1. The Service Authorization Justification Request Form (The SARJ) Community Access to Recovery Services Milwaukee County Behavioral Health Division

2. But First, A Word About the Revised ASAM  Existing Dimensions 1-6  Dimension 1 – Acute Intoxication/Withdrawal Potential  Dimension 2 – Biomedical Complications & Conditions  Dimension 3 – Emotional/Behavioral/Cognitive Conditions and Complications  Dimension 4 – Readiness to Change  Dimension 5 – Relapse/Continued Use/Continued Problem Potential  Dimension 6 – Recovery Environment  New Dimensions 7-8  Dimension 7 – Substance Use Problems  Dimension 8 – Independent Living Skills

3. The Revised 8 Dimensions ASAM Acute Intoxication and/or Withdrawal Potential Biomedical Conditions / Complicat -ions Emotional, Behavioral or Cognitive Conditions and Complications Readiness to Change Relapse, Continued Use or Continued Problem Potential Recovery Environment Substance Use Problems Independent Living Skills ______________________ ­­­­­­_______ ASAM DIMENSION SEVERITY SUMMARY No Problem (0) / Mild (1) / Moderate (2) / Severe (3) / Extremely Severe (4)

4. An Example of the Behavioral Anchors in ASAM Dimension 3

5. The SARJ – Purpose and Rationale  Designed to provide both quantitative and qualitative data to justify requests for:  Continued stay at a given level of care  Discharge from a given level of care to a lower level of care (or out of care)  Discharge from a given level of care to a higher level of care  Transfer from a given level of care to a comparable level of care at a different agency  Additional services across CARS service array (e.g., RSS Employment services, spiritual support, RSC services, new CCS services, etc.)

6. The SARJ – Purpose and Rationale  The SARJ also enables us to use quantitative data to track a person’s recovery trajectory  This data can be utilized not only as outcomes data, but as informational to provide guidance to providers to drive level of care placement decisions.  Examples:  Outcomes: Does the mean ASAM Dimension 7 Score decrease for individuals in AODA Transitional Residential Care between intake and discharge  Placement Decisions: If all of a client’s Dimensional scores are 2 or below, this suggests they should be discharged to a lower level of care (or, at least, a transfer should be considered)* * If a discharge is not requested in this scenario, then a clear rationale for continuation must be provided

7. The Initial ASAM Placement Data and the SARJ – Like Reese’s Peanut Butter Cups

8. The Initial ASAM and SARJ  The scores from the Initial ASAM should be used as the baseline/guideline for the ASAM scores on the SARJ  The SARJ should be submitted when a Service Authorization Request is entered via Avatar or Provider connect (depending on program)

9. The CARS Assessment Results and Placement Form or Report Has the Initial ASAM Scores…

10. ASAM Domain Score Crosswalk CM Independent Living Skills Domain Score SA Treatment Substance Use Domain Score MH Treatment Psychiatric Domain Score CBRF4 Medically Managed Detox 4Inpatient/CBRF4 CSP 3.5 – 4 Med Monitored Res.3.75 PCS** 3.5 – 3.75 Transition Res. 3.25 – 3.5 CCS3 – 3.5Day Treatment3 – 3.25 RSC/TCM2 – 3 Recovery House Day Treatment 2 – 3 Intensive Outpatient (projected) 2 – 3 CM 0.5 – 1 OP/MAT1OP1 RSS/Prevention/SBIRT0.5Prevention0.5 None0 0 0 ** PCS is not a level of care in this context, but is a necessary step for placement into BHD Inpatient services and has thus been added to the LOC Continuum

11. Service Authorization Request Form – An Example Select appropriate request Select 4 Type in “Day Treatment” Select the appropriate team Leave blank Select “Pending” Today’s date 90 days from today’s date

12. Service Authorization Request Justification Form

13. The CARS SARJ in Avatar

15. The Flow from Intake to Service Authorization Request and SARJ

16. Completing the SARJ  Select the type of request  In each Dimension, select the appropriate criteria box, depending on the type of request  Provide an ASAM Dimensional rating IN ALL 8 Dimensions, even if the rating is a zero  Provide an appropriate rationale, particularly for those Dimensions that remain high/have increased and/or those that are your primary source of concern/focus of treatment  Specify ongoing treatment/recovery plan goals if the client continues in the given level of care, AND detail an alternative plan should the request for continuation be denied

17. Completing the SARJ  The SARJ must be completed and submitted before the authorization expires  Authorization expiration is defined as the pre-specified length of the authorization (e.g., TCM = 6 months, AODA Residential = 30, etc.) or the utilization of all units prior to the end of the authorization period  Please note that although the completion of PPS data set may coincide with the submission of the SARJ, they will not always be due during the same time frame

18. Completing the SARJ – The Good, the Bad, and the Ugly The GoodThe BadThe Ugly

19. “Bad” SARJ examples:  Not enough information offered to justify request.  Example: “The need for continued stay” written on a request.  Information listed under wrong SARJ dimension.  Example: Dimension 2 lists mental health medications. On same SARJ, Dimension 3 states: “No emotional or behavioral problems reported”.  Comments too general.  Examples: “Client has coping problems”. Coping with what? “Client has emotional/behavioral or cognitive problems”. Of what kind?  Comments not responsive to need for continued stay or transfer.  “Client continues to have several medical problems”. “Client’s current recovery environment is recovery house”.

