Alexander DeLuca, M.D.
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Growth and Development of Smithers Treatment Center, 1990-1998
by Alexander DeLuca, M.D., FASAM

Our strategy and what we actually accomplished during my tenure as medical director at the Smithers Addiction Treatment and Research Center. This document was prepared for the incoming Roosevelt Hospital administration so they would know what we were about so as not to ruin us. 
So, do you think it worked?
[see also: The Harm Reduction vs Abstinence Follies of Summer 2000]

Introduction

Smithers Treatment Center is a lean and flexible modern addiction treatment center functioning within the Department of Medicine at Roosevelt Hospital. We have thrived over the past eight years while many private treatment centers have closed because we have embraced, rather than avoided, the challenges of, 1) the advancements in the understanding of the neurobiological basis of addiction and, 2) the rise managed care. In this time of rapid institutional change and the merging of various clinical services, it is especially important that the administrative and clinical leadership of both institutions understand the nature and quality that Smithers represents, our potential for generating increased funding and prestige for our parent institutions, and the overhaul and very significant improvement of clinical and administrative services that our team has accomplished. This document will briefly trace the development of the Smithers Center over the past eight years, analyze our current operations and discuss our potential for enhancing both the prestige and the bottom line of Roosevelt Hospital and Beth Israel Medical Center.
 

What We Were

In 1990 Smithers Treatment Center consisted of three basic services: inpatient (hospital) alcohol and sedative detoxification, inpatient rehabilitation of alcoholics, and a small outpatient department. Patients were triaged into one of these services based entirely on a telephone interview with a nurse. Within each service there was little individualization of treatment. For example, patients admitted to the Rehabilitation Unit stayed 28 days regardless of severity of illness or particular array of problems. Staff was very comfortable with alcoholism and with the care and treatment of a predominantly middle class patient population, but was far less skilled in, and comfortable with, the treatment of opiate and stimulant dependence.

Our assessment process was idiosyncratic and cumbersome. Like all clinical addiction centers of the time, we gathered a tremendous amount of data from patients into a very long history form that had evolved over the years. From this various diagnoses and problems were generated, but since the treatment we offered was the same for everyone, formally addressing particular problems was somewhat moot. The data was often incomplete, and very difficult to access and process given it’s length and complexity. We had no way of tracking how our patients were doing either in treatment or afterwards. We could not say with certainty how many patients who started an outpatient program were still in treatment three months later, or which sort of patient had the worst prognosis in our system, or what percentage of toxicology’s remain positive. Having no organized data, no outcome analysis or research was possible and so clinical practice was more the result of evolution than of thoughtful, evidenced-based, design.

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The Goals

In 1991 we outlined the elements that comprise modern, state-or-the-art addiction medicine. We decided that addiction treatment centers:

·    Must become patient - oriented as opposed to program – oriented. Good clinical practice and efficiency demand we deliver targeted treatment to targeted problems

·    Must base treatment plans on a comprehensive assessment of problems in all life areas (not just the addiction) and that standardized, nationally validated tools be used whenever possible to allow comparison of our population and performance with the published literature and to permit research on our patient population to begin

·    Must have patient tracking and data collection and analysis built into the administrative and clinical fabric of the center for two major reasons. One, we will be increasingly required to demonstrate the efficacy of our interventions in order to justify referral and payment in a managed care environment. Two, very little research in addiction medicine is generated from functioning treatment centers; rather, in the vast majority of studies, special research treatment units are established to test one intervention or another. By building computerized data collection and patient outcome tracking into the treatment center, we will be in an excellent position to do important research in the field and generate significant grant money. This will allow us to continue to grow and develop in an economic environment where funds for growth and development are scarce.

·    Must become clinically more diversified and administratively more flexible. Diversification of treatment services follows from a thorough assessment generating different problems that then need to be addressed. Diversification is also demanded by employing national criteria for patient placement, which recognize four separate intensities of detoxification, for example. Administrative flexibility follows from the pressure from managed care and from the demands of good clinical practice and efficiency.  Not all patients require a hospital setting for detoxification, and some that meet criteria for admission to a hospital on day 1 may become stabilized by day 2 such that treatment can safely continue in a subacute setting. Treatment centers need to be able to respond to a patient’s changing clinical condition on a daily basis, rather than on a weekly or monthly basis as was the rule in the past.

·    Must clearly define what the core content of substance abuse treatment is, and prioritize its delivery. As lengths of stay at all levels of care decrease, we have less and less time to accomplish the same treatment goals and therefore need to more carefully design treatment structure and content. The standard of quality in medicine is evidenced-base treatment, and successful addiction treatment centers will redesign their treatment programs along these lines.

What We Have Done

Between 1991 and the present we have accomplished the following concrete, identifiable results in pursuit of the above goals

·  Conceptualized, designed and implemented the Smithers Evaluation Unit (EU).

