Summary of Information on 6 Areas of Detoxification Planning by DASA Providers and Other Stake Holders Work Committee
Information from DASA Providers and Other Stakeholders Work Committee On 4 Topical Areas of Detoxification Services
Section I: Quality Standards for Services Delivery
Section II: Admission Criteria for Detoxification Services
Section III: Diversion to Alternative Service Settings
Section IV: Recovery Support Services
Section – I
Quality Standards for Services Delivery
Work Committee Participants:
Joe Lokaitis, DASA; and Jacome Marco, Healthcare Alternative Systems, Inc.
DHS/DASA Detoxification Quality Standards (Licensure Requirements)
- The staffing pattern for any patient receiving ambulatory (ASAM Levels I-D and II-D) or clinically managed residential detoxification (ASAM Level III.2D) is authorized by organization's Medical Director. Medically monitored detoxification (ASAM Level III.7-D) must have at least two staff persons provide 24 hour observation, monitoring and treatment, one of whom must be a either a registered nurse, a licensed practical nurse, or an emergency medical technician.
- A registered nurse shall plan, assign, supervise and evaluate all nursing care.
- Any patient admitted to a DHS/DASA licensed detoxification services must be medically screened prior to admission. At a minimum, the screening shall assess acute intoxication and/or withdrawal potential, biomedical conditions or complications, and emotional/behavioral conditions and complications. The medical screening shall include, but not be limited to, inquiry in the following areas: A) Primary complaint per patient; B) Date of last physical exam and the name of the patient's primary care physician; C) History of substance use; D) History of past withdrawal symptoms; E) History of concurrent medical symptoms, complications or conditions, including sexual activity and risk for pregnancy; F) History of concurrent psychiatric symptoms, complications or conditions, including suicide/homicide potential; G) History of recent trauma (including physical/sexual abuse); H) Hospitalizations; I) Medications currently prescribed and any allergies to medications; and J) Infectious or communicable diseases.
- The Medical Director shall designate the factors in a medical screening, including a determination of the patient's risk for HIV and tuberculosis infection, and the specific medications prescribed or used by a patient that would require physician review if such medical screening is not conducted by a physician.
- Pregnant women admitted for any type of detoxification shall be subject to physician review no later than 48 hours after admission.
- Any patient admitted to a DHS/DASA licensed detoxification services must be diagnosed either substance abuse or substance dependence and meet the ASAM admission criteria for the specific level of care. This diagnosis and placement must be confirmed by the organization's physician within 72 hour of admission.
- Any patient admitted to clinically managed residential detoxification (ASAM Level III.2D) or medically monitored detoxification (ASAM Level III.7-D) shall undergo a physical examination within 72 hours after admission if on prescription medication or pregnant. All other patients in such care shall undergo a physical examination within 7 days after admission.
- Detoxification patients shall be referred for medical, surgical, obstetric, prenatal or psychiatric treatment or laboratory services when determined necessary by organization's physician.
Along with licensure standards, organizations who provide detoxification services should also maintain excellence in the following clinical practices:
- Engaging patients in the treatment process to maximize continued service participation upon discharge. This would include evidence base practices such as motivational interviewing, stages of change, and the use of culturally appropriate and trauma informed services.
- Patient education regarding the risks associated with substance abuse.
- The development and effective use of a community referral network upon discharge.
Section – II
Admission Criteria for Detoxification Services
Work Committee Participants:
Jayne Antonacci, DASA; Seth Eisenberg, Medical Director, DASA; Marco Jacome, Healthcare Alternative Systems, Inc.; David Johnson, Cornell/Abraxas; Kathie Kane-Willis, Roosevelt University; Dan Lustig, The McDermott Center; Brian Shaw, Macon County; Timothy Sheehan, Lutheran Social Services; Bruce Suardini, Prairie Center; and Ronald Vlasaty Jr., Family Guidance Centers
Admission Criteria for Detoxification
(Notes from Work Committee Meeting on 10/30/12)
- Suggested Changes to Illinois Medical Assistance Program Detoxification Criteria Guidelines
- Ensure that all individuals who are presenting for detoxification in hospitals are assessed by DASA providers and/or individuals knowledgeable about substance use disorders.
- Those patients who are appropriate for DASA detoxification services per the American Society of Addiction Medicine (ASAM) admission criteria should be referred to a DASA provider of Level III.7 services.
- Determination of other acute medical or psychiatric conditions should be determined by medical staff at the hospital. Individuals who are experiencing chronic medical conditions must be stabilized. Individuals who are experiencing serious health or psychiatric conditions should be treated in the hospital, as DASA funded providers are not equipped to treat certain medical conditions (e.g., "active gastrointestinal bleeding" or "ventilator dependent").
