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Every stakeholder wants the quality of substance abuse treatment to be sufficiently high that clients recover from their addictions. Yet, quality too often is seen as elusive, in health care in general as well as in substance abuse treatment. The authors of a recent article on performance measurement in health care said:

“… decades of health services research have shown that the quality of medical care varies to a disturbing extent”. (Leguini, et al, Health Affairs. May/June, 2000)

This section describes the challenge of assuring quality and details several projects that will improve the quality of substance abuse treatment for the citizens of New Jersey. The factors include increasing clinical complexity, state licensure, the certification of substance abuse counselors, national accreditation of provider organizations, increasing use of quality assurance and quality management practices, research on success and failure factors in treatment, evidence- based best practices, and the measurement of outcomes. Many of the items necessary to improve the quality of treatment may require increased funding.

Increased Clinical Complexity

Treatment professionals report that clients bring ever more complex problems to treatment. The research and practice literature reflects this increase in clinical complexity.

In earlier decades, when addiction most often occurred in mid-life, the treatment provider could stabilize sobriety and focus on “rehabilitation”. As younger persons with addiction problems present for treatment, the challenge often is to to “habilitate” the client, i.e. help them learn to grow up.

Increasing numbers of persons bring mental health as well as substance abuse problems to treatment. These “co-occurring disorders” interact, and require that the treatment professional and provider program be more sophisticated in addressing both addictions and mental health problems.

The federal government’s substance abuse block grant names several priority populations that require the use of specialized treatment approaches. One size does not fit all, and professionals and providers must learn new skills to serve pregnant addicts, women who bring infants and pre- school children to treatment, injection drug users, and persons with primary health care needs. In addition, many states also identify priority populations. An example in New Jersey is the welfare to work initiative, that resulted in the Work First New Jersey Substance Abuse Initiative.

New Jersey has an unusually high rate of HIV infection and active AIDS among the substance abuse treatment population. All strains of hepatitis and TB are also concerns. These conditions require unusually high levels of care coordination between substance abuse treatment and the health care system.

The criminal and juvenile justice systems have become increasing involved in treatment for substance abuse, as chemical dependency is a major factor in criminal behavior and recidivism. Court-ordered treatment may conflict with clinically driven placement, continued stay and discharge criteria, necessitates dialogue among the courts, probation and treatment providers and increases the complexity of treatment planning and program management.

New Jersey is also concerned about substance abuse as it impacts upon persons served by multiple state agencies. Pregnant addicts are of concern to maternal and child health specialists as well as substance abuse professionals. Similar crosscutting interests exist for DUI offenders, families in which substance use affects child rearing and child safety, and persons with co- occurring mental health and substance abuse disorders. Joint planning and funding at the state level can result in a multiplicity of appropriate requirements at the service delivery level.

Finally, it is now well recognized that social supports such as housing, transportation, vocational training and childcare are integral to successful treatment and long term recovery. Providing these supports is part of the quality of a program and should be ensured by payers and providers alike.

Providers and purchasers must respond effectively to these client needs, and respond to the clinical complexity with increased skills and expanded knowledge.

State Licensure of Treatment Providers

New Jersey revised the licensure provisions for residential substance abuse facilities effective November 15, 1999. The revised licensure requirements for outpatient facilities will become effective in late 2001. The changes were primarily a simplification and reorganization of previous provisions, with 90-95% of the requirements remaining the same. Of the few changes made, providers and purchasers feel the most impact with DHSS/DAS staff now performing licensure inspections on a regular schedule, and requiring that all standards be met. Other licensure issues for providers concern requirements for certified staff, ASAM physicians, smoking restrictions and frequency of contact differences with other Departments.

This process of tightening up the licensure process has cost implications for some community providers. Task Force members and DAS staff reported that licensure requirements concerning certified counselors and clinical supervisors may be the most difficult to meet in the short-term.

Counselor Certification

New Jersey currently has a voluntary program for the certification of counselors, conducted by the Addiction Professionals Certification Board of New Jersey. The number of certified

of 1516. The lack of significant growth in the number of certified counselors may act to limit expansion in the capacity of treatment programs unless rectified.

The authority and process for counselor certification in New Jersey will be changing as the result of legislation passed in January, 1998 that created an Alcohol and Drug Counselor Committee within the Board of Marriage and Family Therapy Examiners, which is attached to the N.J Department of Law and Public Safety. The new committee will establish standards of practice and oversee a mandatory certification process. In addition to the Certified Alcohol and Drug Counselor (CADC) level, a new Licensed Clinical Alcohol and Drug Counselor (LCADC) level will be established. LCADC’s will be eligible for independent practice in New Jersey.