·    All patients are assessed in the EU prior to referral to any of our treatment programs. The evaluation is staged for both clinical and economic reasons. If a patient is assessed to require detoxification, the rest of the psychosocial history is deferred until the patient is stable. Patients in need of acute detoxification are often too intoxicated and/or ill to be able to complete an exhaustive battery of psychosocial tests and interviews. This staged assessment system also avoids spending hours with patients on day 1 only to have 30% drop out by day 4 conserving our resources for patients who will be around to benefit from them.

·    Standardized assessment tools are now used exclusively. The Addiction Severity Index, the Beck Depression Inventory, the Brief Symptom Inventory, and the Clinical Institute Withdrawal Scale form the core of our assessment. Other studies are collected for experimental and trial purposes, for example, motivational assessments, childhood trauma questionnaires, and so on. These tests highlight problems or problem severity that were often missed using our prior patient database, lend themselves to computerization, and allow us to collect data of research quality.

·    Smithers actively participated in the development of the American Society of Addiction Medicine (ASAM) Patient Placement Criteria (PPC). Dr. DeLuca, our Associate Director for Medicine, was a member of the original ASAM committee that created the PPC version 1, and is currently on the ASAM committee charged with producing a computerized version of version 2. We have integrated the concepts and content of the PPC into our assessment and treatment systems. The integration of the EU, the use of standardized assessment tools, and the PPC have transformed Smithers into a patient-oriented system where individualized treatment follows from problems generated by an objective and standardized assessment with treatment initiated in accordance with nationally recognized placement criteria. These changes have also greatly aided us in our communications with managed care organizations because we can see at a glance with the individual patients problems are, how severe they are, and what level of service is indicated.

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·  Development of a research department.

·    Building an infrastructure to support clinical research proceeded hand in hand with the development of the EU. The Director of Research, Dr. Jeffrey Foote, and Dr. Alex DeLuca, who is also a professional database programmer, largely on their own time and using their own funds for needed software and development hardware, have designed and produced a computer database program (“Trax!”) that performs two critical functions. One, unpaid research assistants recruited from local colleges and psychology graduate schools enter demographic, assessment, and research data on all patients coming through the EU. Follow up studies can be used to follow a patient’s progress in recovery. Two, the program collects weekly tracking data on every patient in treatment at Smithers, including attendance data, use of sobriety medications, urine toxicology results, etc. This powerful capability has tremendous implications for quality of treatment, third party payment, and the advancement of research in addiction medicine. For example, we can now find out for certain if preceding our regular group therapy with a brief motivational intervention is associated with greater retention in treatment and improved patient outcomes. On another level, the tracking system allows supervisors to identify problems with particular treatment programs or counselors and investigate and remedy the situation.

·    The design of the EU, the existence of a research infrastructure, and our varied treatment population has made Smithers a very attractive environment for clinical research in addiction medicine. We have entered into a partnership with the National Drug Research Institute (NDRI) with whom we received funding for the first grant we applied for. The NIAAA is providing 1.5 million dollars over three years for a study of the ASAM PPC, which began in 9/97. We are in the process of applying for a grant to study an innovative group motivational treatment we have designed. Several other non-funded projects are being done, and five papers by various members of our team have been accepted for poster presentation at the Research Society for Alcoholism, 1998 Annual Scientific Meeting. We are planning to meet the summer ’98 deadline for a NIDA grant to study outpatient detoxification.

·  Consolidation of services and clinical administration.

·    In 1995 we moved our entire outpatient department, the EU, all administrative services, and the detoxification unit into the newly renovated Roosevelt Hospital. We have planned the move of our rehabilitation services into the hospital as well, though this latter initiative has been stalled due to unresolved negotiations with the Smithers family. Physical consolidation of services facilitates the clinical and administrative flexibility described above.

·    In 1997 we streamlined the supervisory structure of our outpatient services by replacing five part time staff members each of whom oversaw a separate program with two full time supervisors overseeing the entire outpatient department. This has greatly reduced the culture of fragmentation that had existed and has permitted us to more easily and efficiently plan and implement improved outpatient services as outlined below.

·       Diversification, addition and improvement of clinical service. 

·    All Smithers services have been converted from fixed-length-of-stay programs to variable- length-of-stay using ASAM Continuing Stay and Discharge Criteria and frequently stepping up or down the intensity and content of treatment based on clinical progress. This has made us much more attractive to managed care organizations for whom any fixed-length-of-stay policy is anathema.

·   Diversification of detox services.

·    We have pioneered the use of innovative detox regimens. For example, we are the only center in the City to routinely offer inpatient rapid opiate (clonidine to naltrexone) detoxification and as such receive referrals from other centers to manage difficult cases that have failed outpatient detoxification efforts and from managed care organizations who appreciate the added value this treatment represents.

