Hello everyone and thank you for joining today's webinar, Navigating
the Future of Addiction Treatment with the A Sam Criteria
4th Edition.
My name is Brittany Terman with Optum and I will
be your host today.
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And with that, I'm going to hand it over to
Doctor Sarah Johnson, Senior Medical Director for Behavioral Health for
Intercol.
Doctor Johnson.
Good afternoon, everyone.
I'm Doctor Sarah Johnson, Senior Medical Director for Intercall for
Behavioral Health.
I'm an addiction psychiatrist by background and work closely with
the leadership and our partners at ACM and developing the
ACM Navigator tool, which we'll take a closer look at
later in the presentation.
I'm happy to be joined this afternoon by Doctor Corey
Waller, who I will turn the presentation over to now.
Thanks so much, Sarah.
I'm Corey Waller.
I'm the editor in chief of the 4th edition of
the ACM Criteria.
And yeah, the goal today is to give as as
good of a an overview as we can and answer
some common questions.
I mean this is a 700 plus page book.
So the ability for us to get into any of
the so-called weeds is pretty tough on this.
There will be plenty of access to that type of
education in the coming months.
So we will chat a little bit about that towards
the end.
But we're going to start with just walking through some
trends and challenges in the in the industry.
We're going to walk through the development of the 4th
edition of the criteria, which was a much more complex
approach than the previous editions, and then talk about the
collaborative efforts between a Sam and the different states.
And then, you know, some considerations to prepare for that.
So let's get started and talk a little bit about,
you know, some of the challenges in the addiction treatment
industry right now.
And I've been on, I've been on this ride for
a while now And what I've identified when I first
started this as the only prescriber of buprenorphine in my
city of 500,000 people when I first started in this
in the early 2000s till now where you know, we
have really grown the access to treatment, but we've disproportionately
grown that access specifically to opioid use disorder rather than
to addiction.
And so I would say the supply demand is a
in a little bit of a leveling out phase for
the opioid use disorder component, but we still don't have
a lot of supply of treatment for alcohol use disorder,
benzo use disorder, marijuana use disorder and those pieces.
And so the ACM criteria, as we talked about it
moving forward, really tries to build a system that is
agnostic to the substance and one in which we divide
the components of care up in meaningful ways so that
patients can get what they need independent of the substance.
But more about the physiologic risk, the emotional risk, the,
you know, relational risks that they have in society.
I would say access to care.
We're also trying to find out what access means as
compared to engagement and outcomes.
Again, getting somebody a medication for opioid use disorder is
really, really helpful.
It decreases mortality rates.
So we want to decrease the barriers to that, but
at the same time, we also want to make sure
that we are delivering more than just the medication because
the medication keeps them alive, which is the most important
thing.
And we also want to make sure that they're improve
their function and capability and don't just pivot to other
dilemmas while they're trying to work through this.
Which means that we need to use, you know, good
evaluation of them from a behavioral health standpoint, as well
as, you know, medically interacting with them to understand other
addiction adjacent illnesses, hepatitis, CHIV, skin infections, other issues that
may be going on.
I think there's also still quite a bit of confusion
about how to pay for addiction.
I find this acutely in my current position as ACMO
of a multi state outpatient treatment provider in that I
find some payers are paying for things that have almost
no evidence and then they're having to rate compress the
people who are delivering care that have solid evidence behind
it.
And I think we're still all working to try to
identify our footing.
I think there are also still some problems with the
the regulatory schema in the states as well as the
the alignment with payment.
Because Medicare has a really nice bundle payment rate for
what it looks like to take care of a patient
in an OTP.
Which interestingly if applied to a patient with alcohol use
disorder would also work really well or benzodiazepine use disorder
it would work well.
The problem is, is that only components of that are
paid for in some states based on a combination of
regulations and payers.
And so aligning those to the 4th edition will allow
really the fidelity of care to be delivered across states
rather than certain regions having good access to total care
and some other regions not having that.
I think a specific call out on the coverage slash
state rules would be access to nursing delivered withdrawal management
care in the outpatient space.
Some states pay for that, some some do not.
Some allow for nursing codes to be utilized for addiction
treatment providers and then some do not.
And so figuring out how we align that so that
we can do outpatient withdrawal management and have a nice,
you know, smooth transition from residential treatment to the outpatient
space is going to require more than just the criteria.
It's going to require to make sure that that transition
is covered as well as regulated appropriately to the levels
of care.
And then we're also still evolving in the treatment models
and we'll talk a little bit as we go through
about the role of telemedicine and Otps in this space.
And then I think the biggest one that I deal
with on a regular basis is the availability of providers
capable of treating Co occurring conditions.
And and I would expand that even out to a
lack of availability of providers just to treat the basic
addiction.
Unfortunately what we've done over the last few years, which
I think is counterproductive long term is to say we
don't have enough trained people to deliver care.
So let's lower the threshold for who can deliver care
and then we start to tip into areas where we're
not necessarily delivering evidence based care to that population.
And and we can drill into that a little bit
as we go.
And you know, for those that don't aren't aware of
the ACM criteria, the ACM criteria, it is the most
widely used in comprehensive set of standards for addiction treatment.
