Public Policy Statement on Coordination between Treatment Providers, Professionals Health Programs and Regulatory Agencies
(This is the fourth in a set of eleven policy statements of the American Society of Addiction Medicine addressing Healthcare and Other Licensed Professionals with Addictive Illness)
Professionals Health Programs (PHPs), Addiction Treatment Programs (ATPs), and Regulatory Agencies (RAs) are separate entities with distinct though often overlapping, complimentary and interdependent missions and roles. Each has a different relationship with the licensed professional who has a potentially impairing illness. Optimal cooperation among these three entities is necessary to achieve the proper balance between a professional’s rehabilitation and protection of the public. In the best case scenario, a highly trained professional with addictive illness is safely and successfully rehabilitated and retained as a practicing member to the benefit of the profession, the individual and his/her family, and the public.
An introductory description of these entities appears in the first policy statement in this set, entitled – Healthcare and Other Licensed Professionals with Addictive Illness – An Overview.
Professionals Health Programs (PHPS)
PHPs are organizations that have the dual roles of facilitating the rehabilitation of healthcare and other licensed professionals who have potentially impairing medical conditions and enhancing public safety. These roles are symbiotic in their effect. As a result of this dual role, PHP’s are often positioned between Addiction Treatment Programs and Regulatory Agencies. PHPs provide a confidential conduit for ill professionals to access comprehensive evaluation and treatment as their condition may require. PHPs ideally constitute an alternative pathway to professional discipline in cases where no harm to the public has occurred. PHPs are unique in their ability to provide early identification, intervention, and referral for evaluation and/or treatment and continuing care. They conduct post-treatment behavioral, chemical, and worksite monitoring. Their success is largely attributable to this tripartite model of continuing care monitoring coupled with contingency case management and appropriate levels of confidentiality.
Monitoring is a key role of PHPs. Monitoring is not prevention, diagnosis or treatment; although it includes elements of each. Monitoring is the oversight of the disease status/remission/health of an individual assuring that the individual’s clinical condition is stable. Technically, case management is the oversight function applied for persons under active treatment or continuing care including low-intensity chronic disease management of a clinical condition. Monitoring must be credible, reliable and accurate in order to provide the PHP with the evidence upon which to base its advocacy role on behalf of healthcare and other licensed professionals who have completed treatment and are, indeed, in remission.
Most PHPs do not engage in clinical services. Typically, PHPs do not conduct comprehensive clinical evaluations or offer clinical treatment but arrange for such services to be provided by qualified professionals. The monitoring function of the professional’s remission of addictive or other disease state is a unique function promoting the ongoing health of the treated individual. This allows the PHP to engage in responsible advocacy on behalf of the professional who is in remission. Earned advocacy facilitates non-discriminatory re-entry into the practice of his or her profession. Advocacy on behalf of the compliant PHP participant is appropriate with various entities including, but not limited to, a hospital or clinic medical staff, credentials committee, other credentialing bodies, employers, business partners, professional colleagues, provider networks and regulatory agencies. The role and responsibility of the PHP in providing earned advocacy for the program enrollee who has adhered to all case management and monitoring functions of the PHP cannot be overemphasized.
Another critical function of PHPs is to evaluate ATPs in developing a list of “qualified and approved treatment programs”. Approved ATPs demonstrate expertise in meeting the clinical needs of healthcare and other licensed professionals with addictive or other potentially impairing health conditions. PHPs provide this list of “qualified and approved treatment programs” to the participant when referring for evaluation or indicated treatment. Participants should not be allowed to select an addiction or mental health treatment provider/facility that is not PHP-recognized. The provider of treatment should be a “qualified and approved” program to assure that the treatment received shall have the sophistication and comprehensive multi-disciplinary nature to enhance the probably of treatment success.
Addiction Treatment Programs (ATPS)
ATP applies to all evaluation and treatment entities for ill healthcare and other licensed professionals.
Treatment for addictive illness should be preceded by and based upon a comprehensive multidisciplinary evaluation. Some Evaluation Centers provide only evaluation services. The majority are also qualified to provide indicated treatment. “Evaluation” and “Treatment” are two distinct processes. Centers that provide both services must always ensure any professional evaluated, and in need of treatment, is provided with treatment alternatives acceptable to the PHP, the RA, and the ATP. The availablitility of alternatives minimizes perceived or alleged conflict-of-interest between the evaluation and the treatment processes.
