A Guideline for Credentialing and Privileging of Clinical Professionals for Care of Substance-Related Disorders: A Joint Statement of the American Society of Addiction Medicine and the American Managed Behavioral Healthcare Association
Attachment 2: Summary Table: Practitioners and Privileges
Substance-related disorders are encountered in both general practice and specialty practice settings. While addiction and other substance-related disorders are common in the general population, and especially prevalent among individuals who access healthcare services, these conditions have tended to be both significantly under-recognized and under-treated by healthcare professionals. In relation to their importance as public health problems, addictive disorders have received insufficient attention in formal training programs for physicians, nurses, and mental health professionals (including psychologists, clinical social workers, and professional counselors). Consequently, specific expertise in addiction care among general health care professionals and among mental health professionals has been at times difficult to identify. Similarly, the role of credentialed and privileged providers in delivering specialty care to patients with substance-related disorders has been ill-defined.
All healthcare professionals have a role in the screening, recognition and treatment of substance-related disorders. That role, however, understandably varies given the particular circumstances of a case and the specificity of training and privileging of the practitioner. It is thus imperative that healthcare organizations and organized systems of care develop policies and procedures that define credentialing and privileging processes for evaluating and managing patients with substance-related disorders. In this way it will be possible to more readily recognize practitioners from all healthcare disciplines (medicine, nursing, psychology, clinical social work, and professional counseling) who have special qualifications or expertise in the recognition, treatment, and prevention of substance-related disorders.
A recent trend has been the enhanced role of managed care within the American healthcare landscape. As the delivery of healthcare services has become more concentrated within organized systems of care--healthcare networks such as health maintenance organizations (HMOs), preferred provider organizations (PPOs), integrated delivery systems (IDSs), and large provider networks for specialty care including independent provider associations (IPAs) and specialty ‘carve-out’ systems--the credentialing and privileging of providers has become an area of increasing concern for both individual providers and managed care entities.
As the managers of networks seek to determine who is an appropriately trained and skilled provider for the care of individuals with substance-related disorders, it is important for consumers and managers of health care processes that decisions about credentialing and privileging are made objectively, equitably, accurately, and based on data and reasonable criteria. It is imperative that policies and procedures define credentialing and privileging processes, and that the role of credentialed and privileged providers in delivering specialty care be defined. In this way it will be possible to recognize practitioners from all healthcare disciplines (medicine, nursing, psychology, clinical social work, and professional counseling) who have special qualification or expertise in the recognition, treatment, and prevention of substance-related disorders. Privileging, which has a rich history in the granting of medical staff privileges within hospital systems, has an evolving and more variable history in managed care organizations.
In an effort to add greater clarity to discussions about such issues, the American Society of Addiction Medicine and the American Managed Behavioral Healthcare Association offer the following definitions, framework, and resources:
Credentialing: The process of reviewing, verifying, and evaluating a practitioner's credentials (i.e., professional education, clinical training, licensure, board and other certification, clinical experience, letters of reference, other professional qualifications, and disciplinary actions) to establish the presence of the specialized professional background required for membership, affiliation, or a position within a healthcare organization or system. The result of credentialing is that a practitioner is granted membership in a medical staff or provider panel.
Privileging: The process of determining a health care professional’s current skill and competence to perform specific diagnostic or therapeutic procedures that the professional requests to perform as a participant in or an affiliate of a healthcare facility or system. The result of privileging is that a practitioner is permitted by a healthcare organization or network to conduct those specific procedures.
Framework for Privileging:
We propose that certain clinical processes (e.g., screening for substance dependence or substance withdrawal) are appropriate clinical activities for a full range of generalists and specialists, whereas other clinical processes (e.g., medication management of addiction) are clinical activities for which credentialing and privileging can specify the appropriate type of healthcare professional to carry out the service. We thus present a General Overview of Clinical Privileges for Care of Substance-related Disorders (Attachment 1), and a Summary Table of Practitioners and Privileges (Attachment 2), which specify the clinical privilege categories that might be appropriate for primary care physicians and addiction medicine physicians; for general psychiatrists, psychologists and other mental health professionals; and for addiction specialists from a variety of clinical disciplines.
