Intensive Outpatient Treatment for Alcohol and Other Drug Abuse Treatment Improvement Protocol (TIP) Series 8
Chapter 1 -- Introduction
These are times of change and complex challenges for professionals who work
in the alcohol and other drug (AOD) abuse treatment field. They are
experiencing increasingly intense pressure to provide comprehensive, cost
efficient, and high quality care for AOD abuse patients. Government policies
appear to be shifting away from a predominant focus on interdiction and toward
an emphasis on prevention and treatment. Yet, only limited, overextended, and
diminishing resources are available to provide treatment. These changes and
challenges are occurring during a time when AOD disorders and their treatment
are both increasing in complexity.
As a result, treatment providers are challenged to search for and consider
innovative, measurably effective, and less costly approaches to the treatment of
people with AOD use disorders. These challenges occur within the context of an
evolution in health care policy and changes in the national health care system.
Managed care and managed competition are now potent forces in health care and
are likely to be important aspects of health care reform. At this time, the
long-term impact of yet-to-be-established national health care policies on AOD
treatment is unknown. Thus, in the face of advanced complexity of AOD use
disorders, treatment professionals can expect to continue to be charged with
providing treatment that achieves a balance between cost efficiency and clinical
efficacy.
As AOD abuse treatment professionals examine issues of treatment
effectiveness and cost, they are growing increasingly aware of the need to
provide specialized treatment services for special groups. A few of the many
groups that may benefit from special and often complex treatment services
include:
Persons with combined psychiatric and AOD use disorders
Ethnic and cultural minority group members
Persons who are homeless or experiencing housing instability
Clients with the HIV virus or AIDS
Gay and lesbian clients
Pregnant women
Elderly persons
Those who are involved with the criminal justice system.
A number of these groups are the focus of other TIPs that readers may wish
to refer to for an in-depth discussion of the particular problems and treatment
of these groups.
One of the most useful responses to the challenges that face treatment
providers has been the development of continuum-of-care models that match
specific levels of treatment with the individual patient's particular treatment
needs. Until recently, two models dominated the field of alcohol and other drug
abuse treatment:
The medically managed 28-day inpatient treatment program, and
The low-intensity, traditional outpatient service model, which usually
offers one weekly session of individual or group therapy.
A critical look at the traditional use of these two models has led to the
recognition of a significant gap in the AOD treatment delivery system. In many
instances, clients receive too few treatment services and are underserved;
others receive more treatment services than they need. In both cases, clients
receive the only level of care that is available or that they are able to find.
Further, the treatment of AOD use disorders has historically been fragmented
in several ways. For instance, clients often receive a burst of intensive
inpatient treatment followed by low-intensity aftercare services that are
inadequate and insufficient. Also, patients who require multiple treatment
services often must obtain these services at different treatment sites. For
example, it is common for patients with combined psychiatric and AOD use
disorders to receive psychiatric treatment at one site and AOD abuse treatment
at another. Thus, AOD clients in vulnerable conditions often have to accept
undue responsibility for coordinating their own care.
One of the responses of AOD abuse treatment providers to these challenges
has been the development of the intensive outpatient treatment (IOT) level of
care. IOT actually refers to a range of types of organized care. While it is a
less intense level of care than inpatient care, IOT nonetheless provides a
substantial range of treatment intensity. This level of care has been adapted
to several models such as day treatment and evening programs. The IOT level of
care is designed to bridge the gap between medically managed or medically
monitored intensive inpatient treatment and traditional outpatient services of
low intensity.
Although programs that provide AOD abuse treatment at an intermediate level
of care have existed to some degree for several years, the widespread
development and study of these programs has only recently gained momentum.
Pressures from insurance and managed care companies, as well as demands from
many sources for more cost-effective publicly funded treatment, have contributed
to the growth of IOT programs.
The development and study of IOT programs are complicated by a remarkable
variation in the intensity and scope of treatment services provided by IOT
programs and a lack of standardization regarding quality of care measures.
Standardization of the names and descriptions of intensive outpatient treatment
programs does not exist. For instance, some intensive outpatient day treatment
programs describe themselves as partial hospitalization programs, while other
programs that provide precisely the same services simply call themselves IOT
programs. Similarly, there is wide variation in the extent of coverage for
intensive outpatient treatment by third-party payers. The variation in coverage
by third-party payers may be related to the variations found among IOT programs.
While the need for programs that provide an intermediate level of care seems
obvious, the need for program evaluation is less obvious but equally critical.
There have been fairly consistent findings of similar patient outcomes for
inpatient and outpatient treatment across a range of measures -- findings that
support the further development and study of intensive outpatient treatment.