Clear majority of states either use it specifically through law
and regulation or at least have a something closely honed
to it or with that.
And it's been around since the late 80s and it's
overtime been improved.
I will say one way to constructively think about this
is that when the ACM Criteria was originally developed, it
was developed to better describe the care that was actively
being delivered at the time as compared to the 4th
edition which was developed to build the system of care
that the evidence shows works.
And so that's why there are some differences that we,
as we go through and keep in mind that the
methodological approach to the development of the 4th edition of
the ACM Criteria is really akin to what it looks
like to build an ACLS, you know, advanced cardiac life
support guideline or an advanced trauma life support guideline.
And that was the goal all along is to have
the evidence drive what it is that we say patients
should have access to for care.
If we look at, you know, the this this 4th
edition, one of the biggest pieces is that we've really
tried to make it so that the language is consistent
for medical providers and behavioral health providers and care management
and utilization management so that we're not speaking different languages.
We also tried to make it the easy button in
a way for regulators and payers because we were, we
were really clear on the language or tried to be.
I know we're not perfect, but we worked really hard
to make sure that if something needed to be done
that we said it needed to be done.
If something could be added, we were specific.
We modified how we talked about different levels of providers
so that if we said, quote nurse, we were very
clear that we said these are the skills that this
person must be able to deliver in order to do
it, rather than listing a title.
Because each state may have different scope of practice requirements
for an LPN versus an RN versus ABSN.
And so we wanted to make sure that what we
said is a person delivering this care needs to have,
within their scope of practice, ABC and D And so
while those titles may change at the state level, the
skill set required to deliver the care shouldn't.
And we really worked hard to make sure that we
could put that into a book so that if a
person walks in to an addiction treatment facility in state
A in demographic B, meaning they're in the rural space
and they're sitting here or urban in a different state,
that they have access to pretty clear pathways of care
that they could get in either one of those.
And you could exchange those and we would at least
know where they should go, even if we don't have
access to that.
A common theme as we talked through this is that,
well, we don't quote have that where I live.
And I think that if we look at the totality
of healthcare, that's how most of it works in a
sense, is that if you work in a I'm an
emergency medicine doctor by initial training.
And with that, I've worked in rural and remote hospital
settings in their emergency department, as well as level 1
trauma center, dense urban facilities.
And if I'm at a level 1 trauma center in
Philadelphia where I trained, I have access to every specialist
I could imagine.
But when I was working in an emergency department in
rural Michigan, I did not.
And so in order for them to get the care
that they needed, the gastroenterologist, the endocrinologist that you know,
the surgeon, we had to send them to the care
or provide that via telehealth on that side.
So we were tried to be as pragmatic as possible
about what is truly available and how the specialty access
sits in the ether of of healthcare.
Overall.
If we look at the core components of what really
occurs with the ACM criteria, it is the patient shows
up, we do a quick level of care assessment.
We try to make this as rapid as possible, meaning
as we talk about the dimensions in a minute, if
you have a problem with dimension 1 and you need
to go get care, we're done with that initial level
of care assessment.
It should take 3 to 5 minutes.
If you're sick and have level 1, we should be
able to get you to where you need to go,
whether that's the emergency department or residential treatment.
And then what we add is the dimensional analysis into
a deeper pathway which churns through the decision rules and
pushes you into the continuum of care.
This is what the old version did, and it kind
of only did this.
The 4th edition adds to this, a treatment planning pathway
that can occur within each of these circles so that
we make sure that we're doing more than just level
of care placement.
I always talk about when we were just using the
ACM criteria for level of care placement, it was something
that we had developed a Swiss watch for, something that
a sundial could do.
And you know, you could look at somebody and be
like, man, I think that person needs to go to
the hospital or that person needs residential care because of
a quick AB and C.
We don't need to build a massive 700 page book
to say he's a hospital.
We need the book to describe how to build a
treatment plan that has a continuum of care.
Who should be delivering those components of care, whether it's
medical, whether it's psychotherapy, whether it's psychoeducation, whether it's addiction
treatment supports, and how much of each of those do
they need?
So everybody needs some of those, but most individuals need
different amounts of those.
The good news is, is that there are patterns in
who needs what based on the type of disease they
have in the dimensional issues that we find.
And with those patterns, we're able to identify quote levels
of care that are really built specifically to handle that
pattern of maladaptive behavior situation.
And so if we look at the kind of the
guiding principles of where we started from this, you know,
we want to make sure that the patient ends up
where they need to be, not where, you know, maybe
they want to be or some random person thinks that
they should be, but where they need like if you
need medication, you go to a place where you can
get medication.
If you need psychotherapy or further Co occurring evaluation, that
that's where you end up.
And so that's important also with no arbitrary prerequisites, meaning
that you can't fail this or start this.
It is this is what the data says you should
get.
Let's go there.
The multi dimensional assessment, you know, is ultimately important from
a multitude.
And I would say the dimensional criteria that we talked
about in the 4th edition is the most important part
of the book.
