Navigating the future of addiction treatment with The ASAM Criteria® Fourth Edition

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. Before we begin, Please note the following housekeeping items. At the bottom of your audience console are multiple application widgets that you can use to customize your viewing experience. If you have any questions during the webcast, you can click on the Q&A widget at the bottom of your screen to submit a question. We do capture all questions and we'll be providing follow up to questions as appropriate.

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Additionally, this presentation does use streaming audio. You may listen to the audio through your computer speakers or headphones. To ensure the best possible system performance, please be sure to shut down an EVPN connections and connect directly to the Internet. 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.