment
   social influences. Substance Use and Misuse.
8. Simpson, D. D., Joe, G. W., Rowan-Szal, G. A.,
   Greener, J. (1995). Client engagement and
   change during drug abuse treatment. Journal of
   Substance Abuse, 7(1), 117-134.
9. Simpson, D. D., Joe, G. W., Rowan-Szal, G. A.,
   Greener, J. M. (1997). Drug abuse treatment
   process components that improve retention.
   Journal of Substance Abuse Treatment, 14(6),
   565-572.

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Evaluation The Screening Process

• The process through which a trained individual or
  counselor, a client or participant and available
  significant others determine the most appropriate
  course of action given the individuals needs ,
  problems, and characteristics AND the available
  resources within the community

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The Screening Process

• Establish rapport
• Gather Data from the individual and others that
  may include the administration of screening
  instruments and assessment instruments
• Should include presenting problem, current and
  historic substance use, health,mental health,
  substance and psych related Tx history, mental
  status, and social environmental, and/or economic
  constraints

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The Screening Process

• Screen for psychoactive substance
  toxicity/intoxication/withdrawal, danger to self
  or others current and history of
• This begins the best practice of developing
  rapport with the individual, helping she/he
  become aware of problems, and having the
  individual participate in the process examples
  of having patient sit by nursing station as other
  folks stroll on by

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Evaluation the Assessment process

• An ongoing process through which the counselor
  collaborates with the client and others to gather
  and interpret information necessary for planning
  treatment and evaluating an individuals progress
• May also employ various screening and assessment
  instruments (SA/MH/Phys)
• The process should be sensitive to age, gender,
  racial/ethnic cultural issues and disabilities
  (physical and mental)

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Placement

• Just cause you got a hammer doesnt mean
  everythings a nail
• John Keppler MD

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Placement

• In the public sector waiting list atmosphere
  these can be difficult questions to address
• Originally designed for private sector
• However, they remain a reasonable and helpful
  set of guidelines

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The beginnings

• Cleveland criteria
• Minnesota folks (Hazelden) response to managed
  care
• ASAM growth and influence
• Texas department of insurance criteria
• National Association of Treatment Providers
  NAATAP
• Effect on managed care debatable but as a set of
  empirically based guidelines they can asist
  systems that have waiting lists and help ensure
  quality client care

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What are Placement Criteria

• After comprehensive screening and assessment the
  patient is sent to intervention or treatment
  based upon the the severity of the clients needs
  according an agreed upon set of guidelines - the
  Placement Criteria

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Principles

• Objectivity based on Assessment
• Least restrictive choice of level of care
• Provider (system) responsibility to make
  arrangements for care the client needs if they do
  not provide it i.e. refer the client to another
  provider who does have the care necessary within
  the continuum
• Self Help, i.e. AA/NA/CA/EA/OA/SA, though
  their principles often integrated into program
  are not treatment.

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Levels of care

• Early intervention (0.5)
• Outpatient services (I)
• Intensive outpatient or partial Ihospitalization
  (II)
• Residential or Inpatient services (III)
• Medically-managed intensive Inpatient services
  (IV)

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Dimensions of assessment

• Acute intoxication and/or withdrawal potential
• Biomedical conditions and complications
• Emotional/behavioral conditions and complications
  (psych stuff)
• Treatment acceptance or resistance
• Relapse/continued use potential
• Recovery/living environment

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Therefore..

• Clinician knowledge of each of these problems,
  severity of them and ease of their resolution
  form the basis for the treatment recommendation
• So in a perfect world intensity and duration of
  treatment is recommended based on the severity of
  the clients illness

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Domains of the Assessment for placement purposes

• Acute intoxication and withdrawal potential
• Biomedical conditions and complications
• Emotional/behavioral conditions and complications
• Treatment acceptance/resistance (stage of Tx,
  patient preference)
• Relapse continued use potential
• Recovery living environment

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Withdrawal potential

• What risks are associated with the patients
  level of intox., Id there significant risk of
  severe withdrawal Sxs or siezures, Are bthere
  current signs of withdrawal, Does patient have
  supports to participate in OP detox.
• Qualitative and quantitative blood and urine
  screening for drugs of abuse and laboratory tests
  for abnormalities that may accompany acute or
  chronic substance use. These tests may also be
  used during treatment to monitor for potential
  relapse.