To assist healthcare organizations (hospitals and clinics) and managed care entities in defining the role of generalist and specialist healthcare providers and mental health providers in the evaluation and management of substance-related disorders, and in the establishment of credentialing processes for licensed independent practitioners (including those with special qualifications in addictions practice), ASAM and AMBHA recommend that the professional societies and certification entities listed in Attachment 3 be consulted as indicated.
PARTICIPANTS IN ASAM-AMBHA WORKGROUP
Barry Blackwell, M.D.
Jonathan D. Book, M.D. .
William Eckbert, M.D.
Barry M. Gershuny, M.D.
Pamela Greenberg, M.P.P.
Chris Kvasnica, MSW, CICSW
David K. Nace, M.D.
Rick Rawson, Ph.D.
Ethan S. Rofman, M.D.
Ian A. Shaffer, M.D.
Sheila B. Blume, M.D., FASAM
James F. Callahan, D.P.A
Christine Kasser, M.D.
David Mee-Lee, M.D.
Michael M. Miller, M.D., FASAM
GENERAL OVERVIEW OF CLINICAL PRIVILEGES FOR CARE OF SUBSTANCE-RELATED DISORDERS
It is recognized that the framework expressed in the General Overview of Clinical Privileges and in the Summary Table of Practitioners and Privileges reflects general principles about who is able to competently address which assessment and treatment needs. Where an “X” appears in the Summary Table, it should be understood to mean that, in general, practitioners within that stated grouping would be appropriate to receive the given clinical privilege. Where a "Y appears in the Summary Table, it should be understood to mean that selected clinicians, with demonstrated training and experience, would be appropriate to receive the given clinical privilege. Where neither an "X" or "Y" appears, it should be understood to mean that, in general, practitioners within the stated group will not have had the training and experience to be automatically privileged to provide the stated service. However, even in this category, if an individual can demonstrate appropriate training and experience, the granting of privileges would be possible.
An example is formal diagnostic assessment for presence/absence of substance dependence: general practitioners (MD/DO/NP) can and should screen for such conditions, but the diagnostic assessment to confirm the condition generally requires special expertise. Similarly, when intoxication states and withdrawal states are so severe that physiologic instability necessitates care in a hospital intensive care unit, then general internists are typically more thoroughly prepared to manage such cases than psychiatrists without internal medicine training.
The General Overview and Summary Table are guidelines and certainly not the final word on these topics. There are indeed selected clinicians who possess the training and/or experience to perform certain assessment and treatment activities that surpass those delineated in the Overview and Table. Moreover, credentialing is an already complex process, and the level of detail appearing in the General Overview and Summary Table may be too precise to easily operationalize. However, an organization which has established broad categories of practitioner type and privileged activity may find the Overview and Table useful in determining how to approach more specialized privileging decisions for selected individuals. Thus, what has been proposed should be viewed as a stimulus to managed care organizations and practitioners alike as they explore more fully their own privileging policies and procedures, and viewed as a guide, not an absolute standard.
1. Privileges applicable to primary care physicians, nurse practitioners, physician assistants, general psychiatrists, mental health clinical nurse specialists, general psychologists, other mental health professionals, addictionists, and addiction specialists from nursing, psychology, social work, and professional counseling:
Assessment/Diagnosis of Intoxication
2. Privileges applicable to primary care physicians, nurse practitioners, physician assistants, general psychiatrists, mental health clinical nurse specialists, addictionists,1 and addiction specialists from nursing:
Assessment/Diagnosis2 of Withdrawal
Management of Mild to Moderate Withdrawal
Management of Mild to Moderate Intoxication
Medication Management of Addiction3
3. Privileges applicable to general psychiatrists; addictionists, addiction specialists from nursing, psychology and professional counseling; primary care physicians; plus psychologists, mental health clinical nurse specialists, and other mental health professionals:
Assessment/Diagnosis of Addiction and Substance-related Disorders
4. Privileges applicable to general psychiatrists; addictionists1; selected primary care physicians; addiction specialists from nursing, psychology and professional counseling; plus psychologists, mental health clinical nurse specialists, and other mental health professionals:
Addiction counseling: individual, group and family
5. Privileges applicable to primary care physicians, addictionists1 from primary care and other medical specialties, and selected addictionists1 whose primary specialty is in psychiatry:
Management of Severe or Complex Intoxication
Management of Severe or Complex Withdrawal
6. Privileges applicable to primary care physicians and addictionists1 from primary care and other medical specialties:
Management of medical complications of addiction and other substance-related disorders
7. Privileges applicable to general psychiatrists, addictionists1 whose primary specialty is in psychiatry, general psychologists, mental health clinical nurse specialists, and addiction specialists from psychology:
Management of psychiatric complications of addiction4 and other substance-related disorders
8. Privileges applicable to addictionists,5 addiction specialists from nursing, psychology, and professional counseling; plus general psychiatrists, psychologists, mental health clinical nurse specialists, and other mental health professionals:
Screening/Referral for dual diagnosis6 (mental health disorder plus addictive disorder)
9. Privileges applicable to addictionists5 whose primary specialty is in psychiatry; addiction specialists from psychology; plus selected general psychiatrists, selected general psychologists, and selected addictionists5 from primary care and other medical specialties:
Assessment/Management of dual diagnosis6 (mental health disorder plus addictive disorder)
[Note: Please see the attached “Summary Table: Practitioners and Privileges” for a tabular presentation of Attachment 1.]