And if you're going to pick any place to start
reading or to look at or to, to learn more
about it would be the dimensional analysis in the subdimensions
because that drives treatment planning and level of care all,
all at the same time.
We wanted to make sure that those treatment plans are
individualized and are not just like cookie cutter for people
who walk in that we have interdisciplinary care, evidence based
handle Co occurring biomedical, all of those things.
And and we utilize these guiding principles.
And then we pushed it through a methodological program with
a modified Delphi methodology with a 18 writing groups, 130
plus authors, 3000, you know, comments, thousand plus fully extracted
articles so that we could pull it into the writing
groups that then would grade each of those things.
It would go to an external source to be looked
at and come back in.
And then it went through full editorial review for those
pieces.
So it wasn't two or three people sitting in a
room deciding what quote the country should do for care.
This was built so that it had the data behind
it and could stand the test of time.
And with that, you know, those those goals are to
make sure that we are building a science based specialty,
that it's not just, you know, how I got better
and this is what I want to do.
You know what I think works because what I've seen,
we don't need anecdote or other person's history to deliver
that.
We need those things for experience and wisdom, but not
to initially determine where somebody should go for care when
there's clear evidence and how to approach that.
Definitely moving toward the chronic care model, especially for those
with the disease for an extended period of time and
the facilitate that patient centered care.
In fact, we have a whole dimension that is specifically
built for that patient centered approach to care and then
wanted to make it again the easy button.
That is something that we harped on throughout this.
Again, this is what we talked about.
Writing committee evidence, review, review the 3rd edition standards, draft
the new standards based on the evidence, went through voting
panels, public comment, and then then it went through the
drafting and narrative review section editor reviews, my review.
I've read this book now almost 7 times and every
time I read it, I find things and I'm like,
oh, we should have explained that a little better.
And we will because we're going to be updating this,
at least the minutia of this, not the structure of
it.
But we'll be making sure that we issue clarifications and
updates and areas that need to be more specified either
every year starting, starting this year.
So is the goal.
And then as it went through there, it also had
to have the RQIC in the board review and approval
process.
So this took 2 1/2 years from start to finish
to get the new addition built and out some of
the biggest new pieces.
And I think, again, this is for those familiar with
the ACM criteria, you'll recognize what the third edition dimensions
were on the left.
On the right are the 4th edition versions of this.
And I think it's important of note, we removed readiness
to change as a specific dimension mainly because it did
not impact level of care decisions.
It's something that should be integrated into all dimensional analysis
of are how ready are you to change your intoxication
risk?
How ready are you to actually treat your biomedical conditions?
How ready are you to approach your cognitive or psychiatric
disorder?
So, so in the end, instead of it being a
singular one, it's incorporated into all of those.
And then dimension 6 was added for person centered consideration.
So if we look at those first 3 dimensions, I
call those the death dimensions because if we miss something
there or don't get you into the appropriate treatment for
those, it will kill you quickly.
If you're intoxicated and I don't recognize that you're going
to have an an issue with your respiratory rate, you
can die.
If you're an overt withdrawal from alcohol and not getting
treatment, you can die.
If I don't start you on addiction medications to appropriately
decrease your craving or stabilize that withdrawal, you can die.
So we can have four questions in that first, dementia
and realize I'm done with the initial assessment and you
need to go to the hospital.
Biomedical conditions the same.
You can have nothing in one, but you're in congestive
heart failure in a fib and I and you need
to go to the hospital.
You can be acutely psychotic or suicidal or homicidal and
those things need to be immediately taken care of.
And somebody's not going to want to sit there for
an hour and a half and have a chit chat
about their childhood.
So we want to make sure that those death dimensions
are identified quickly, that the patient gets to the level
of care that they need so that we can continue
to treat them appropriately.
Then we move into the clinically focused dimensions, dimension four
and five.
And these are the functional dimensions that we have, the
death dimensions and the functional dimensions, the substance use related
risks.
How likely are you to go and buy drugs when
you leave my office Is a simple way to think
about that.
Recovery environment interactions this is really important to think about
because as we have people that may have a place
to live, I know a lot of 22 year olds
whose parents are like, I'm happy to take them back,
please get them into my house.
But the minute that person shows up, it's a complete,
you know, knock down, drag out fight in that house.
And so that is recovery environment interactions not do you
have a roof because those are very different things.
And we use dimensions one through 5 to determine the
level of care.
Once we've done that, we look at the dimension 6,
those person centered considerations and then we get to well,
if we're unable to get them to the level of
care that they should go to IEA level 3.5 Coe
residential treatment provider.
And you're like, we don't even have one of those
in our state.
My answer is yeah, no, that's, that's that is true.
And so this is where we get into know differently
than the other specialists and that we have to either
refer or we do the best what what we can
with what we have.
So as we get into it, the way to think
about it is if somebody needs IOP, right, 2.1 IOP
and but I'm not an IOP and there's not one
anywhere that they can get transferred, you know, transportation to
we can work on just is seeing them more often
to get them as close to that level of treatment
as we can, but we definitely don't want to not
give them treatment.
So we recognize those realities, but that six allows us
to really create a, a plan that is bespoke for
not only the location that this person is in, but
their needs as well.
