D.  Develop Integrated Summary And Initial Treatment Plan

 

OBJECTIVE

 

Integrate assessment information from various sources, as a basis for formulating the diagnosis and treatment recommendations, followed by involvement of the patient in prioritizing problems and negotiating the initial treatment plan.

 

ANNOTATION

 

1.              Consolidate and interpret the information obtained during the assessment process in a narrative form.

2.              Include a diagnostic formulation.

3.              Review comprehensive assessment and integrated summary, including past treatment response.

4.              Incorporate an interdisciplinary perspective in presenting treatment recommendations.

5.              Involve the patient in prioritizing problems to be addressed in the initial treatment plan.

6.              Review the patient’s motivational level and goals and match the patient needs with available programming (see Table 1).

7.              Identify treatment options and discuss them with the patient.

 

  Table 1.  Treatment Plan and Expected Outcomes

Treatment Plan	Expected Outcomes
Rehabilitation with optimal goals	·   Complete and sustained remission of all SUDs ·   Resolution of, or significant improvement in, all coexisting biopsychosocial problems and health-related quality of life
Rehabilitation with intermediate goals	·   Short- to intermediate-term remission of SUDs or partial remission of SUDs for a specified period of time ·   Resolution or improvement of at least some coexisting problems and health-related quality of life
Care Management	·   Engagement in the treatment process, which may continue for long periods of time or indefinitely ·   Continuity of care (case management) ·   Continuous enhancement of motivation to change ·   Availability of crisis intervention ·   Improvement in SUDs, even if temporary or partial ·   Improvement in coexisting medical, psychiatric, and social conditions ·   Improvement in quality of life ·   Reduction in the need for high-intensity health care services ·   Maintenance of progress ·   Reduction in the rate of illness progression

 

 

DISCUSSION

 

The integrated summary has also been referred to as the case formulation.  The purpose of the integrated summary is to blend the disparate pieces of the assessment process into a more cohesive summarization.  The summary needs to include biopsychosocial strengths and weaknesses that the patient brings to treatment.   The summary also serves as a dynamic understanding of why the patient’s SUD evolved.  The integrated summary serves as the foundation for the development of the treatment plan.  Consistent with JCAHO standards, it is important that the information upon which the treatment plan is based appears within the assessment database and does not appear de novo in the integrated summary (JCAHO, 1999).

 

The integrated summary is intended to be interpretive in nature, providing more than a restatement of facts already present in the assessment.  The clinician must use professional judgment to evaluate the information and discuss with the patient how his/her various strengths and problems interrelate to affect the treatment process.  For example, patients may indicate that some problems, such as homelessness or ambivalence about change, may need to be addressed before others.  Principles and techniques of Motivational Interviewing (Miller & Rollnick, 1991; Miller et al., 1992), rather than confrontation, can enhance treatment engagement and outcome (Bien et al., 1993; Miller, 2000).  The integrated summary will typically reflect the results of an interdisciplinary team discussion; however, there may be local variations.

 

SUDs often follow a chronic, relapsing course, making individualized treatment more complicated (McLellan et al., 1996; O’Brien & McLellan, 1996).  Treatment has not yet been well conceptualized for many patients who either have responded with minimal improvement to repeated rehabilitative treatments or are unable or unwilling to engage in rehabilitation efforts, but desire other services.  Even when patients are unable and/or unwilling to participate in rehabilitation or show minimal benefit, there are opportunities to address SUDs in other care settings.

 

Care management approaches for SUDs are similar to management of other severe and persistent disorders for which no cure has been identified, such as bipolar disorder or diabetes mellitus (McLellan et al., 2000).  Recent evidence suggests that approaches emphasizing engagement with the patient over long periods of time, case management, and integration of substance abuse treatment interventions with treatment for the coexisting conditions result in reduced substance use and associated complications (Drake & Mueser, 2000; Osher & Drake, 1996; U.S. DHHS, 1994; Willenbring et al., 1995; Willenbring & Olson, 1999).  In the absence of serious co-morbidity or with appropriate specialist consultation, care management can be provided within a variety of clinical settings.