20. “Good” SARJ Examples  Clinical details that speak to the domain – client has mental health issues and Dimension 3 reports current update  SARJ form corresponds to service request, casenotes and IRP or treatment plan – consistency across sources  Weave client’s history into the updated information report  “Though he has been progressing with his abstinence and recovery, the client continues to struggle with acceptance and depression related to the loss of one of his sons. He continues to struggle with expressing his emotions in a healthy manner that does not include substance use. The client also struggles with a prior diagnosis of depression and reports having used marijuana to stabilize his emotions and feelings in the past.”  Describe what client is thinking and what he/she wants  “Client wants to transfer to Recovery House with IOP so he can work. Income is a priority for him. He feels he has had enough residential tx. As a clinician, I feel client needs 30 more days of residential tx to stabilize and work on his recovery plan. The client and I have discussed this issue and I agreed to submit this request.”

21. “Good” SARJ Examples Continued…  Describe the client’s health insurance status including steps taken to apply  Alternate Plan completed with information like community resources available for client.  For example, an agency may offer the client information on community resources like the Counseling Center, AA or other support groups. An agency may continue to work with the client at no charge to finish programming.  Recovery Environment described in detail.  “Client can’t return home due to using in the house. Client interviewed with bridge housing provider and has been waitlisted.”  “Client returning home to partner who is in recovery, attends support groups and will in turn offer support to client. Client’s family has been supportive, in particular his father, who has 20 years sobriety.”

22. A Good SARJ – With Some Minor Recommendations  Dimension 1 Score: 3  Dimension 1 Comments:  Client has history of substance abuse; his substances of choice being alcohol and crack-cocaine. Client was drinking on a daily basis and would occasionally drink to the point of vomiting or blacking-out. Withdrawal symptoms might include lack of appetite and mood changes; however, he was often observed as having a low appetite at his baseline. Client last used alcohol prior to his move to Agency A Nursing Home (NH) on 10-13-2015. Client was using crack cocaine on a weekly basis. His withdrawal symptoms included behavioral and mood changes. Client last used crack cocaine prior to entering NH.  Dimension 7 Score: 1  Dimension 7 Comments:  While in the NH, client did not use alcohol or crack cocaine and greatly reduced/abstained his use of cigarettes. Prior to his move into Agency A, he was drinking daily or almost daily, generally beer. He was also using crack cocaine on a weekly basis; buying and using it when he could or having friends purchase it for him. Client would continue to use substances regardless of how he was doing medically. For example, even when he was experiencing severe symptoms of COPD, he would continue to use crack cocaine and experienced difficulty breathing and pain. Client had no desire to stop or reduce his use. His sobriety came when he began declining medically and was unable to function at a level that would give him the ability to use. Note the discrepancy between Dimension 1: Acute Intoxication and Withdrawal, and Dimension 7: Substance Use. An elevated score in Dimension 1 generally cannot occur in the absence of an elevated score in Dimension 7.

23. A Good SARJ – With Some Minor Recommendations Dimension 3 Score: 4 Dimension 3 Comments: Client was diagnosed with Schizophrenia Paranoid Type along with Personality Disorder, NOS. Client would show symptoms consistent with these diagnoses when he was decompensated, e.g. hallucinations. Throughout the past few years, and especially the past six months, client has remained stable psychiatrically, and showed no signs of auditory or visual hallucinations. He showed little insight into his mental health and was last staged in the Late Persuasion stage of treatment. Client was hospitalized for psychiatric reasons during October of 2004, December of 2000, May of 1995, November of 1994, September of 1991, May of 1987, November of 1986, May of 1986, and April of 1970. Dimension 4 Score: 4 Dimension 4 Comments: Client had little to no insight into his mental health and AODA issues and an internal locus of control, yet a lack of accepting responsibilities for his actions. Prior to entering Agency A, client was making his contacts with his treatment team and was medication adherent. However, he continued to use alcohol and crack cocaine regardless of physical, medical, and environmental consequences. For example, he was living with his sister and was told if he continued to use he would not be welcome to stay there any longer. Client continued to use, was kicked out, and had to move to a room and board. Client had no motivation or desire to change his substance use. The fact that the client is in a later stage of treatment for MH concerns should at least be noted in Dimension 4, even if it does not change the Dimension 4 rating.

24. Questions?  Please contact CARS at 414-257-8085 and ask for:  Matt Drymalski  Mary Ann Repnik  Zak Conway  Janet Fleege