California’s Efforts to Develop Treatment Standards dave neilsen, msw and Donna Lagarias, PhD Program Services Division, Treatment CA Dept of Alcohol and Drug Programs September 2009

To reshape and reposition ADP’s operations for a comprehensive and integrated continuum of services, based on a chronic care model, ensuring system accountability, efficiency, and effectiveness To reshape and reposition ADP’s operations for a comprehensive and integrated continuum of services, based on a chronic care model, ensuring system accountability, efficiency, and effectiveness. Continuum of Services System Re-Engineering (COSSR)

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

Why Standards Now? To describe quality treatment in a chronic care model To support performance measurement and quality improvement efforts by programs and counties

Treatment Standards Criteria Continuum of care that includes many 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 Standards Incorporate our current understanding of: Substance use conditions, problems, and dependency (physiology and behavior) Barriers to engagement Best business practices

Treatment 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 Life Are clients adequately prepared with the skills and social supports to sustain a prolonged recovery outside the boundaries of the program?

Key Resources That Informed the First Drafts Primary literature, reviews and policy papers in the field of substance 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 Process First 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 Practices adapted from NQF Standards Screening and Brief Intervention for Substance Use Conditions Screening Brief Intervention Initiation and Engagement in Treatment Assessment Engagement in Treatment Withdrawal Management

Best System Practices adapted from NQF Standards Initiation and Engagement in Treatment Services and Supports Planning Care Management / Services Coordination Therapeutic Interventions Psychosocial Interventions Adjunct Pharmacotherapy for Opioid Dep. Adjunct Pharmacotherapy for Alcohol Dep.

Best System Practices Supplemental Sections under construction: In Support of Recovery Business Practices for Improved Services Considerations for Individualized Care

Best System Practices Supplemental In Support of Recovery Family Strengthening Transitional and Supportive Living Crisis Intervention Literacy, Education and Work-related Supports

Best System Practices Supplemental Business Practices for Improved Services Clinical Supervision Quality Improvement Staff Development Child Care Tele-Health

Best System Practices Supplemental Considerations for Individualized Care Youth Perinatal Gender Trauma Criminal Justice Involvements

Practice 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 Interventions Motivational Enhancement Therapy (MET) Cognitive Behavioral Therapy (CBT) Community Reinforcement Approach (CRA) Structured family and relationship therapies 12-Step Facilitation Therapy Contingency Management

Core Treatment Standards, v1 A first attempt to describe discrete components of quality treatment for substance use disorders

Core Treatment Standards Aims Inform the public Set expectations for quality programs Provide the basis for performance measurement and continuous quality improvement

Core Treatment Standards Content 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?

5100Alcohol 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.

5400Referral 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.

5500Services 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: an integrated package of supports Best System Practices Core Treatment Standards for Programs Certification Standards for Counselors System-wide training NIATx and more User-friendly data system for: Performance measurement Continuous quality improvement

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 Data Continuous Quality Improvement Efforts

CALIFORNIA’s Continuous Quality Improvement Efforts Discharge Query: Use in Past 30 Days 1 Any alcohol consumption in the past 30 days, CalOMS data 2 Increase / no change in drug use compared to admission, CalOMS data

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