By Paul H. Earley, MD, DFASAM
President of the American Society of Addiction Medicine (ASAM)
Medical Director of the Georgia Professionals Health Program, Inc.
Drug overdoses are currently the leading cause of accidental death in the country, with more than 70,000 deaths in 2017. The urgent need to provide quality care to the large numbers of patients suffering from substance use disorders (SUDs) has rightly resulted in increased scrutiny of the available treatment options. It has also driven significant efforts at the federal and state level to improve the quality of addiction care and availability of evidence-based treatment.
American Society of Addiction Medicine (ASAM) strongly supports the wide adoption of research-validated standards of care, viewing them as essential to transform the addiction treatment system and expand access to safe and appropriate treatment. But implementing these standards comprehensively and with fidelity to the evidence base poses a significant challenge to our current treatment infrastructure.
Nearly 30 years ago, ASAM led the development of national standards for addiction treatment. The ASAM Criteria® provides a standardized framework for assessing patients with SUDs. It matches each patient to the type and level of care based on that individual’s biomedical, addiction, and mental health conditions, as well as their psychosocial needs. The ASAM Criteria also defines the complete continuum of care and service characteristics for each care level.
The ASAM Criteria standards have a critical role to play in national efforts to advance treatment for the disease of addiction. They are the most widely used and comprehensive guidelines for placement, continued stay, and transfer or discharge of patients with SUDs. However, comprehensive implementation of The ASAM Criteria requires a system-wide approach that requires coordination across providers, payers, policy makers, and system administrators.
Multiple Components of The ASAM Criteria Standards Work in Tandem
The ASAM Criteria define rich standards for a complete system of care, including (1) assessing patients’ needs across six dimensions, including factors critical to recovery such as withdrawal potential, medical needs, emotional and behavioral conditions, readiness to change, potential for relapse, and an individual’s living situation and support systems; (2) utilizing research-based decision rules that interpret the multidimensional assessment and match patients to the proper level and type of care; (3) placing each patient on a continuum of treatment services based upon individual needs; (4) establishing characteristic service standards for each level of care within that continuum; and (5) setting proper staffing levels, assessment and treatment planning needs, therapeutic requirements, and ensuring proper support systems and documentation. These components all work in tandem to ensure patients receive the right level of care for their evolving needs as they enter and progress through treatment.
The ASAM Criteria framework establishes a common language and universal standards to help payers and healthcare systems construct a full range of services for patients with SUDs. Research over the last three decades has demonstrated the validity of these standards and has shown that patients who are optimally matched to the appropriate level of care with The ASAM Criteria have better outcomes, including lower hospital utilization, lower attrition, and reduced substance use at follow-up visits.[HH2]
Supporting Effective Implementation of The ASAM Criteria
Complete implementation of The ASAM Criteria ensures that patients have access to all treatment levels across the care continuum and providers follow the service standards for each level(s) of care. For this system to work, it is essential that payers use the same standards as providers to secure proper patient coverage. This approach requires coordinated efforts by healthcare systems, policy makers, and payers.
With effective implementation, providers conduct a standard, multidimensional assessment as patients enter treatment, covering the six dimensions described above; use the results to determine the appropriate level of care to meet each patient’s needs; and develop an individualized treatment plan. As patients progress through treatment, providers use these same assessment and treatment matching processes to determine whether to increase or decrease the level of care to best meet evolving treatment needs. Recurrent training and close supervision of the treatment processes are necessary to ensure that patient placement rules are accurately followed.
The ASAM Criteria standards are premised on the knowledge that addiction is a biopsychosocial disorder; the illness is characterized by biological, psychological, developmental, and social factors that influence its proclivity and course. As the specific factors at play differ, ensuring each patient is treated as an individual provides the best outcomes. The criteria do not support predefined treatment limits or lengths of stay. Instead, they require reassessment of the six dimensions driving determinations that a patient is ready to transition to a different level of care. This patient-centered approach requires a significant shift in how most addiction treatment services are currently structured and financed.
In the recent Wit v. United Behavioral Health (UBH) decision, the United States District Court for the Northern District of California found that the payer misled regulators about its guidelines being consistent with The ASAM Criteria®. The court found that “ASAM is a recognized source of generally accepted standards of care” and that UBH was liable for breach of fiduciary duty and denial of benefits claims because of its failure to align medical necessity criteria with The ASAM Criteria. This decision suggests that payers can no longer simply state that they adhere to these nationally accepted standards of care. They must be able to demonstrate that these standards are applied in practice.