ATPs are clinical centers specializing in the diagnosis and treatment of addictive and/or mental illness in healthcare and other licensed professionals. These programs possess expertise in dealing with issues specific to professionals with addictive illness and its associated co-morbidities. They provide a spectrum of therapeutic services which addresses the biological, psychosocial, and spiritual components of these disease states. An ATP’s primary purpose is to provide healthcare and other licensed professionals with potentially impairing illness with state of the art clinical care facilitating the remission of the active disease state and long-term recovery.
Regulatory Agencies (RAS)
RAs are branches of State government charged with credentialing and licensing of healthcare and other licensed professionals. State statutes mandate the regulation of these professions to insure delivery of quality healthcare or other services to the public. They investigate and address licensees who violate the state’s practice acts or other comparable legislation. Their primary mission is to protect the public.
ASAM is aware of the significant variability that exists among ATPs, PHPs, and RAs from state to state. ASAM also recognizes that some ATPs differ in their philosophical and operational approaches. ASAM acknowledges the political nuances, funding levels, state statutes, and other factors influencing how effectively these entities function individually and collaboratively. Where impediments to optimal functioning exist, they should be challenged by all involved. This ASAM policy statement on Coordination among these three entities provides a broad-based generalized vision. Its recommendations reflect an attempt to express parameters to be followed under ideal conditions. Those PHPs which have established trust and credibility with their Regulatory Agencies appear to function at highly effective levels. Those RAs which provide a safe and effective alternative to discipline by a confidential conduit through their PHPs also appear to be the most effective. Having an established alternative to discipline enhances the willingness of colleagues and others to report concerns regarding professionals with potentially impairing illness, and lessens resistance from ill professionals in need of assistance. ATPs that specialize in evaluation and treatment of healthcare and other licensed professionals provide particular expertise in addressing those issues specific to this population of ill individuals.
Coordination Among All Three Entities
Interagency communication and cooperation are critical in achieving optimal results. Healthcare and other licensed professionals occupy safety-sensitive positions and every effort should be directed to ensure their ability to practice their profession with reasonable safety.
PHPs are unique in their ability to provide early identification, intervention and referral before the public is compromised by actual on-the-job impairment. They should refer to only qualified ATPs and periodically assess the status of those programs. Unless specifically structured to do so, PHPs should avoid making diagnoses or providing direct primary treatment. They should facilitate case management and the establishing of continuing care when appropriate. The main focus of a PHP should be their participant’s fitness-for-duty from the standpoint of disease remission, while leaving to RAs the role of determining the licensed professional’s competency and skills. Under no circumstances should a PHP misrepresent itself as speaking for an RA. If membership requirements are met, PHPs should join and actively participate in the Federation of State Physician Health Programs (FSPHP), taking advantage of this organizations collective experience and wisdom. PHPs should utilize the FSPHP Guidelines unless the circumstances of a particular case dictate otherwise. They should demonstrate accountability by submitting periodic reports to their stakeholders, and embrace transparency and accountability by inviting independent audits.
An additional role of PHPs is education. PHPs work to provide evidence-based education to all involved regarding addiction and other potentially impairing illnesses. PHP’s interface with RAs, state legislatures, hospitals, clinics, professional associations, public groups, professional liability insurance carriers and others. PHPs educate these entities on the role of the PHP, ATPs, RAs, and the importance of coordination among the three to the benefit of individual licensees and the public. PHPs can also respond in an informational manner, educating on all of these issues, to licensed professionals, family members, colleagues, or the media.
ATPs should periodically report patient progress to PHPs, solicit secondary interventions from them when necessary, and invite participation in discharge planning. This is especially important with respect to return-to-work considerations and stipulations. The repository of all clinical records is the ATP, and should remain in that domain unless otherwise expressly authorized by the patient (See Public Policy “Confidentiality”). ATPs should carefully coordinate discharge planning with the PHP and provide discharge summaries to PHPs immediately after discharge. ATPs should maintain financial and administrative independence, avoiding all conflicts of interest with PHPs.
When legislative reform is indicated, RAs should endorse the adoption of statutes that provide rehabilitative alternatives to discipline for a licensed professional when there is no evidence of public harm. RAs assistance via regular review of PHP reports and PHP policies and procedures enhances the accountability and relationship by and between PHPs and RAs. This accountability and relationship is facilitated by mutually acceptable periodic performance audits. Effective PHPs can thus be provided public advocacy by RAs parallel to the way PHPs provide advocacy for the ill professional who has been accountable and compliant. RAs should avoid unintentional undermining of PHPs in failing to support the PHP in the event of participant non-compliance. RAs should utilize their PHP as the licensing Board’s expert consultant in all matters relating to licensed professionals with potentially impairing illness.
