Getting patients the services they need using a computer-assisted system for patient assessment and referral—CASPAR

Abstract

The two goals of this technology transfer study were to: (1) increase the number and appropriateness of services received by substance abuse patients, and thereby (2) give clinical meaning and value to research-based assessment information. A software-based Resource Guide was developed to allow counselors to easily identify local resources for referral of their patients to additional clinical and social services. Two hours of training were provided on the use of the guide. It was hoped that this software and training would provide the counselors with a concrete method of linking the Addiction Severity Index (ASI) assessment information on patient problems to appropriate, available community services. We expected improved treatment planning, increased problem services matching, better patient–counselor rapport/satisfaction and better patient-performance during treatment. Data were analyzed from 131 patients of 33 counselors from 9 treatment programs, randomly assigned to 2 groups—Standard Assessment (SA) or Enhanced Assessment (EA).

Patients of counselors in the EA group (1) had treatment plans that were better matched to their needs, (2) received significantly more and better-matched services than patients in the SA group, and (3) were less likely to leave treatment against medical advice and more likely to complete the full course of treatment than patients of counselors in the SA group. They did not have higher levels of patient satisfaction or helping alliance scores. These findings are discussed with regard to integrating empirically supported procedures into contemporary, community-based substance abuse treatment.

Introduction

There has long been recognition of a gap between what is known to be effective clinical practice—as judged from the scientific literature, and what is common practice in “real world” conditions (Lamb et al., 1998). Over the past 10 years there have been significant advances in the development of effective medications, procedures and behavioral interventions for the treatment of addictive disorders (See Institute of Medicine, 1995, Lamb et al., 1998). For example, a number of admission procedures have been found to significantly increase intake attendance, including phone reminders (Dexter and Goetzke, 1995, Kluger and Karras, 1983), mailed reminders and phone orientations (O’Loughlin, 1990, Swenson and Pekarick, 1988), and decreasing the call-appointment delay (Festinger et al., 1996, Stark et al., 1990). Additionally, intensive case management (McLellan et al., 1999), the participation of family members in treatment (Higgins et al., 1994, Sisson and Azrin, 1989, Carise, 1992, Carise, 1995), Behavioral Couples Therapies (Fals-Stewart et al., 1996, Epstein and McCrady, 1998, O’Farrell and Murphy, 1995) and Motivational Interviewing (Miller and Rollnick, 1991) have all been shown to improve treatment effects.

While these therapies and interventions have established empirical support and acceptance within the scientific community, they have largely remained undelivered in community treatment programs. New and effective treatments, in any form, cannot help patients if they are not practical, accessible or utilized and researchers cannot simply assume that a “scientifically” better intervention will be advantageous, desirable, or even cost effective. To bring validated, effective interventions into community-based treatment programs, scientists must be aware of the significant economic, political, technological, and practical issues faced by the treatment community (see McLellan et al., 2003, Carise and Gűrel, 2002, Carise et al., 2002). There is a recognized need to increase the transfer of what we have learned through clinical research into widespread treatment practice (Backer and David, 1995, Lamb et al., 1998).

Perhaps the best place to begin this technology transfer effort is with one of the most fundamental clinical processes: the initial assessment and treatment planning activities. Accurate patient assessment, which fosters the ability of substance abuse treatment providers to meet their patients’ needs, may be one of the most important yet under-emphasized elements of contemporary addiction treatment. The clinical logic behind patient assessment and service planning process is direct. If patients’ problems are accurately and comprehensively assessed, they may feel “heard” by their counselor potentially leading to the development of rapport and even a stronger helping alliance (See Luborsky et al., 1996, Barber et al., 1999, Barber et al., 2001). If this process leads to a jointly determined and feasible treatment plan for addressing the identified problems, the potential for the patient to continue with the treatment process is increased. If in addition to problem assessment and recognition, the counselor and the treatment program offer potentially effective services for the identified problems (either onsite or via referral), there is the potential for relief from those problems and with it, further likelihood of continued participation, increased retention (See Higgins et al., 1994) and the beginnings of the sustained, positive behavioral changes referred to as recovery.

However, current treatment assessment activities are widely thought to be time consuming and not clinically useful (See McLellan et al., 2003). Thus, if more clinically sensitive and useful assessment methods were developed and if they assisted the clinician in meeting requirements such as treatment planning and the biopsychosocial assessment, there is reason to think that there might be broad willingness to put them into practice.

