There is an increasing requirement for evidence-based treatment in substance abuse programs and closer scrutiny for accountability in health care delivery and quality improvement (Miller et al. 2005). More than 10 years of research in the ASAM Criteria Validity Study and several controlled studies indicated that use of the ASAM criteria is associated with less morbidity, better client functioning, and more efficient service utilization than mismatched treatment (Gastfriend and Mee-Lee 2003). As such, the ASAM criteria, if implemented faithfully, can assist the addiction treatment system in meeting these pressing requirements. However, the ASAM criteria orient treatment-matching according to fixed levels of care; and level of care is a coarse distinction that lumps together heterogeneous groups of patients with a range of needs.
Instead, it may be more advantageous to orient placement criteria in the opposite direction—meeting patient needs rather than fitting program requirements (Longabaugh et al. 1995; McLellan et al. 1997). This approach of needs-to-services matching is clinically useful whether performed formally in a
research design or informally in the clinic. The key operations are a multidimensional consideration of the patient's range of needs and the provision of services to address those needs. Results from several studies have shown that matching clinical services to patient needs generally yields the best outcomes in that distinct problem area, validating needs-to-services matching (Ball and Ross 1991; Institute of Medicine 1990–1992; Joe et al. 1991; McLellan et al. 1983a, 1983b, 1993a, 1993b, 1994; Moos and Finney 1995).
Although needs-to-services treatment matching is a logical starting point for a new model of care planning, it is still necessary to consider the setting or level of care within which services can best be
provided. A highly flexible, individualized approach to level-of-care assignment seems essential to clinical quality and cost efficiency. To achieve this integration with flexibility, Gastfriend (1994) proposed to the National Consortium on Patient Placement Criteria an approach termed the Cumulative Block Increment (CBI) model. Based on a building-block concept of small service units (e.g., hour-by-hour of care), this approach recommended a high-resolution assessment of individual clinical needs, followed by grouping these needs to determine the best setting for the constellation of services necessary for the patient. With the CBI model, services could be designed to taper more incrementally in an individualized fashion and would integrate level-of-care consideration with needs-to-services matching. Although the CBI model appears to offer face validity, as did earlier PPC models, empirical validation is necessary. To further advance exploration of alternatives to traditional fixed levels of care, the ASAM PPC-2R (Mee-Lee et al. 2001) proposed an experimental matrix format that matches the patient's needs to specific treatment services, rather than to broader levels of care (Table 6–3). The matrix format is multidimensional and is formatted in three columns. For each assessment dimension (which corresponds to Dimensions 1 to 6 of the traditional PPC), the "risk rating and description" (first column) suggests the severity of the patient's problem in that dimension. The treatment priorities represented by the "types of services and modalities needed" (second column) suggest the specific types of treatment
services/modalities the patient requires, as well as the intensity with which those services should be delivered to appropriately address the patient's multidimensional service needs. The corresponding rating in the "intensity of service/level of care/setting" (third column) suggests the intensity of the level of care and setting that appropriately allow the treatment and service plan to be effectively delivered. Each dimension is considered separately (unbundled) from the other dimensions to allow independent assessment of all areas of potential concern, followed by an assessment of dimensional interaction.
CONCLUSION
Psychiatrists, physicians, and other providers can address patients' substance use problems on a rational basis with the help of published patient-placement criteria. Adoption of formal rules such as the ASAM PPC-2R is under way in numerous states, managed care entities, professional provider societies, and provider groups, and interest in the criteria has increased internationally. Initially, such criteria relied more heavily on consensus recommendations than on empirical matching data, but outcome research data drive their continuous revision. The technology for conducting psychosocial treatment matching studies has been rapidly increasing in sophistication, and has been demonstrated to yield adequate reliability and concurrent validity. Although its predictive validity continues to be studied, the national research portfolio on placement criteria is expanding. Given the push for evidence-based practices and recent dramatic cost pressures, there is an essential public health need for further research in this area if addiction services are to continue to grow in quality and availability.
KEY POINTS
Treatment outcome research demonstrates that treatment for addictive disorders is effective, but that no single model or level of care is appropriate for all individuals. The services themselves and where they are delivered should therefore be individualized to each patient's assessed needs.
The patient placement criteria incorporate multidimensional assessments of severity-of-illness and level-of-function; problem and priority identification; treatment matching of needs-to-services; and level-of-care placement within a broad continuum of care. Ongoing assessment of progress and treatment response determines movement to less or more intensive levels of care.
The most widely used and researched patient placement criteria tool for addiction treatment is the Patient Placement Criteria (PPC) for the Treatment of Substance-Related Disorders of the American Society of Addiction Medicine (ASAM). The most recent edition, published in 2001, includes criteria for people with co-occurring mental and substance use disorders.
The ASAM PPC describe a broad range of levels of care. Yet benefit plans, public funding, and provider programs are frequently restricted to a limited continuum of care, even though a broader
range of options could provide longer lengths of care and monitoring using the same or even fewer resources.
More than a decade of research on the ASAM PPC supports the predictive validity and cost-effectiveness of the use of PPC. Based on this research, a variety of computer-assisted assessment and placement tools are in development.
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SUGGESTED READING
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Print Close Window A. Thomas McLellan: Chapter 7. Evolution in Addiction Treatment Concepts and Methods, in The American Psychiatric Publishing Textbook of Substance Abuse Treatment. Edited by Marc Galanter, Herbert D. Kleber. Copyright ©2011 American Psychiatric Publishing, Inc. DOI: 10.1176/appi.books.9781585623440.345610. Printed 10/7/2011 from www.psychiatryonline.com
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