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VI A.Psychiatrist or other physician or prescriber of medications for substance use disorders

Element Details

Definition:

Programs that offer treatment to individuals with co-occurring disorders offer pharmacotherapy for both the mental health disorder and the substance use disorder through the services of prescribing professionals. These programs may have a formal relationship with a psychiatrist, physician, or nurse practitioner (or other licensed prescriber) who works with the clinical team to increase medication compliance, decrease the use of potentially addictive medications such as benzodiazepines, and offer medications such as disulfiram, naltrexone, acamprosate, or buprenorphine that are used in the treatment of substance use disorders.

Source:

Interviews with program director and clinical staff (and prescriber if possible).

Item Response Coding:

Coding of this item requires an understanding of the specific competencies of the prescribing professional and his or her level of involvement with the clinical treatment team.

  • Mental Health Only Services = (SCORE-1): No formal relationship with a prescriber for this program. The program has no formal relationship with a prescriber who is experienced and competent to prescribe medications for individuals with a co-occurring substance use disorder.

  • (SCORE-2): Consultant or contractor off site. The program has an arrangement with a prescriber, who is experienced and competent to prescribe medications for substance use disorders, to serve as a consultant or as an offsite provider.

  • Dual Diagnosis Capable = (SCORE-3): Consultant or contractor on site. The program has an arrangement with a prescriber, who is experienced and competent to prescribe medications for substance use disorders, to serve as either a consultant or contractor who renders services on site but who is not a member of the program’s clinical staff (i.e., is only available for direct patient care).

  • (SCORE-4): Staff member, present on site for clinical matters only. The program has a prescriber, who is experienced and competent to prescribe medications for substance use disorders, as an onsite staff member to provide specific clinical duties, but who does not routinely participate in the organized activities of a clinical team. This prescriber may be accessed by staff on a limited basis, but this is not routine.

  • Dual Diagnosis Enhanced = (SCORE-5): Staff member present on site for clinical, supervision, treatment team, and/or administration. The program has a prescriber, who is experienced and competent to prescribe medications for substance use disorders (including those with advanced credentials in addiction psychiatry or addiction medicine), as an onsite staff member. And: This prescribing staff member is also an active participant in the full range of the program’s clinical activities, is an integral member of the clinical team, and may serve in a key clinical decision-making or supervisory role.
Enhancing MHOS Programs

Many addiction treatment providers consider this item to be pivotal and challenging to achieve. Access to a psychiatrist, physician, or other prescriber can provide a foundation that moves a program from MHOS to DDC and is associated with many other aspects of co-occurring capability. However, even programs with physician coverage along with policies for clinical practice and patient admission criteria may be rated at the MHOS level.

MHOS programs typically do not have a formal relationship with a prescriber. They must refer patients in need of addiction medication or medication evaluations to a prescriber outside the program. DDC programs have contracted with a consultant prescriber who can evaluate and treat patients on site. These contracted arrangements may be inadequate to cover the needs of patients, but most patients can be initiated on medication when indicated. The DDC program consultant prescriber is typically available for circumscribed clinical duties only.

Enhancing DDC Programs

Whereas the DDC program prescriber is focused on clinical and patient management responsibilities, the DDE prescriber has taken on a more expanded role. The time allocated for patient care can be formally or informally augmented to allow clinical meetings with a team or individual staff. To the extent the prescriber can act in a clinical leadership capacity and in a teaching and supervision role, the program may enhance its co-occurring capability. These relationships are often stronger if formalized and recognized. We have also seen prescribers who act as unofficial leaders for a clinical team.

In order to become DDE, Deerpath Associates decided to ask their nurse practitioner to attend weekly clinical team meetings. These meetings occurred every Wednesday morning from 9:00 to 10:30. The nurse practitioner actively participated in the morning meetings, which not only cut down on the amount of time staff needed to contact her by e-mail or phone to discuss shared patient issues, but also created an opportunity for her to educate staff, supervise, and lead. Staff appreciated this new relationship and the nurse practitioner became more of a leader in the program.