PROFESSIONAL SOCIETIES AND CERTIFICATION ENTITIES
AAAP: American Academy of Addiction Psychiatry
Jeanne Trumble, M.S.W., Executive Director
7301 Mission Road, Suite 252
Prairie Village, KS 66208
AAFP: American Academy of Family Physicians
Robert Graham, M.D., Executive Vice President
8880 Ward Parkway
Kansas City, MO 64114
AAP: American Academy of Pediatrics
James E. Strain, M.D., Executive Director
141 Northwest Point Boulevard
Elk Grove Village, IL 60007
AAPA: American Academy of Physician Assistants
Steven Crane, Executive Vice President
950 North Washington Street
Alexandria, VA 22314-1552
ABPN: American Board of Psychiatry and Neurology, Inc.
Stephen C. Scheiber, M.D., Executive Vice President
500 Lake Cook Road, Suite 325
Deerfield, IL 60015
AMAP: American Medical Accreditation Program (American Medical Association)
Gail Thomason, J.D., Interim Vice President of Quality and Managed Care Standards
Michael Gallagher, Director of Accreditation Field Operations
515 North State Street
Chicago, IL 60610
ANA: American Nurses Association
David W. Hennage, Ph.D., M.B.A., Executive Director
600 Maryland Ave., SW, #100 West
Washington, D.C. 20024-2517
ANCB: Addictions Nursing Certification Board (ANCB)
Sandra Tweed, Ph.D., R.N., C.A.R.N., Director
4101 Lake Boone Trail, Suite 201
Raleigh, NC 27607
American Osteopathic Academy of Addiction Medicine
David Kushner, CAE, CMP, Executive Director
5550 Friendship Boulevard, Suite 300
Chevy Chase, MD 20815-7201
APA: American Psychiatric Association
Steven Mirin, M.D., Medical Director
1400 K St., N.W.
Washington, D.C. 20005
APA: American Psychological Association
Janet Ciuccio, Executive Administrator
College of Professional Psychology
750 First St., N.E.
Washington, D.C. 20002-4242
ASAM: American Society of Addiction Medicine
James F. Callahan, D.P.A., Executive Vice President/CEO
4601 No. Park Avenue, Arcade 101
Chevy Chase, MD 20815
ICRC: International Certification and Reciprocity Consortium
Rhonda McKinnon, Executive Director
P.O. Box 14148
Research Triangle, NC 27709-4148
NAADAC: National Association of Alcoholism & Drug Abuse Counselors
Linda Kaplan, Executive Director
1911 N. Fort Myer Drive, Suite 900
Arlington, Virginia 22209
NAADAC: NAADAC Certification Commission
Linda Kaplan, Executive Director
William Malone, Certification and Recertification Administrator
1911 N. Fort Myer Drive, Suite 900
Arlington, Virginia 22209
SPAAM: Society of Physician Assistants in Addiction Medicine
Don Daly, PA-C
12851 E. Grand River
Brighton, MI 48116-8596
TEL: 810-227-1211, Ext. 556