The ASI is a research-derived problem assessment interview that allows for comprehensive assessment of patients’ problems at the time of treatment admission. The ASI interview produces reliable and valid measures of the nature and severity of patients’ problems (McLellan et al., 1985, McLellan et al., 1992a). Research has shown it can be used effectively as the basis for providing tailored, appropriate treatment services and that patients who receive services for their identified problems are more likely to remain in treatment and have better during-treatment and post-treatment outcomes (See McLellan et al., 1997, McLellan et al., 1992b, Hser et al., 1999). Because there are well-specified training procedures for the interview (See Fureman et al., 1994) and because of two decades of research findings showing that problem assessment and service planning with the ASI can be reliably, validly and usefully applied by researchers and clinicians across a wide range of patient populations and treatment settings, the ASI has been widely adopted by researchers and treatment providers in numerous countries (Sweden, Thailand, Egypt, Iran, Ireland, Chile, Brazil, France, Scotland and others) and across the United States in 27 different states, at least 80 cities or counties, and by large treatment provider systems (e.g. the Veterans Administration, the Indian Health Service, Kaiser Permanente, Value Behavioral Health).

Despite the broad use of the ASI in patient assessment, survey research in the US has shown the instrument is used largely because it has been mandated by state, county, or program administrators—not because it is valued for its utility by the staff who are asked to use it (See McLellan et al., 2003, Crevecoeur et al., 2000). Indeed, a recent survey of a nationally representative sample of treatment programs in the United States indicated that staff in these treatment programs considered the problem assessment–service planning phase of treatment to be merely “paperwork” with no inherent clinical value (See McLellan et al., 2003).

Why would this clinically important and administratively required clinical procedure be considered so trivial? Based on hundreds of ASI trainings, we had a simple working premise: the process of doing an ASI (or any admission assessment) was frustrating to the counselor since it is time consuming and in most cases does not take the place of the additional admission forms and narrative summaries they are required to produce. Moreover, most programs do not have adequate services available onsite that would address the various health and social problems presented by these patients, the process of finding appropriate off-site services for patients’ problems is inherently difficult and time consuming and most addiction counselors are not trained to do this type of case management activity.

We hypothesized that if this research-derived, assessment tool (the ASI) could be made more relevant to the clinical tasks of assessment and treatment planning, it would be better implemented, lead to increased patient engagement, and better treatment performance. With support from the US Office of National Drug Control Policy, we developed the computer-assisted ASI software suite known as the DENS ASI (the Drug Evaluation Network System Addiction Severity Index) (See Carise et al., 1999). The DENS ASI software reduces the time necessary to complete the ASI interview, but more importantly, provides many of the necessary reports and patient-level narrative summaries required by treatment regulatory agencies, accrediting and managed care organizations.

In the course of over 250 ASI and DENS trainings in the United States our staff had encountered large phone-book type of compilations of social services providers within the local communities, including providers of physical and mental health, housing, parenting, employment, legal and other services. An example of one such compilation is the book produced by the United Way (“First Call for Help”). However, most of these books showed little signs of use, often because they were unwieldy or physically removed from the assessment process. We reasoned that if we were able to convert this type of information on available community services into an easy to use electronic format and then develop a brief training on how to link appropriate, accessible services onsite as well as within the community to the problems presented by patients in their ASI assessment interviews, we might enable a more comprehensive assessment and services planning process.

To this end, we requested permission from the United Way to use their electronic database as a framework to create the linking software for the Philadelphia area (referred to as the Computer-assisted System for Patient Assessment and Referral—CASPAR), and have made this software available at no charge to all our collaborating treatment programs in the Philadelphia, Pennsylvania area.

With this background, the present paper reports initial tests of implementing the CASPAR system in nine substance abuse treatment programs in Philadelphia, PA, USA. We hypothesized that if the technology were provided and counselors were trained in assessment and treatment planning (including using the CASPAR to link the patient problems from the ASI with free or low-cost services targeted to those problems), those counselors would show evidence of:

• A better match between the problems identified by the patient on the ASI assessment and the problems included by the counselor on the treatment plan, and

• a larger number and better-matched services or service referrals.

And their patients would show:

• Better counselor–patient rapport—specifically better helping alliance and patient satisfaction scores, and

• better treatment performance—specifically increased attendance and program completion rates.