- Those patients presenting at hospitals or referred from DASA providers who do not meet criteria for ASAM Level III.7 and need more medical care will need to be treated in a hospital. Some individuals (e.g., late stage alcoholics or benzodiazepine users) may require medication assistance. Individuals who require these medications should not be placed in DASA Level III.7 detoxification services.
- Patients who present in hospitals with benzodiazepine use or late stage alcoholism should be carefully assessed and monitored for extended, life threatening withdrawal symptoms. Utilization management of these cases should allow for the possibility of lengthier hospitalizations to monitor for these withdrawal symptoms, especially where medications are necessary to help with withdrawal.
- Ensure that patients are stabilized before releasing them (e.g., ensure that no medication for detoxification had been given for 24 hours) and assess their condition before releasing them. They must have a period of no medication in order to be properly assessed as stabilized.
- Consider linkages for Opioid dependent individuals to detoxification services in the community or Methadone maintenance programs, if the person has no other medical problems.
- All hospitals should be required to provide linkages to community based treatment to stop patients from revolving through the system.
- Real time access to treatment slots need to be made available and detoxification services followed by treatment and aftercare. This infrastructure needs to be developed.
- Monies and workforce should be set aside to help build this capacity.
- Technology grants or other infrastructure grants might be used to fund this capacity building under Medicaid.
- Assessment of need for substance use disorders should be completed by a DASA provider and/or someone with a high knowledge of substance use disorders.
- Evaluation of the continuum of care must be maintained in order that the hospital remains Medicaid eligible.
Section – III
Diversion to Alternative Service Settings
Work Committee Participants:
Margaret Egan, Office of Cook County Sheriff (Tom Dart); Marco Jacome, Healthcare Alternative Systems, Inc.; Kathleen Kane-Willis, Roosevelt University; Marvin Lindsey, Community Behavioral Healthcare Association of Illinois (CBHA); Maureen, McDonnell, TASC; Rick Nance, DASA; Arun Pinto, Human Service Center and White Oaks; Allen Sandusky, South Suburban Council On Alcoholism & Substance Abuse; and Timothy Sheehan, Lutheran Social Services of Illinois
From Detox Cycling to Community Stabilization & Recovery
Recommendations from the Diversion to Alternative Services Group Presented to HFS & DHS/DASA on November 9, 2012
- Inform understanding of the dynamics among frequent users of hospital detox
- Recommend strategies, especially regarding necessary community services and linkage strategies
- Challenge: Time line
- Gathering more data and evidence base analysis of the clinical presentation and service needs of the highest-cost frequent users.
Building Systems Solutions
Goals for Patients
- Less inpatient detoxification, unless medically necessary
- More connection to the community treatment and recovery support system
- Exit chronic crisis & begin to build durable recovery
Goals for Systems
- Improve outcomes, reduce expenditures
- Use the right service at the right time
Understanding the Population
What we see:
- Chronic chemical dependency
- Likely a mix of drugs and alcohol, not opiates alone
- Extreme poverty
- Continual crisis
- Likely includes time in jail as well
- They will build capacity as they exit crisis, but initially their capacity may be limited
- Mental health issues are part of the picture, even if not the overt reason for SSI/SSDI disability
- Must partner with patients to develop readiness for change
- Providing new options (housing, services) and care coordination are key
- It is also enacted in the style of clinical work
Questions to Clarify Patient Needs
- Degree of medical complexity present when admitted
- Could these patients be handled in a community detox setting? A free-standing medical detox?
- Both are less expensive
- Range, severity and duration of medical and mental health problems and basic needs
Note: The amount of each service needed will depend on greater data/clinical information
What is needed?