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BIOMEDICAL -current and past med conditions,
current meds, impact of physical illness on
ability to participate (needs care while in Tx?)
Liver Dz, Hep Screening for infectious and other
diseases often found in substance-dependent
persons (e.g., HIV, tuberculosis, hepatitis
B,C,et al.). Such individuals, particularly those
with evidence of compromised immune function, are
felt to be at high risk for these disorders. For
example, patients exposed to social or
environmental conditions conducive to the spread
of tuberculosis should be routinely screened for
this disorder. I.E. STDs must be asked
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Emotional/Behavioral conditions

• Assess the status past hx/meds/screening tools
  etc The Big 3
• Take a careful hx med induced psych/self
  medication/two independent disorders
• Kids are not little adults!! Very, very high MH
• peeing on a burning cat,
• Mental status Mental Status Mental Status!!!
• DDx a real issue that accounts for a lot of
  relapse

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• The high prevalence of co morbid psychiatric
  disorders in substance-dependent patients implies
  that many such patients will require specific
  pharmacotherapy directed at their co morbid
  disorders.

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Tx Acceptance and Resistance

•    Prior efforts to control or stop substance use
  outside of a formal treatment setting should be
  discussed, as well as the patient's attitudes
  toward his or her previous treatment and current
  beliefs/attitudes about treatment.
• Prochaska and DiClemente
• A history of any prior treatment for substance
  use disorders, including the following
  characteristics setting, context and duration,
  can you or patient identify what lead to relapse

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Relapse/continued use

• Is the client in immediate danger of using ?
• Evaluate if the client has any awareness of
  relapse triggers
• What are the levels of the clients cravings?
• Previous completed Txs and reuse think craving!
  Unaware of triggers!
• What are the consequences of the client using at
  this time?

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Prochaska and DiClementesStage of Change

• Precontemplation
• (No intention or plans to change)
• Contemplation
• (Start to consider change, but no commitment to
  do so)
• Preparation (Make a commitment to change)
• Action (Make behavior changes)
• Maintenance
• (Work to preserve gains made in action phase)

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Recovery/Living Environment

• Assess those elements that may threaten
  engagement and recovery
• Consider influence of family and friends and
  working situation
• Assess positive factors as well
• A good time toask if the family will participate
• Recall..with adolescents your likelihood of
  success without family participation is low

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• Successful treatment of substance use disorders
  may involve the use of multiple specific
  treatments, which may vary for any one
  individual, may change over time, and may involve
  more than single,similar approaches. It is
  crucial if screening or the history indicates
  psych impairment or multiple relapses

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Treatmentshould result in

• Not simply stabilizing the clients condition,
• But altering the course of the illness
• The primary goal of addiction treatment is to
  meet the treatment needs of the client
• These needs are biological, psychological, and
  social
• Modalities employed should include those elements
  the counselor and client decide should be worked
  upon and this should be reflected in the
  treatment plan
• To see if it works we measure things

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Effectiveness can be measured in terms of

• Decreased substance use
• Improvements in medical and physical health
• Improvements in psychosocial/family functioning
• Greater employment stability or independence
• Better success in school
• Decreases in criminal justice involvement
• Relapse prevention preparedness
• Retention. OR we can measure quality..

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Quality, quality, what for art thou?
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Components of Quality

• Community-standard care (average)
• Optimal care (superior to average)
• Efficacious care (using practices known to get
  patients better)
• Patient or family satisfaction
• Avoidance of adverse outcomes
• Attainment of positive outcomes

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Dimensions of Quality

• Structure
• components or organization of care
• resources and capacity
• Process
• ways in which care is delivered
• Outcomes
• results or effects of clinical care

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Structure

• qualified staff
• licensure and accreditation status
• number/location of clinics (geo. access)
• provider network
• contracted service types
• MIS/computer capacity

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Process

• availability of services, based on urgency of
  need
• appropriateness of care, based on need
• types and quantity of services provided
• consumer involvement in care
• continuity of care

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Quality

• It is clear that each program should have a
  process wherein a cross sectional group
  (vertically configured) reviews client
  satisfaction/complaints/errors/relapse/AMA/med
  errors/incident reports etc etc
• Quality also demands that we approach the patient
  a bit differently than traditionally done in the
  past and we discriminate between types of
  patients in order to understand specifically how
  the illness has affected the patient

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General Outcome Domains (?look familiar?)

• AOD use
• Employment/vocational functioning
• Medical status/health
• Family/social functioning
• Legal problems
• Psychological status/health