Maybe they have a loved one, they can't go to
resident residential treatment because they got to take care of
somebody at the house.
They have kids, they have a pet they don't want
to leave behind.
These are all things that we run into and that's
what dimension 6 is there to help us out with
as we develop the level of care components.
We do the dimensions one through 5, we talk about
6, we apply that through the dimensional admission criteria.
There's always a question in this new one like, well,
where's the risk rating?
Or that the risk ratings in the dimensional admission criteria
are now the same thing.
Because what we found in the 3rd edition is that
some people would look at the risk ratings, but not
look at the dimensional mission criteria and vice versa.
And then we were getting into utilization management arguments.
And so we've now integrated the risk ratings into the
dimensional admission criteria and that need to recognize those patterns
of care for a combination of medical or psychotherapy or
psycho education or addiction treatment supports led to the development
of these levels of care.
For those of you who knew the 3rd edition, we
have eliminated the quote withdrawal management levels of care, which
were a parallel set of levels of care.
Those are now integrated into here.
And the .7, the medically managed care levels are where
those withdrawal management levels went.
But they also allow us to do more than just
withdrawal management.
They allow us to get rapid initiation of medication, aggressive
consistent treatment for hepatitis C, HIV, other infectious disease issues
in those places, those addiction adjacent illnesses and for people
with complicated longer term medical conditions that need that ongoing
support but don't need to be seen every day or
every week.
Then we have that 1.7 which allows that to happen.
So if you look all the way to the right
four, that is a hospital A4 psych as a psych
hospital, which is different.
A level 4 medically managed inpatient is where you have
a addiction specialist in a hospital that can get somebody
into an ICU.
Most, I would say a lot of hospitals don't have
don't have that.
They may have an ICU, but they don't have an
addiction specialist.
And then we have the psychiatric hospitals which don't have
IC us and that but so we don't call it
a level 4 unless you are a hospital with immediate
direct referral to the ICU 3.7 medically managed residential.
That is where withdrawal management takes place for someone who
requires overnight monitoring but doesn't need all of that intensive
care risk that a hospital can provide.
So the way to think about it is overnight access
to medical providers in a four overnight access to nursing
providers and a 3.7.
And then we have 2.7, which is the outpatient version,
meaning it has all the same employees as a 3.7.
But somebody doesn't need overnight monitoring to have a safe
place to go.
They're able to take their beds.
They have somebody to call or drive them if they
have issues.
And so this would be a level 2.7.
And the only difference between a 2.7 and a 3.7
is overnight monitoring.
It's the only difference between who needs to be hired,
what the scope of care of delivery is and all
of those things.
The only difference is that overnight monitoring piece and then
1.7 is for that person who needs, you know, weekly
or monthly continuing care because they have a mild disease
and their dimension 1-2 and three is there, but very
mild for that interestingly is a pattern.
If you're looking at this, if you look at that
top right 3.7, if you are a 3.7 and you
have an outpatient office connected to it, you can be
every other level of care without having to hire another
person.
So it's built so that if you're a three seven
without having to hire another human being, you can be
A-35 without having to hire another human being, you can
be a three one.
So somebody can get all of those levels of care
in the residential space.
If you build a three seven, it's just about modifying
the programming to fit what they need.
And if you have an outpatient connected to that, then
you have all of the staff and scopes of practice
required to also deliver 271725152.1.
You can do all of those things out of a
three seven.
And if you're a 27, you can also deliver everything
below and to the left for that.
And if you're a 3/5, you can deliver everything below
and to the left.
And that's the way that this was designed, so that
if somebody builds a 2.5, they have everybody that they
need to also be A-15 and A2.
What and and this way instead of having each of
these have to have their own designated license, their own
designated, you know, issues that we that we look, you
know, have to monitor and a whole different group of
people responsible for interacting with it.
We can say this is licensed as an outpatient Sud
provider and they are licensed to provide these levels of
care and it simplifies the licensing aspect of you know
of the States and have they write the regulations as
well as how we you know pay for it.
We have added level 1.0 which is outpatient and this
is long term remission monitoring.
These are for patients who have had greater than one
year of being in remission and just need a specialty
touch up.
The way to think about that is if you have
someone who has diabetes, their primary care may be managing
that, But once a year they pop in and see
their endocrinologist because they're going to ask different questions that
a specialist might ask.
And it's no different for patients with addiction.
And so if we have patients with addiction, most primary
care docs aren't going to do a recovery capital assessment,
right?
They're not going to reevaluate the dimensional analysis to make
sure that they're doing OK in each of those dimensions
and that they're connecting with relapse prevention pathways.
They just don't know that.
So that's what one point O is meant for.
And then we've added recovery residency, which is specifically pegged
to what the old National Association of Recovery Residencies level
2 is the NAR level 2.
And this is for people who don't need overnight monitoring,
but still needs skill building in in a place that
has the ability to, from a peer standpoint, interact with
them in the same location on a consistent basis.
Because many of our patients ultimately have to relearn how
to live their life in a sense, do the laundry,
make food, do those things.
And so the recovery residencies allows for those things to
happen.