- Systems to link crisis behavioral health patients from hospitals to community services
- Especially in high-volume communities like Chicago
- Crisis services, then services that help change behavior
- Integrated care addressing medical, substance abuse, mental health, trauma, homelessness
- Full spectrum of community substance abuse interventions
- High level of engagement, especially in the first weeks of care
- Frequent contact – daily in some cases
- Services targeted to stages of change
- ACT-like services at the beginning for the most disabled patients
Spectrum of Care for Community Stabilization & Recovery
- Crisis Stabilization
- Medical detox for those requiring medical stabilization
- Less expensive alternatives for non-medical detox:
- Ambulatory detox & social setting detox
- Medical clearance is required
- Medication to control cravings
- Care coordination to engage people in services
Addressing Behavior Change through Community Substance Abuse Services
- Need linkage to community services:
- Residential treatment
- Limitations in current State Medicaid certification and reimbursement
- Intensive outpatient
- Recovery homes & halfway houses
- Specialized, intensive services are needed for this population
- Independent care coordination that bridges levels of care and settings to keep people engaged in early recovery
Medication-Assisted Treatment (MAT)
- Expansion greatly needed
- 3-4 month wait to enter methadone treatment
- Bridge methadone is the minimum intervention
- Challenges in the current state Medicaid plan on reimbursement and prior authorization for MAT
- Should include all medications that reduce cravings and stabilize patients
- Including methadone, buprenorphine, naltrexone, campral, and antabuse
- Continuity of MAT care during jail stay is needed
- Some can be provided by newly funded CCEs
- Capacity may be limited during the first implementation year and limited by target populations of funded CCEs
- Some may be provided by Medicaid MCOs
- More likely to be office-based rather than intensive, outreach-oriented, community based care coordination
- More/more intensive care coordination will be needed
- Illinois Medicaid Plan for Substance Abuse does not reimburse for independent case management
- This service is in the state Medicaid Mental Health Plan & Targeted Case Management in the Medical Plan
- This gap also presents problems for compliance with the Illinois Parity law and the parity requirements of the ACA
Community Recovery Supports
- Supportive housing
- Transitional and permanent
- Targeted vocational support to build capacity for self-reliance
- Extensive recovery supports
Effective Hospital Linkage Approaches
- Hospitals state that it is difficult to connect with the community substance abuse treatment system
- Effective models:
- Emergency Department Diversion: EDAs + crisis beds (as was done by DHS in the Tinley Park project)
- SAAS for mental health admissions
- SBIRT (as was done at Stroger Hospital 2004-2008)
- Hospitals should be required to have ongoing linkage agreements with community substance abuse treatment agencies in their communities
Tinley Park EDA - Early Results
- 25-30 crisis clients intercepted at South Suburban hospitals each month
- 80% have co-occurring substance use disorders and psychiatric disorders
- Major depression is the most common
- 70-75% are engaged in services within 14 days and are still engaged after 30 days
- Avoid continued cost shifting
- Accurate assessment of clinical needs
- Targeting services to address these needs
- Tracking patient participation in related systems (criminal justice, homeless, emergency room) to evaluate any cost shifting
- Build a Bridge to the 2014 Medicaid Expansion
- Need to address limitations in current state plan
- MAT, care coordination, residential treatment
- Need to expand community infrastructure
- Additional provider certifications may be needed
- Prior authorization and continued stay review processes need to be adjusted
- How does this new system become institutionalized in the implementation of Medicaid managed care?
- Identify the resources that can be brought to bear to create a cross-systems solution
- Clarify data questions
- Develop services model
- Do we need to create capacity vs. use existing capacity ongoing?
- Develop service protocol to address frequent users
- Develop cost analysis/fiscal impact statement
- Interview initial patients to develop a broader picture of their complex challenges and needs
- Analyze potential links to other crisis systems e.g., police, jails
Section – IV
Recovery Support Services
Work Committee Participants: Maria Bruni, DASA;Jeffrey Collard, Haymarket Center (McDermott Center); Marvin Lindsey, Community Behavioral Healthcare Association of Illinois (CBHA); and Peter McLenighan, Stepping Stones, Inc.
Information on Recovery Support Services
(HFS/DASA Recovery Support Work Committee)
- Supportive Housing for Individuals with Substance Use Disorders
In May, 2009, the Journal of the American Medical Association (JAMA) published research findings confirming that the costs of providing housing and case management to chronically medically ill homeless individuals are more than offset by the reduced costs of emergency department services, inpatient hospital services, nursing home services, and other social services (Sadowski, et al., 2009). Called the Chicago Housing for Health Partnership (CHHP), the program formed in 2003 to scientifically test the efficacy of a "housing first" treatment model to improve the health of chronically ill homeless individuals. Participants who were provided housing with case management used one-third fewer inpatient hospital stays and one-quarter fewer emergency room visits than their peers who relied on the usual care system.
Research conducted by the Technical Assistance Collaborative found that in Illinois SSI monthly stipends are approximately $650, yet a typical one-bedroom apartment in the Chicago metro area rents for nearly $900 per month. If persons in permanent supported housing pay 30% of their monthly income on rent, the typical SSI recipient would pay $200 per month. Rent subsidies are not only needed, but cost effective, in reducing spending on publicly-funded health and social services.
