1. ASAM Continuum of Care Implementation at Tarzana Treatment Centers
Ken Bachrach, Ph.D., Clinical Director

2. Overview of Tarzana Treatment Centers’ SUD Services
60 inpatient beds used for detox and psychiatric stabilization – 3.7 and 4.0; and WM 3.2, 3.7 and 4.0
275 adult residential beds - 3.1, 3.3., 3.5 and WM 3.2
40 youth residential beds – 3.1, 3.5
Outpatient DMC services - 1.0, 2.1
OTP and MAT services – methadone, buprenorphine, and XR-naltrexone

3. Preparing for DMC-ODS and Use of the ASAM Assessment
Started 6 months in advance
Needed to review how it differed from what we were currently doing
Overlapped with the ASI to some degree and we also used an ASAM screen and care determination grid
Had weekly meetings to prepare for this, particularly as July 2017 approached

4. Staff Training
Started nearly one year ago with an all day ASAM training with Dr. David Mee-Lee with Phoenix House
Purchased online ASAM training classes which were required of all SUD counselors prior to July 2017
Went back and forth with SAPC as to whether we could use our version of the ASAM assessment or were required to use SAPC’s
Agreed to use SAPC’s version
Partnered with UCLA to provide basic and advanced MI and CBT training to TTC staff

5. Staff Training and Administrative Burdens
Residential staff needed repeated trainings on the ASAM criteria as well as on how to determine the SUD diagnosis
Takes a tremendous amount of time to get staff to consistently do things correctly
These trainings, tracking, auditing, and administrative burdens of obtaining authorizations are unfunded mandates, the costs of which providers need to absorb

6. Implementation and Tracking
Hired a Clinical Supervisor of Admissions and 3 authorization support staff to help develop and oversee these new administrative tasks
Developed a centralized internal system using Sharepoint to track ASAM assessments for patients so that they would be reviewed prior to being sent to SAPC
Practiced doing ASAM’s and uploading them to the Sharepoint site for review prior to July 1st.
Hold two meetings a week to address DMC-ODS issues
Hiring more staff to do QA and program supervisors are doing more auditing

8. RESIDENTIAL REAUTHORIZATION
Complete Service Request Form
Provide Current Treatment Plan
Perinatal Patients
Medical documentation
Criminal Justice Patients
Identification Number must be documented on SRF
Save all the above as one document in this naming format:
Reauth Res 3.1 Jim Sorg
and Attach the completed Discharge and Transfer Form to
In Subject of enter the name of the upload.
Reauth Res 3.3 Jim Sorg
Place originals in the chart
Recovery Bridge Housing
Initial Authorization
Complete the SRF for RBH
Copy of the Treatment plan, if available or
Verification of Enrollment in Treatment Services
(OP.IOP, OTP, OP-WM)
Save as one attachment and name RBH Auth Res 3.3 Jim Sorg
the attachment to
In Subject of enter the name of the upload.
RBHAuth Res 3.3 Jim Sorg
Place originals in the paper chart
Medical Documentation to substantiate pregnancy and or postpartum
Discharge
Discharge Transfer form
Documentation of enrollment in Treatment Services
Save as one attachment and name
RBH Discharge Res 3.1 Jim Sorg
and Attach the completed Discharge and Transfer Form
Place originals in the paper chart
Discharge Res 3.3 Jim Sorg
123456

9. Moving from Education to Competence
Taking a class on the ASAM and knowing how to complete the form does not mean someone understands how to use the six ASAM dimensions
It is a new way to conceptualize SUD cases for most of the counselors
Some counselors are having trouble grasping the ASAM scoring – it is clinical tool and they often think more concretely than conceptually
More than just a placement tool, the ASAM dimensions are used for developing the treatment plan and for documentation in progress notes
The ASAM dimensions are also being used for continuing stay and discharge planning

10. Determining the Level of Care for Residential
The onus is on providers to argue for more than Clinically-Managed Low Intensive Residential Services (3.1) to LA County, since patients are to be placed in the lowest level of care possible, according the the ASAM Determination of Care Chart
An example is on the next slide

11. There is no differentiation between the 3 levels of care for Dimensions 2,3,and 4 for 3.3 and 3.5 and only a slight difference on Dimensions 5 & 6 for Dimensions 5 & 6. With the aim to place the patient at the lowest level of care, it is on the provider to always argue why someone needs to be at 3.3 or 3.5 rather than 3.1.

12. Moving Between Levels of Care (LOC)
All changes are based on the use of the ASAM assessment and medical necessity
Move from Withdrawal Management to Residential or Outpatient is quite simple, based on the ASAM ratings on the six dimensions
Movement within residential from 3.5 or 3.3 to 3.1 is often the result of stabilization on Dimensions 3 (Psych), 5 (Relapse Potential) or 6 (Living/Recovery Environment)
While patients generally move down LOC in residential, we had instances where patients moved from 3.1 to 3.5 due to psychiatric issues (Dimension 3)
There are also times outpatients need to moved to Withdrawal Management or Residential

13. Youth Residential
Youth ASAM is 18 pages, longer than the adult, and youth generally have shorter attention spans
Youth complain that the questions are redundant, even though they may not be
Initial LOS is only 30 days, but since it takes youth 2-3 weeks to settle into treatment, and half don’t have families to go back to or else there is tremendous much work needed with the families
Even though we can extend past 30 days, many of the youth want to leave after 30 days, since it is not initially presented as a longer program – they view treatment as a sentence

14. Youth Residential
When we used to have youth for 90 days, they got more engaged in treatment early on
Youth often are counting the days, since they know only 30 days are approved at a time, based on medical necessity
Initially we got requests rejected to extend treatment past 30 days, since we weren’t using SAPC’s treatment plan. This issue has since been resolved.
Discharge planning on 30 day stays are difficult since it requires a lot of work to coordinate with patients, DCFS and probation, and continuing services near where they live. Have to start early even though may need to extend stay, which puts providers in a bind.

15. Role of the LPHA
We have used more LPHA’s now to review ASAM assessments: RN’s, psychology post-docs, licensed MH staff
We have teams of LPHA’s at some sites who review them
At other sites the program’s clinical supervisor(s) reviews them
LPHA’s are more involved in the assessment and review process as a result of the ASAM
LPHA’s also are auditing charts more, and spending more time training staff on the ASAM

16. Reflections on This Change
Required counselors and supervisors to learn the ASAM criteria, which is a very positive development for the field, although some staff are struggling to master this
There is an over-abundance of paperwork now compared to before; Hopefully, as the system moves forward, things can be streamlined to reduce the paperwork and administrative burden
The increased administrative burden needs to be taken into account when arriving at reimbursement rates
Counties need to realize that they need to be able to adapt to a variety of EHRs and not require providers to use their particular form, but rather just include the data elements they require

17. THANK YOU!