Unfortunately, there has not been an organized effort to identify the particular
benefits of IOT or to determine the specific elements of IOT that lead to
successful outcomes. This Treatment Improvement Protocol (TIP), based on the
experience of members of a national multidisciplinary consensus panel, is an
initial effort toward meeting such an objective.
The Purpose of This TIP
There is a need for education about IOT among AOD treatment providers,
payers, and people who make referrals for AOD treatment. This TIP provides an
introductory review of IOT, documenting the clinical viability and utility of
IOT, and stressing the range in IOT services within the broader continuum of
care. This TIP describes the rationale for the development,
institutionalization, and study of the IOT level of care. It identifies the
roles of IOT in relation to the other levels of care, and reviews appropriate
and existing patient admission and placement criteria. It describes the
essential and desirable components of an effective IOT program. It reviews
salient staffing issues and needs associated with IOT programs. Finally, this
TIP addresses the special issues and challenges associated with IOT, including
the needs of special groups, legal and ethical issues, quality improvement
challenges, and reimbursement issues.
The same forces and challenges that have prompted the development of the IOT
level of care have promoted a greater awareness of the need for all health care
programs to increase cooperation, collaboration, and functional linkages. AOD
treatment programs are using assertive case management models to closely monitor
patients' treatment across the continuum of care and through multiple service
delivery systems. Indeed, AOD treatment programs are increasingly providing a
greater range of services and are coordinating closely with other programs that
address the needs of AOD clients.
Various challenges, including a heightened accountability to payers, have
prompted the development of specific diagnostic and patient placement criteria
for assessing the appropriate level of care for patients in AOD treatment
settings. Patient placement criteria are instrumental in determining the
optimal points for the transfer of patients from one level of care to another.
The emphasis given here to intensive outpatient treatment does not suggest that
traditional levels of care for AOD disorders are without purpose or efficacy.
IOT programs have gained a reputation for effectively treating highly
functioning patients with relatively intact family systems and good psychosocial
supports. It must be considered that many of these patients are achieving
recovery and experiencing qualitative improvement in their lives not in spite of
being treated in IOT programs but rather because of the distinct qualities and
advantages of IOT programs. These successes suggest that IOT programs can
effectively treat a wide variety of patients who were previously considered
treatable only in inpatient settings.
Advantages of IOT Programs
The IOT level of care has several clinical and consumer advantages. For
instance, the cost of IOT treatment is often less than half the cost of
inpatient treatment. As a result, IOT treatment is often measured in months
rather than days or weeks. This allows patients more time to learn new
behaviors, participate in self-help groups, and practice relapse prevention
strategies. In an IOT program, patients can continue to function in
already-established roles with minimal disruption to work and family life. In
fact, work and family life are better stabilized through the support and
structure offered by IOT.
The intensity of the IOT level of care promotes close bonding among
patients. Access to the world outside of the program increases opportunities to
practice learned behaviors and new responses such as drug refusal skills, open
communication, and stress reduction techniques. Patients who participate in
treatment within a therapeutic setting while returning daily to their home
environment can practice relapse prevention techniques in the milieu in which
they live. These patients can also be assessed more accurately with regard to
their problems and progress. There is a greater opportunity for treatment
providers to strengthen patients' psychosocial supports and to intensively
intervene within their family systems.
Some IOT programs provide access to noninstitutional housing such as
apartments or houses near the program site. Others operate in conjunction with
a residential treatment option. In shared housing arrangements, patients
experience a milieu similar to the natural living environment. They experience
greater responsibility than they would in an institutional setting such as a
hospital.
Underlying Principles Of the TIP
Several principles serve as the foundation for this TIP. In turn, these
principles can be incorporated into the philosophy and management of IOT
treatment programs.
Treatment works. The suggestions, recommendations, and
shared experiences that are presented in this TIP are based on the premise and
documented empirical evidence that therapeutic clinical interventions have a
significant impact on AOD use disorders.
A continuum of care will cost-effectively enhance patient care.
The treatment of patients within a continuum of care is the most cost-effective
response to the treatment of AOD use disorders. The organized use of a
continuum-of-care treatment system allows patients to be matched to the level of
treatment they need, with precise transitional services available to meet the
changing needs of individual clients. A true continuum of care should allow for
longer-term care for clients who need it.
A multidisciplinary approach is vital. A multidisciplinary
approach to the assessment and treatment of patients with AOD use disorders is
essential to good patient care. AOD-dependent patients often have several
complex problems. The expertise and involvement of specialists from several
disciplines are critical for positive patient outcomes. Similarly, a large
repertoire of treatment skills and techniques is required to respond to the
complex and changing needs of patients.