·    We are now able to offer detoxification services in the inpatient hospital setting, the subacute inpatient (rehab) setting, and as an outpatient service. The Short Term Assessment and Treatment (STAT) Unit was implemented in 1994 after discussions with HIP regarding their need for an alternative to hospital-based detox. The STAT unit is a sub-acute inpatient service for patients who require inpatient detoxification for social, psychiatric, or medical reasons but who do not meet criteria for an acute care hospital bed. After careful retrospective and prospective review, we determined that approximately 30% of the patients we had historically admitted to the acute hospital setting could be safely and effectively cared for in the sub-acute program. We started providing outpatient detoxification in 1997 and demand for the service has steadily grown, and clearly this is the wave of the future. Smithers has become recognized as a leader in outpatient detoxification. Our Associate Director for Medicine was asked by the Office of Alcohol and Substance Abuse (the NYS regulators) to assist with the writing of the new regulations for outpatient detox units soon to be licensed by the state. He is also involved in producing a curriculum for State mandated course that applicants for said license will have to take.

·    We plan further expansion of outpatient detox programs (day hospital detox, 23 hour observational beds). Again, this variety of intensities of service and the ability to quickly and easily move patients from one level of care to another make us very attractive to managed care and other referral sources and provide a veritable gold mine of potential clinical research studies.

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Expanded clinical services other than detoxification.

·    Group motivational interviewing (GMI). Our most recent treatment innovation, we designed a group version of the well published motivational interview technique as an introduction to treatment for patients ambivalent about committing to protracted treatment, and as an experimental intervention to determine if ‘pre-treatment’ with GMI enhances subsequent treatment outcomes. The pilot study is complete and we are finishing the process of submitting the study for grant funding. 

·     Nurses Helping Nurses Program, developed in response to the increasing numbers of nursing professionals seeking our services and to the lack of excellent, thorough assessment and treatment services tailored to this population in NYC. 

·    Trauma Group. A pilot implementation of our concept of manual-driven treatment (see below). Having noted the literature documenting the extremely high proportion of addicts having histories of major trauma (rape, incest, sexual abuse, and domestic violence) and the relationship of traumatic experience to relapse, we designed a series of group sessions as additional therapy for patients with this history.

·    First Step Program. This was our first attempt at breaking down the rigidity of program-oriented treatment which many patients were unable to conform to. Begun in 1992, the First Step Program was designed as a Case Manager model of treatment in which the counselor individually tailored a treatment regimen for patients who were having difficulty staying connected to treatment in traditional groups. It has allowed us to keep patients in treatment that we had previously lost.

·    Day Program 2. In the mid-1970’s Smithers opened one of the first intensive outpatient programs for inner city alcoholics and addicts in need of major structure and support. This was Day Program 1. In 1985 we started the Smithers Evening Rehabilitation Program (SERP) to meet the needs of employed persons requiring daily intensive treatment. Day Program 2 is our most recently instituted intensive outpatient program. It meets in the mornings and is targeted at employable addicts in need of intensive outpatient treatment and assistance and support in re-integrating into the work force.

·    Hospital consultation service. In 1996 we implemented an addiction consultation service in Roosevelt Hospital for a variety of reasons:

·    To find and offer ongoing treatment to med/surg and psychiatry patients with drug and/or alcohol problems.

·    To provide a clinical service to the staff and patients of Roosevelt Hospital by assisting with difficult cases on the ward and arranging timely and effective discharging planning.

·    To increase the visibility of Smithers in the hospital and improve relations with other departments

·    To increase awareness of addiction problems and treatment among the Hospital staff and offer ongoing assistance and training.

The consultation service was significantly improved in 1998 with better coordination of services with the Substance Abuse Liaison at the request of Dr. Barrish.

·   Core 20 initiative. We are changing our outpatient treatment model from a 1970’s milieu group therapy without specified content and style to a modern manual-driven approach based on cognitive-behavioral and motivational therapies. The improved efficacy of this treatment model is supported by research and has other advantages as well. It will now be possible to measure the amount and type of treatment delivered and track the patient outcomes with our computer tracking system. This is an active area of research in addiction medicine and we intend to be major contributors in this arena in the very near future. The conversion to this improved treatment structure will be complete by the fall of 1998.

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Conclusions and Recommendations

Smithers Treatment Center is a nationally known and widely respected center of excellence in addiction medicine. Our Chief is a past president of the American Society of Addiction Medicine, and our Associate Director for Medicine the chairman of its certification review course. We are repeatedly called on by the State of New York to provide expert consultation on matters of substance abuse policy and programs. We have put together an excellent leadership team of proven creativity and productivity. We are a model of how to re-design administration and treatment in order to flourish in a managed care environment. At no expense to the hospital system, we have computerized our system, established a clinical research center, and are poised to become nationally known as an academic research center. As an intact unit, we can and will bring prestige and funding to our parent institutions.