So there could be a situation where you have a
2.5 with a recovery residency because they don't need a
licensed individual to be there overnight with them, but they
need to have a place to stay that is therapeutically
aligned and capable of doing that.
So we've now defined that as a specific level of
care for that population.
If we go to integrating the Co occurring capability, if
we look here you can see Coe and you see
Coe at 3-7 and three five.
The reason you don't see it at the point ones
is because Co occurring enhanced requires masters level professionals to
be delivering care.
So masters level or above and in A31 and A21
only require supervision from that.
So they don't have the requisite staff to be able
to deliver it.
And So what we did from the previous one is
that we integrated Co occurring capability, which is different than
Co occurring enhanced capability means that I'm designed with the
expectation that the clear majority of my patients is going
to have a mental health disorder that we need to
identify.
And we need to refer as well as the ability
to manage low acuity stable patients without having to clog
up our psychiatric colleagues offices on patients that honestly we
should just be taking care of because it is such
a common reality in this population.
Creating integrated treatment plans appropriately so that we're talking with
those outside providers consistently and delivering care that takes that
into account and then making sure that the program content
addresses those Co occurring conditions as we deliver it.
This is built just to show you that all of
these pathways exist.
And as we've integrated the risk ratings into the dimensional
admission criteria, there are a bunch of yes no questions
you can quickly run through.
This is to determine which medical level of care, which
means they're dimensional drivers or dimension 1-2 and three.
And as you go through there, you should be able
to quickly identify who needs to be at the hospital
versus out at a 1.7.
And so we've now done this for each level of
care to make it a lot easier for people to
quickly move through that level of care assessment from the
decision rules.
And we published all of those in the book.
So you don't have to go hunt the hunt those
down somewhere or reconstruct them.
They're all very specifically put out in that pathway and
the journey.
It looks a lot like what it is, but it's
a little more constructed in the reassessment piece.
So level of care assessment, dimensional admission criteria, they get
the treatment at whatever level.
As we're doing this treatment planning, we then work the
plan.
The plan should be something like the primary issues with
this patient or dimension 1, continued intoxication.
Patient continues to seek out other means of intoxicants despite
being on medication assisted treatment for opioids and is now
using a lot of marijuana.
So we're going to focus on that.
So they're dimensional driver is dimension 1.
It makes it easy to treatment plan when you use
the dimensions because then you can clearly state this is
the dimensional driver.
This is the intervention that we're going to apply to
that.
And this is the outcome that we agreed upon together
that we would like to see.
And then you continue to reassess each of those dimensions.
And if you take care of that dimension 1 and
now they're dimensional driver is dimension 4.
Now they'll go from a .7 level of care needing
medical intervention down to a .5.
So that's the way that we built it.
So that the core of this is really understanding and
utilizing those dimensional drivers, the chronic care model.
You know we talked about Co occurring integrated withdrawal management
and biomedical services.
One thing I do want to point out on this
slide with the levels of care as we look at
it quickly is the one place where we left bio
so 3.7 cuz these are again medically managed and so
why did we call out bio?
Well bio at 3.7 specifically delineates a medically managed residential
treatment that can do Ivs and wound care with a
wound vac.
We wanted to put that as a standard treatment capacity
for all of three-point sevens.
But when we went out and had it reviewed by
the people out in the ether who do this work
on a regular basis, they're like, that is not an
easy ask.
And we recognize that there's a small percentage of ones
that can actually deliver that service.
And then it's going to take a a while for
people to get up to that level.
So we've separated that out with the full intention of
eventually 3.7 bio just being rolled into a standard 3.7.
But for now they are separate.
And so again, the difference between 3.7 bio and 3.7
is the ability to deliver IV infusions and medications as
well as wound care via wound vac management.
All right.
And if we get to again, back to here, we
look at the shared decision making, the holistic approach in
that chronic care model, integrating recovery support services.
Again, you have a bank account, you have an ID.
Can you, you know, make your own appointments?
Can you own, you know, some of the organizational capacities
of your life?
Those are really, really important given that addiction is ultimately
a disease of isolation.
This allows for us to help them to reintegrate back
into society and then recognize and start to implement plans
for treating those the social determinants of, of health and
then getting people transitioned appropriately between levels of care.
So they're not like, all right, great.
I had withdrawal management and then drop off a Cliff
and disappear.
We, you know, so the whole goal with this is
to have that seamless transition of patient care as they
move through the system.
New content.
We did spend a lot of time talking about treatment
planning.
Again, a big focus for this one, telehealth and other
technologies integrating recovery supports, trauma sensitive practices, pain, cognitive impairment.
These are things that we spent a lot of time
talking about how to integrate those into care and you
know, again, expert panels and pulling the data to be
able to deliver those pieces.
All right, a couple of I'm going to answer a
couple of questions that popped up that I think are
relevant to this.
So a question that pops up is what level of
care is an opioid treatment program?
An opioid treatment program is like a methadone clinic.
Clear, not anymore.
I mean, it's methadone and buprenorphine and others.
But that the old school methadone clinic OTP, what level
of care is that?