Cost: Costs for supported housing coupled with other supportive services including case management vary depending upon the housing setting, which may include:
- Apartment of single-room occupancy (SRO) buildings, townhomes or single family homes that exclusively house formerly homeless individuals;
- Apartment or SRO buildings or townhouses that mix special-needs housing with general affordable housing;
- Rent-subsidized apartments leased in the open market;
- Long-term set-asides of units within privately owned buildings.
Cost estimate: Supportive housing subsidies for 100 persons @ $600 per month for 12 months = $720,000.
- The Recovery Coaching Model
The recovery coaching model is an evidence-based, manual-driven, community-based recovery management program for people who have entered substance abuse treatment. The program uses recovery coaches to help people in addiction treatment acquire the resources and skills they need to sustain recovery over time.
The Manual for Recovery Coaching and Personal Recovery Plan Development (Loveland and Boyle, 2005)--developed in Illinois through funding from the Illinois Division of Alcoholism and Substance Abuse (DASA)—incorporates the evidenced-based practices motivational interviewing, contingency management and strengths based case management which are included in the U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration National Registry of Evidence Based Programs and Practices.
Following the Manual, a recovery coach meets with clients individually at least once a week for six months, which will bridge their transition from treatment into the community, and then at least once a month for an additional six months.
The recovery coach works individually with clients to develop a written recovery plan that outlines strategies for building recovery capital. The plan contains specific action steps to achieve goals under each domain. For example, in the area of employment and education, the client may state: "I would like a job." The client and Recovery Coach will then develop an action plan with discrete steps necessary to get a job. For each of these steps, the client and Recovery Coach will develop weekly contingency management plans to ensure that each step in the action plan are completed.
An independent evaluation of a three-year, federally-funded, Recovery Oriented System of Care project conducted at Haymarket Center showed significantly positive outcomes. The project was implemented with 480 adult men who had already relapsed within one year of completing residential substance abuse treatment prior to enrollment in the project. The outcomes included significant decreases in substance use and mental health symptoms, high-risk behaviors for HIV, and crime; and significant increases in recovery supports and overall health. It is recommended that Medicaid reimburse programs for recovery coaching as well as case management services provided to support individuals' long-term recovery.
Cost: The project as implemented at Haymarket Center cost $2,000 per client for the full year of recovery support. This is slightly more than half of the cost of a typical 28-day residential treatment stay at Haymarket. Estimate: Recovery Coaching for 200 individuals for 12 months ($2,000 x 200) = $400,000.
- Medication Assisted Treatment
There is a well-founded science-base for understanding alcohol and other drug dependence as a chronic, recurring brain disease (NIDA, 2010). An abundance of research has consistently shown that chronic drug use affects the brain in fundamental ways often remaining long after the drug using behavior has stopped. Using brain-imaging technologies, research demonstrates the biological basis for addiction and has provided the basis for a biopsychosocial perspective of chemical dependency. From this knowledge, it is now widely understood that for some addicted persons, medications are critical to treat drug-induced brain deficits in order to help sustain a symptom-free lifestyle and long-term recovery. In much the same way that research provided for medications development used for other chronic diseases such as hypertension, diabetes and asthma, addiction medicine is following the same course. Methadone, Buprenorphine (Suboxone), and Vivitrol are all effective medications found to be instrumental to initiating and sustaining the recovery process among individuals with histories of alcohol and other drug dependence. In terms of the length of time that patients should remain on these medications, the guidance from field of addiction medicine is for physicians to use the same considerations that would be applied to the care of patients with any other chronic disease treated with any other therapeutic regimen. That is, as with all other medications, medications used to treat addiction should be continued as long as they are effective and do not cause side effects, and as long as there is reason to believe that termination would be associated with risks to the patient.
Cost: The cost of supporting 100 patients on Methadone for 12 months = $443,820; the cost of supporting 100 patients on Suboxone for 12 months = $600,000.
Loveland, D., & Boyle, M. (2005, July 25). Manual for recovery coaching and personal recovery plan development. Retrieved on March 18, 2010, from http://www.bhrm.org/guidelines/RC%20Manual%20DASA%20edition%207-22-05.doc
- National Institute on Drug Abuse. (2010). Drugs, brains and behavior: The science of addiction. NIH Publication No. 10-5605. Bethesda, MD: National Institute on Drug Abuse.
- Sadowski, L., Kee, R., VanderWeele, T., & Buchanan, D. (2009). Effect of a housing and case management program on emergency department visits and hospitalizations among chronically ill homeless adults: A randomized trial. Journal of the American Medical Association, 301: 17, 1771-1779.