Tools to Support Effective Implementation
Recognizing the challenges that healthcare providers face in applying The ASAM Criteria across systems, ASAM continues to refine the tools available to support standardized and objective implementation. ASAM developed a computer-guided multidimensional assessment tool that codifies the complete set of decision rules contained in The ASAM Criteria text. In addition, ASAM is piloting a national certification program to evaluate whether residential (Level 3) treatment programs can provide services aligned with The ASAM Criteria. ASAM also offers extensive education and training related to The ASAM Criteria, including continuing medical education (CME) courses and online training modules. Each of these is described below.
Clinical Decision Support
The ASAM CONTINUUM® software is a clinical decision-support tool that provides counselors, clinicians, and other treatment team members with a structured interview for assessing and caring for patients with addiction, substance-related, and co-occurring conditions. The decision engine uses research-quality questions across all six dimensions of The ASAM Criteria, including the Addiction Severity Index (ASI), Clinical Institute Withdrawal Assessment (CIWA), Clinical Institute Narcotic Assessment (CINA), and others. Together, these tools produce a patient assessment, suggestions as to appropriate type and level of care, and a psychosocial narrative report.
National ASAM Level of Care Certification Program Pilot
While The ASAM Criteria has been in place for decades, until recently there has not been an objective assessment mechanism to determine if a particular center or healthcare system is equipped to deliver addiction treatment services at the criteria-defined standards for specific level(s) of care. ASAM and CARF International have partnered to bridge this gap and are planning to launch the ASAM Level of Care certification program by the end of 2019. Once established, this certification process will create transparency, patient confidence, and accountability around the services each system offers. It will also give addiction treatment providers recognition, validating their ability to deliver services consistent with The ASAM Criteria. Importantly, this program will not replace traditional accreditation programs.
Phase I of the pilot, completed in May, tested the ratable certification elements and certification process, including a proprietary scoring methodology. CARF certified seven of ten programs evaluated, each of which demonstrated their capacity to deliver a specific ASAM level of care.
Phase Two of the pilot, now underway, is testing enhancements to the ratable elements and evaluating the accuracy and efficiency of the certification process in diverse locations with varying program sizes, payer mix, regulatory environments, and accreditation status. The program will be expanded to certify individual treatment centers that provide multiple levels of care.
Upon first general rollout, certification will be available for adult residential treatment facilities at Levels 3.1, 3.5, and 3.7 of The ASAM Criteria®. The certification process will be expanded to more populations (e.g., adolescent programs) additional types of disease management (e.g., withdrawal management, co-occurring disorder treatment) and across the continuum of care (e.g., all care levels 1 through 4) in a stepwise fashion.
Education and Training
Rigorous training and supervision are essential to realizing the full potential of The ASAM Criteria. Thus, ASAM is expanding our suite of education and training tools to support implementation of these standards. In September, ASAM will launch The ASAM Criteria® Course, which includes competency-based learning activities that teach providers the skills and practices needed to appropriately apply the standards. As providers learn to comply with the guidelines, the course can also serve as a first step towards instituting a credentialing program. The ASAM Criteria Course will be available through the ASAM E-Learning center this fall.
ASAM also offers both live and online training for clinicians using the ASAM CONTINUUM software and is developing trainings and publications to prepare treatment programs for level of care certification and to strengthen their capacity to deliver evidence-based services that align with The ASAM Criteria standards. A science-informed guidebook will soon be available to help healthcare systems and addiction treatment programs navigate effective adoption of The ASAM Criteria. Future efforts will expand education and training for other critical stakeholders, including payers, healthcare system administrators, and supervisors.
Conclusion
The opioid epidemic has brought a long-overdue focus on addiction treatment system reform. Policy makers at both the state and federal level are providing significant resources to support the adoption of evidence-based practices, including The ASAM Criteria. Our entire field needs wholesale reform to ensure patient care is coordinated and thoughtful and to implement changes that ensure fidelity to research-validated standards.
Like all standards, implementing The ASAM Criteria requires an iterative quality improvement process. Ongoing oversight, reevaluation, and continuous process improvement is critical to ensuring addiction treatment programs, and the broader addiction treatment system, are equipped to deliver high quality, evidence-based care. ASAM will continue to focus on reshaping addiction treatment by increasing standardization of services, improving quality, expanding access to care, and, ultimately, giving patients with substance use disorders the best chance to achieve and sustain recovery from this crippling illness.