Well, the way that it's designed is that an OTP
in the way that Samsung defines its staffing could be
a 2.7 or 1.7 right out of the gates without
having to hire another person.
They can do both of those things just depending on
hours of operation and what specific things they want to
deliver.
So the OTP or opioid treatment program is built into
2.7 and 1.7.
Those are the, those are the levels of care.
Now clearly they have all the staff, if they want
to do 2.5 or 2.1 or 1.5, they can also
deliver all of those 'cause they have all the staff.
It's just about developing the programming to deliver those intensities
and types of care.
The other is telemedicine.
Like where does that fall into this?
Well, the way to think about telehealth is it is
a mode.
It's not a level of care, it is a modality
of care.
So the totality of care, we found no evidence that
the totality of care can be delivered via telemedicine.
Here we looked if it was a level of care,
the data would have shown it and we would have
done it.
Is it a way to effectively and efficiently get somebody
medication?
Absolutely.
So for opioid use disorder patients, can the initial visit
be done via telemedicine?
Based on the data, the answer is, yeah, as fast
as we can get them on medication, the better.
Can the totality of their care be delivered via that
metric without, you know, appropriate psychoeducation or, or psychotherapy or
other addiction treatment supports?
The data doesn't show that it can.
It's an incomplete version of care, but it can definitely
be added in to the other comprehensive care.
So the people have quick rapid access, especially for those
that have transportation issues or a homebound or have disabilities,
you know, we should be able to work with them
where they are.
The other one was what happened to 3.2 withdrawal management.
It was rolled into the 3.5 and the main reason
being is 3.2 was asking people to work outside of
their scope of practice.
So it was asking counselors and social workers to deliver
what is ostensibly medical assessments.
And that wasn't very, very cool.
So what we did is we rolled it in 3.5,
which requires a medical director to write policies and procedures
and and that's where that currently lives.
And again, the risk ratings are integrated into the dimensional
admission criteria.
So those are now the same thing.
All right.
So reasons to adopt the 4th edition and some of
the barriers to getting that done.
So at this point, I would say most of the
payers would love for the 4th edition to happen pretty
quickly.
And what I've found is that because they don't want
to have to administrate the third and 4th edition at
the same time, it's just really complex to to do
that from for many different ways.
And the states have to do a couple of things
in order for this to to happen.
So the states have to have the actuarials evaluate how
much money it cost to deliver the 4th edition and
have that rolled into what we call the cap rate,
which is the amount of money that states are paid
to deliver Medicaid Services.
And then that cap rate is adjusted based on the
new criteria.
That then rolls down into the managed care organizations or
however states administer their Medicaid product.
And then it gets the payers then utilize the 4th
edition to deliver that care.
But that means that the states will have to write
the regulations that allow for these new levels of care
and those new levels of care.
Will be licensed to deliver the appropriate intensity and scope
of practice of care.
Once that's done, then we have billing codes.
Those already exist.
We made sure that everything that we said needs to
be done matched an existing code.
So there's no magic of having to invent that.
It's just again, putting it together.
I'd say again, Medicare, their bundle did a really good
job of incorporating what typical addiction care looks like.
The biggest issue is how often somebody sees a medical
provider or has access to a nursing provider or targeted
case management.
Those are the areas of conflict across the states.
But once we figure out the cap rate, how that
gets paid for and the licensing piece, which is all
happening in real time right now, that's when it trickles
down to the providers.
Now what I will say if you're a provider like
I am and we just will be fully compliant with
the 4th edition in January because we've modified our notes
to flip the dimensions.
The the level of care is higher fidelity in the
outpatient space for the 4th edition, meaning it may say
2.7 or 1.7 or 1.5.
But the way that that's talked about in the 3rd
edition is just level 1.
So it's actually easier to just move to the 4th
edition as a provider and then slide that over pretty
quickly as soon as everything else catches up.
And I if you're a residential treatment provider, it's not
as easy because we have withdrawal management sitting parallel to
the other levels of care as a residential provider.
But it is definitely doable for all of those.
But the 1115 waivers will have to be updated and
that's so by 2026 is when I think we'll be
seeing a, you know, when the clear majority of regulations
have caught up.
Many states will already be doing this next year and
many of the payers have already started beefing up internally.
And therefore the 1115 waivers and all in the cap
rates, all of that's going to happen next year.
But 2026 is when I think that we're going to
see the largest portion of states move over to the
the 4th edition.
Why is this important?
It's consistency.
We can have a common language like if I work
in, like I said, that level 1 trauma center, or
I go work in that rural center and somebody walks
in and is having a heart attack.
It doesn't matter which one of those places that I'm
working at.
The standard of care and the evidence is the same.
You need somebody to go in and open the artery
on your heart so it gets more blood and more
oxygen to the myocardium and so you don't die.
And the only difference between a rural place and an
urban place is whether or not you get a helicopter
ride to get that needle and that, you know, stent
placed in in your heart.
And so we need to figure this out for addiction.
And we're getting really close, but once we've established that
this is the way in which we treat care, then
we can have the consistency like we do for trauma
centers.
So like a level 1 trauma center, level 2 trauma
center, those are the same throughout the country.
If you say level 1 trauma center, we know what
that means.