Assessment and Placement Instruments

DHSS/DAS is requiring the use of two instruments that improve and standardize clinical practice. The Addiction Severity Index (ASI) is a well-known outcomes/assessment instrument that collects information on 7 scales. The ASI assists clinicians to accurately track the level of functioning of clients and provides information which can be used in the development of an individualized treatment plan. DHSS/DAS and several providers will soon study possible alternatives to the ASI.

The American Society of Addiction Medicine (ASAM) developed a set of placement, continuing stay and discharge criteria. Use of the second edition of these criteria is now required of New Jersey treatment providers. Other organizations are also using the ASAM criteria, e.g. the

managed care organization Value-Options. The criteria allow purchasers and treatment providers to use a common standard about the level of care that is most appropriate for an individual client. If ASAM criteria are used, access to appropriate care will improve significantly, assuming

availability of the recommended care levels.

National Accreditation and Quality Management Standards

Several national accreditation bodies have developed standards that apply to substance abuse facilities and programs. Providers can voluntarily elect to apply for accreditation when they meet the standards of the national body. In several other states, mental health and/or substance abuse agencies are allowed to use accreditation to meet some or all of the requirements of state licensure.

Each set of accreditation standards requires applicants to have in place an internal quality

management (QM) or quality assurance (QA) program. These programs establish internal agency performance benchmarks, and then measure performance against the benchmarks. Corrective action is taken when the benchmark is not met. The New Jersey licensure standards also contain a QA section.

Research on Successful Treatment Practices and Adoption of Best Clinical Practices

One of the Task Force presentations concerned outcomes based treatment services. The presentation identified clinical risk factors that increase the likelihood of client failure in treatment (single, male, no high school diploma or GED, not working) and also identified

treatment factors that increase the likelihood of successful outcomes. Success is supported when the provider engages the client and is able to retain the client in intensive treatment, followed by “maintenance care” and participation in self-help activities.

This kind of information is termed “evidence-based practices” or “best practices”. The quality of treatment services is improved when professionals and providers routinely use such best

practices. As best practices change from year to year, based on experience and research, they are most effective when providers attain evidence-based performance though training and clinical supervision, rather than through licensure requirements.

Outcome Measurement

New Jersey is one of 18 sites for a national pilot outcomes research study known as TOPPS II, which stands for Treatment Outcomes Performance Pilot Study, second round. This project is being managed by DAS in conjunction with the Robert Wood Johnson Medical School at UNDMJ. Twenty-three treatment providers are participating, and clients will receive an initial interview and then follow-up 12 months later.

The goal of the project is to develop and refine an outcome measurement process that can routinely be used in New Jersey to determine the effectiveness of various types of substance abuse treatment for specific kinds of individuals. This information can lead to improvements in provider performance and client outcomes over time. Public and private purchasers are

increasingly concerned that client outcomes be measured and that services be delivered in a cost- effective manner.

Procedures for Consumer and Provider Appeals and Complaints

An additional method for assessing the quality of care is to provide an avenue for complaints and to monitor the number and nature of complaints and appeals. The Office of Managed Care, DHSS operates such a process. Analysis of complaints received from January 1 through October 23, 2000 shows that six of 955 complaints concerned substance abuse treatment. Four of the complaints concerned approval by managed care organizations for residential stays, and two concerned payment of providers.

Clients, families and providers are unfamiliar with the OMC/DHSS process. The complaint procedure may be accessed via a free telephone number, 800-393-1062.

DHSS should implement measures to publicize the availability of this assistance.

Task Force Subcommittee on Quality

The subcommittee identified three critical recommendations: A comprehensive continuum of care is essential.

Clinical practice and research must be blended, and “best practice” guidelines should be disseminated.

Outcomes from the TOPPS II study should be incorporated into the best practice guidelines.

Taken together, these methods for improving the results of substance abuse treatment can have a powerful impact on client recovery and provider performance. It is critical that public and private purchasers support such efforts, and that treatment providers give guidance and fully embrace quality improvement initiatives. This subcommittee would like to continue working through 2001, discussing how to implement quality improvements and possibly seeking assistance from a state university on best practice implementation.

SIGNIFICANT SUBSTANCE ABUSE TREATMENT PROJECTS IN NEW JERSEY IN