Selecting an Appropriate Treatment
Evolving Approaches to Treatment Matching. The process of matching patients to treatment services has evolved through at least four approaches, each with a fundamentally different philosophy (Mee-Lee, 2001).
Complications-driven treatment gives only cursory attention to the diagnosis of substance use disorder. In this approach, rather than actively treating the primary alcohol or other drug disorder that is causing the patients symptoms, only the secondary complications or sequelae are addressed. The gastritis or bleeding esophageal varices are controlled; the depression is medicated; fractures are splinted or pinned, but care for the addictive disorder is superficial or non-existent.
In contrast, diagnosis, program-driven treatment recognizes the primacy of the substance use disorder, but the diagnosis alone drives the treatment plan, rather than the specific assessed needs of the patient. Patients are assigned to fixed lengths of stay in programs with static approaches, often in response to available funding or benefit structures.
Individualized, assessment-driven treatment emphasizes multidimensional assessment. Problems are identified and prioritized in the context of the patient’s severity of illness and level of function. Treatment services are matched to the patient's needs over a continuum of care (Shulman, 1994). Ongoing assessment of progress and treatment response influences future treatment recommendations. This continuous quality improvement cycle—assessment, treatment matching, level of care placement, and progress evaluation through assessment (see Figure 1)—represents an approach to care that much of the addiction treatment field still struggles to implement (Mee-Lee, 1998).
In outcomes-driven treatment, which is the newest approach, the promise of matching patients to treatment has yet to be fully realized. For all the current rhetoric about outcomes, performance measures, accountability, and evidence-based treatment, this approach to addiction treatment is only just beginning to be articulated and actualized.
Uses of Placement Criteria. Placement criteria are irrelevant to the first two approaches to patient placement (complications-driven and program-driven treatment). In the latter two approaches (assessment-driven treatment and outcomes-driven treatment), however, placement criteria play an integral role by providing a structure for assessment that focuses on the patient’s assessed needs. Criteria also provide a nomenclature to describe an expanded set of treatment options and guidelines to promote the use of a broader continuum of services. Overall, the placement criteria are intended to enhance the efficient use of limited resources, increase patient retention in treatment, prevent dropout and relapse, and thus improve patient outcomes.
The Concept of "Unbundling." At present, most addiction treatment services are “bundled,” meaning that a number of different services are packaged together and paid for as a unit. Similarly, the first edition of the ASAM criteria "bundled" clinical services with environmental supports in fixed levels of care. Today, however, there is increasing recognition that clinical services can be and often are provided separately from environmental supports. Indeed, many managed care companies and public treatment systems are suggesting that treatment modality and intensity be "unbundled" from the treatment setting.
Unbundling is a practice that allows any type of clinical service (such as psychiatric consultation) to be delivered in any setting (such as a therapeutic community). With unbundling, the type and intensity of treatment are based on the patient's needs and not on limitations imposed by the treatment setting. The unbundling concept thus is designed to maximize individualized care and to encourage the delivery of necessary treatment in any clinically feasible setting.
A transition to unbundled treatment would require a paradigm shift in state program licensure and reimbursement. In terms of treatment, there would no longer be “programs” but rather a constellation of services to meet the needs of each patient. The systems currently in use for billing, reimbursement, and funding would not support unbundled treatment. All of these obstacles are reasons for delaying an abrupt change to the new paradigm, but the ASAM criteria encourage exploration of unbundling by suggesting ways to match risk and severity of needs with specific services and intensity of treatment.