We know what staff they're going to have, that they
have a research capability, that training capability.
If it's a level 2 trauma center, we know that
they have less research, typically less training, but still have
the ability to deliver the specialty services.
We know all of those things.
And so it's very predictable to build systems of referral
around those.
Whereas right now we got like Jimmy John over here
is doing this and then my place is doing this.
And we're kind of this is what we do for
outpatient treatment.
It's a freaking mess.
And so this way, this will help us to clarify
to the field, this is what we do.
Just refer the patient will identify which level of care
they need.
That level of care will reflect how much medical psychotherapy,
psychoeducation and addiction treatment supports care they need.
And then they will get that until the dimensional drivers
say that we need to do a different level of
care and the barriers.
We talked a little bit about this, probably talked a
lot about that.
That by itself is a three hour lecture.
But we're going to work through these places.
This is one of the many things I will say
that ACM has done a great job thus far.
We've built a ton of education in parallel.
So this year and next year you're going to have
more education than we've ever rolled out for the third
edition.
The state adoption.
This is all the stuff that we talked about, you
know, on those pieces.
And then driving the state adoption again, just cannot build
it enough.
You need to be involved in helping your state's right
the 1115 waiver so that they recognize what care needs
to be delivered.
We have a ton of implementation processes and tools that
are on open and free on the ACM website and
a ton of guidance.
You know, we have webinars like this, but we're putting
together hours and hours of training depending on if you're
a counselor or a therapist or medical provider.
And those will be available to the field already available
on the ACM website.
But we'll have a ton of free ones that'll be
coming out on a combination of YouTube and state websites
that'll be available everywhere and coming from the source rather
than somebody's interpretation of it.
And then all of these things have to, you know,
be supported.
And what I will say is that we have a
unique opportunity now because we still have a bunch of
the opioid settlement dollars sitting in the ether.
And so the a good utilization of those funds would
be to help providers get ready for this through training
and electronic health record updates, helping payers get ready for
this by building dashboards and pulling data and creating, you
know, local state collaboratives, getting policy makers through the Governor's
Institute and many other forms in which they can interact
to get on the same page for how they talk
about this.
And then healthcare systems, once it feels more familiar with
them, they'll know how to integrate this into a standard
healthcare system because right now they just have no idea
how to do this at scale.
All right, I'm going to hand off to my colleague
here and then we'll go from there.
Thanks.
Thanks so much.
Doctor Waller.
You have your description of all the complexities and challenges
have teed up my part of the presentation perfectly.
So we'll take a a quick look at a tool
that we we hope can help ease the transition and
support clients through the change to the 4th edition of
the ACM Criteria and then hopefully leave a few minutes
at the end for questions.
So if anyone has questions that they have not yet
entered into the chat, it would be a great time
to do that.
The ACM Navigator was first released in 2021 with the
3rd edition ACM criteria.
I did see a question in the chat about how
long that will be available and we do not have
any plans to completely do away with that.
And it will live in our historic criteria because we
realized that that some it may take some clients some
time to convert over and that will continue to live
in the historic criteria.
Although our current development efforts have moved on to the
4th edition and creating that and maintaining that in our
criteria.
This software tool was the culmination of months of talking
with payers and providers, along with our colleagues at ACM
about the challenges in the real world facing those that
work with Sud patients.
And what resulted was an interactive utilization management tool that
moved the criteria into a software program that streamlines and
improves the Sud review process.
What we found in talking with people across the country
was that major barriers were efficiency and also as Doctor
Waller described, getting payers and providers to speak the same
language and they need to do that in an efficient
manner.
And that's exactly what the tool is intended to do.
So as I said, this tool was developed through an
exclusive partnership with a Sam and we have enjoyed working
with their leadership so much over the past a few
years and look forward to hopefully a long productive future
together building out all of all of the new content
that they are creating with the future editions of the
criteria.
It provides a seamless workflow integration for both intercall and
non intercall users that can bringing the criteria into their
peer management systems and in a very seamless fashion so
that they're not going back and forth between books and
and computer system.
It's all right there for the user.
It uses an interactive question and answer format that condenses
reviews into less than 15 minutes.
Some of our users report that they have done reviews
as quickly as 7 minutes.
We always tell them it's not a race, although we
we do realize that they value that efficiency and we're
glad that we can support that.
This tool is comprehensive content.
It includes all the dimensions and the levels of care
that we talked about earlier in the presentation, and it
is considered to be fully consistent with the ACM criteria.
Doctor Waller and the the staff at ACM review the
content that that's in this tool & off on it
and many of our users are able to use it
to fulfill state mandates.
And then finally, there's also inter rater reliability as well
as transparency solutions that many of our clients found valuable
when when they are required to use those by accrediting
bodies or states.
So all of the dimensions and levels of care that
that we looked at earlier in the presentation are set
up into a very easy to use question and answer
format that covers the full continuum as well as all
the domains of the ACM assessment.
As you answer these, this assessment starts with the level
of care requested because we know that that's how reviews
come to people that are they're doing this work in
the real world.
