Comprehensiveness of coverage of the subject area

Five of the seven criteria sets included distinct criteria for substance abuse services-a best practice. The other two simply incorporated some of these issues under discussions of different treatment settings-a worst practice.

Six other best practices were criteria that included the following:

• a withdrawal scale for inpatient detoxification;

• language on maintenance to prevent relapse;

• language demonstrating an understanding that relapse during the beginning stages of treatment is common and is not treatment failure: "Re-entry due to relapse should focus on relapse triggers, and actions the patient can take for such triggers." We like this preventive approach, which is followed by the following, clinically sound recommendation, "The patient should not be run through the same program as previously completed (after a relapse)."

• automatic admission for medical detoxification for a CIWA-A score greater than or equal to 20 for consumers using multiple drugs;

• detailed text on mobile crisis; and

• detailed text on treating women who are pregnant.

Four other worst practices included the following:

• Two criteria sets required participation in 12-step programs in order to access other services. While the panel concurs that research supports the efficacy of combining such services with a 12-step program, this raises a common concern of NMHA's constituency: the denial of desirable services when a consumer refuses certain others s/he finds undesirable. We recognize that lack of 12-step participation is not the norm, but we believe it is too strong to completely disregard consumer choice to address substance abuse programs without a 12-step approach. In addition, therapy is often needed first to convince consumers of the benefits of such an approach. Some sample worst practice language follows: "Traditional individual psychotherapy alone is not considered an appropriate primary treatment modality for substance abuse treatment;" and "the treatment plan must include participation in organized support groups."

• One vendor uses a positive urine screen as a criterion to exclude a consumer from intensive outpatient services, rather than recognizing that relapse during the early stages of treatment is common-and not sufficient to conclude that this treatment setting is a failure.

• One vendor did not include the involvement of a child and adolescent psychiatrist in the residential treatment criteria.

• One vendor's acute admission criteria for substance abuse were dependent on the consumer having a co-occurring mental illness which is severe enough to prohibit treatment in a less intensive setting. In short, the consumer would have to meet the admission criteria for the mental illness, regardless. The substance abuse criteria were not relevant.

Attention to co-occurring disorders

Given the high rate of co-morbidity, the panel was disturbed by the lack of text addressing the needs of consumers with co-existing mental health and substance abuse treatment needs. The following are two best practice examples we were able to identify that addressed these issues with significant substantive language:

• "[Vendor] recognizes that a substantial percentage of those with mental illness can present with a co-occurring substance use disorder. Co-occurring disorders are typically difficult to diagnose, since many of the symptoms are similar, and it is often difficult to unravel the interacting effects of the disorders. In these situations, it is imperative that the symptoms or behaviors that present the greatest risk are addressed first and foremost to assure safety, and that an appropriate treatment plan must be in place which addresses both disorders in an integrative fashion."

• "If a true dual diagnosis patient, the treatment program must include appropriate attention to each diagnosis. For example, should a patient with schizophrenia be treated on a substance abuse unit, that unit must provide daily psychiatric attention and the ability to safely distribute and monitor psychotropic medications." We like this attention to this special population whose needs are often ignored.

Key findings

"Report card" on information sharing

Methodology

Development process

Comprehensiveness

Corporate philosophy

Access issues

Compliance

Child and family issues

Substance abuse and co-occurring disorders

Cultural competence

Provider autonomy

Coordination/ consultation among providers

Denial notification and appeal processes

More observations, recommendations and areas for further study