Staff should be cross-trained. Despite the need for specialists in
various areas, treatment providers should encourage cross-training of staff.
Despite dissimilar training backgrounds, clinical staff should share a common
treatment and recovery philosophy. Staff education is essential, and programs
should schedule regular times for the review and discussion of books and
articles on AOD use and treatment, including published research.
Integration of treatment is essential. It is no longer acceptable
to treat one problem at a time and simply refer untreated issues to another
provider. Rather, it is essential that treatment be integrated, and that
patients receive appropriate care for existing and anticipated addiction,
psychiatric, and medical problems. They must also receive the additional
support services necessary to achieve problem resolution. Case management
services are an important component of AOD treatment. Such services are a
particularly important aspect of providing a continuum of care and integrating
treatment and other services for IOT patients.
Treatment should be individualized. No single approach to AOD
treatment will work for all patients. Rather, treatment should be
individualized for each patient, with special treatment goals to meet the
particular needs of each patient. AOD treatment should involve a wide variety
of clinical interventions.
Treatment programs should be accountable. Treatment interventions
and decisions should be based on proven, empirically supported outcomes. The
optimal care of patients requires a high level of accountability. Models of
treatment should be based on proven outcomes, and placement decisions should be
based on known rather than assumed benefits to patients.
Overview of the TIP
Chapter 2 -- Placement Criteria and Expected
Treatment Outcomes
This chapter defines IOT as a level of treatment and a range of services and
intensities that exists in the context of the larger continuum of care. Within
the IOT level of care, several different program models can be adapted to
numerous settings. The chapter provides a review of these levels of care, a
detailed description of the IOT level of care, an overview of admission and
placement criteria, and dimensions for assessment based on the Patient
Placement Criteria for the Treatment of Psychoactive Substance Use Disorders
developed by the American Society of Addiction Medicine (Hoffman
et al., 1991). This chapter highlights the importance of individualized
treatment planning and the use of specific treatment goals.
Chapter 3 -- Components of an Effective IOT
Program
To provide a balanced perspective on IOT, this chapter includes a discussion
of the rationale for IOT, as well as the advantages, disadvantages, and
challenges faced by IOT programs. The chapter describes treatment services
that, although not proven to be essential, can be considered core elements of
IOT programs, and treatment services that can be considered optimal elements of
an enhanced IOT program. Common clinical issues such as retention and relapse
are discussed.
This chapter provides an overview of human resource issues and program needs
associated with an IOT level of care. There is a discussion of the recommended
professional qualities of staff members. Guidelines for clinical competency,
such as skills for evaluation, counseling, and family therapy and knowledge
about self-help resources, case management, and crisis management are outlined.
There is also a description of ethical guidelines, professional education
standards, staffing level guidelines, and staff stressors. The chapter also
recommends specific ways that IOT can be designed to support treatment staff
members.
Chapter 5 -- The Treatment Needs of Special
Groups
This chapter describes the treatment needs of some special groups, including
women, cultural and ethnic groups, homeless people, gay men and lesbians, people
with HIV or AIDS, elderly patients, persons in the criminal justice system, and
patients with combined psychiatric and AOD use disorders.
Chapter 6 -- Special Fiscal and Administrative
Issues
The TIP includes a discussion of financial issues related to public and
private funding, managed care, and program costs. There is also a discussion of
quality improvement issues, including guidelines for program evaluation.
The final chapter describes some common legal concerns associated with IOT,
many of which have ethical implications. There is an overview of the Federal
laws and regulations protecting the rights to privacy of people seeking or
receiving AOD treatment services. Rules governing the use of consent forms are
discussed. This chapter reviews the rules for communicating with others about
AOD patients, including how agencies communicate with one another and how
programs can warn others of a patient's threat to harm. Exceptions that permit
programs to disclose information are described, and practical information about
patients' right to confidential services and the use of legal guidance is
provided.
Summary
The development of the IOT level of care is a partial response to many of
the changes taking place in the addiction treatment field and throughout the
national health care system. This TIP was written to provide information about
the IOT level of care; to educate providers, payers, and others about the
appropriate use of IOT; to encourage further development of IOT; and to assist
IOT providers to evaluate and improve their programs. It is the hope of the
consensus panel that this TIP and the further development of IOT will help
target the level of care to patients' needs, rather than expecting patients to
adapt to levels of care that are more or less intense than required. IOT is a
valuable, cost-effective, and clinically effective segment of the continuum of
care for AOD use disorders. It is hoped that this document will serve as an
impetus toward the further demonstration of the efficacy of a continuum of care
and a multidisciplinary approach to the treatment of AOD disorders.
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