And as you answer a question, a very complex algorithm
behind the scenes drives you to the next question based
on your response and you end up with a recommendation
that tells you whether or not the level of care
that has been requested is appropriate.
And it also provides service recommendations such as prompt medical
evaluations for patients who may have who may have some
of those that I like that the death dimensions that
may have concerning answers and those also a recommendations for
continuation of medication for abuse disorders or recovery residence work.
Since we've created this product, one of the things that
I have have gotten to do is provide support to
our clients that are using it.
And overwhelmingly they like this tool and find it helpful.
They find that it increases their efficiency and they find
it easy to use.
And when they do have challenges, we are able to
very quickly either provide answers through the support that that
we provide in house.
And if it goes beyond user applications or software issues,
if it's something more related to interpretation of the criteria,
we are able to directly connect them to the experts
at ASAM and that that's very fun and rewarding.
What of our clients Colorado Access?
They, they and their legal department were were kind enough
to provide us with a testimonial about their use because
of their enthusiasm for the product and and since acquiring
the ACM Navigator, it has allowed Colorado Access to streamline
our case review process and improve efficiencies in our reviews.
Consistency and air prevention are crucial for healthcare.
The ACM Criteria Navigator is helping maintain a reliable and
accurate process for Colorado Access.
This was a significant improvement to our workflow and our
team's efficiency and we we just love getting feedback of
that nature because those are the things that this product
was just was designed to do.
Then another question that that I've seen in the chat
and and Doctor Waller may wish to speak more specifically
to this at the end, but I saw a question
regarding how to prepare teams for this transition.
And while the the product can can help ease growing
pains with the transition, we also provide education support when
when clients license the tool, they have immediate availability of
an on demand webinar that really focuses on using the
the the platform in the Aircol platform.
It does not go into great depth about the actual
criteria because many of them are already using that and
that's just not as big of a lift for them,
Although it does provide a high level overview for those
who desire more in depth education.
Things that that can be provided would would be office
hours or supplemental education program through our education department and
we provide ongoing support to clients if they are having
challenges using the tool or applying the criteria.
And something that we'll be very excited to offer after
the first of the year for clients who either desire
or mandated by states to receive training directly from a
Sam is, is a reseller program where we will be
able to make the ACM fundamentals course available in the
same learning management platform.
And, and again, as, as clients use the tool, we,
we have a very, very efficient client support team and
education team that they are able to send escalations through
and, and we help them address those as quickly as
possible.
So I'll transition back to Doctor Waller to talk more
in detail about future plans, but did want to highlight
the the road map for future editions of the ACM
criteria, all of which will be built out into the
Navigator and available for use in the tool.
Great.
Thanks, Jessica.
I appreciate it.
And the, and so this is take this with a
grain of salt as some things are moving faster than
we hoped and some things are, you know, going to
take take their time.
But the at this point, all of the dimensional admission
criteria have been pressure tested.
We're almost done putting it into our continuum platform so
that we can test it at its scale with you
know, about 15 to 20,000 patients a month on that.
So that's going to be helpful for us.
But we've sent this out for testing.
We've identified a couple of little algorithmic pathways which will
need to be updated, but that's that's already there for
the adult.
Now for adolescents and transition age youth, this is the
big one.
And so right now we already have the framework out.
We are currently testing the dimensional emission criteria for the
the adolescents.
And it is similar levels of care, but a little
different because a lot of the care is being pushed
down based on the data that we found as we
did all of the methodological evaluations for this, we found
that the outpatient levels of care and the school based
and home based levels of care needed to be much
more enhanced and, and the major focus.
So those are being tested and defined specifically.
And So what we'll find is in probably Q1 of
next year, so 2025, we will have the finalized version
of the dimensional admission criteria, the levels of care, all
of the scopes of of practice so that people can
start to absorb especially regulators and payers because a lot
of them are waiting for the adolescent version to come
out before we fully roll out the quote totality of
the 4th edition.
So Q1 next year, which is right around the corner.
That's, you know, couple of months we should have that
out for consumption and then by Q4 of 2025, possibly
earlier, we'll have the book completed to send to the
publisher and then Q 12026.
So it'll be done for all, you know, regulatory purposes,
Q1 next year, done completely from a written standpoint, Q3
to four next year and then the publisher will roll
that out and Q1 of 2026.
But we're closer than what this looks like from the
actual work product.
But again, we want to take the same care that
we did for the adult version to make sure that
we get it right out of the gates.
I'll pass right back to you for this one.
Or is this this one?
Yeah, no, this one's.
I can speak to this a little bit as well
and then hand it over.
So they're working with provider networks.
This is going to be really, really important.
So ACM has a number of videos that are going
out, the internal staff education can happen, you know, over
time.
And then working with state agencies is something that we're
doing together.
And then I know that just for your team is
is also working on each of these components specifically as
well.
And on that note, we are right at the hour
and need to conclude this presentation, but we really appreciate
all of you spending your afternoon with us learning more
about the ACM criteria.
Thank you, Doctor Waller, so much for your time, and
I hope that everyone reaches out if they have any
further questions or would like any further information about the
ACM Criteria Navigator.
Thanks everybody, appreciate your time.