The structure and functioning of ATPs, PHPs and RAs are clearly circumscribed yet overlapping. It is in the best interest of all parties to understand and respect the boundaries between them. Ideally they should function effectively through collaborative mutual respect for each other’s clinical, therapeutic, and legal expertise. This requires an understanding and consideration of the primary mission, operational constraints, and complimentary goals of each. Maintaining appropriate boundaries does not preclude meaningful effective cooperation and coordination. The conjoint effort among ATPs, PHPs, and RAs can successfully foster rehabilitation of healthcare and other licensed professionals while simultaneously protecting the public. In the attainment of these dual goals, well-coordinated ATPs, PHPs and RAs are not only collegial but rather interdependent and symbiotic in meeting the needs of individuals, families, professions, and society at large.
The American Society of Addiction Medicine recommends:
Professionals Health Programs (PHPs)
• Embrace and incorporate Federation of State Physician Health Programs (FSPHP) guidelines into core operations.
• Provide immediate intervention, initial assessment, appropriate triage, rapid referral for evaluation &/or treatment, and post-treatment laboratory, workplace and behavioral monitoring.
• Establish a written contractual relationship with recovering program Participants which, among other things:
o requires total abstinence from all unauthorized and/or non-prescribed mind and/or mood altering addictive and/or addiction potentiating substances, including alcohol.
o delineates all parameters of case-management and monitoring (laboratory monitoring, workplace monitoring, and behavioral monitoring).
o emphasizes the expectation of compliance with the PHP contract, and defines non-compliance.
o includes written consent for release of information, authorizing the PHP to send periodic written and verbal reports, as indicated, to need-to-know parties.
o defines the sending of compliance or non-compliance reports to appropriate external entities regarding a Participant’s participation.
• Ensure that program Participants are aware that PHP advocacy is contingent upon compliance, and ceases with:
o failure to respond to treatment.
o non-compliance with case management or monitoring as outlined in the Participant’s contract.
o behavior by the Participant which constitutes an imminent danger to the public and thus requires immediate referral of the case outside of the PHP and into the purview of the appropriate Regulatory Agency.
• Conduct extensive education about addictive and mental illness as well as the behavioral indicators of possible or potential impairment for a wide range of stakeholders in professional health, patient/public safety and related areas.
• Widely publicize the availability of the PHP and contact information.
• Adhere strictly to confidentiality as required by State Statutes, Federal Regulations, and internal PHP policies.
• Emphasize that while rehabilitation for individuals with potentially impairing illness is critical, protection of the public is paramount.
• Build trust with RAs through mutual open, honest, direct communication.
Addiction Treatment Programs (ATPS) For Professionals
• Recognize addictive illness as a primary disease state requiring lifelong total abstinence from all unauthorized and/or non-prescribed mind and/or mood altering addictive and/or addiction-potentiating substances, including alcohol.
• Have the ability to provide comprehensive, multidisciplinary evaluation for possible addictive illness, mental illness, and co-morbid disorders. The evaluation must include collateral information in addition to the self reports of the healthcare or other licensed professional undergoing evaluation and/or treatment. Evaluations should include ancillary, neuropsychological and neurocognitive testing as indicated. Any diagnosis made by an outside entity must be validated though the clinical activities of the ATP.
• Offer the choice of alternative treatment sites acceptable to the ATP, the PHP, and the RA in those cases when the ATP has conducted a comprehensive, multidisciplinary evaluation that has established a diagnosis and recommended treatment.
• Secure written authorization from the licensed professional so that the results of the evaluation and treatment services offered by the ATP may be released to appropriate entities. Authorization to the licensed professional’s PHP should be a condition of successful treatment completion.
• Have the ability to provide comprehensive, multidisciplinary treatment for alcohol and other substance use disorders, addressing the physical, psychosocial and spiritual dimensions of the disease of addiction.
• Utilize best practices with evidence-based treatment protocols.
• Orient patients to the 12-Step approach to personal recovery and support patients in exploratory involvement in such activities during the treatment process.
• Work closely with the licensed professional’s PHP throughout the evaluation and treatment process.
• Secure and maintain accreditation from a nationally recognized accreditation entity.
Regulatory Agencies (RAs)
• Clearly understand the distinction between illness and impairment by recognizing that illness does not necessarily equate to actual or functional impairment, i.e., a diagnosis does not establish the inability to practice a profession with reasonable skill and safety (See Public Policy #2 in this set of policy statements, “Illness vs. Impairment in Healthcare and other Licensed Professionals”).
• Embrace a rehabilitative and less punitive, philosophy in those cases where the ability to practice safely can be monitored by the PHP and there has been no demonstrated harm to patients or the general public.
• Enter into a formal contractual agreement with PHPs to define roles and responsibilities and have open lines of communication in order to lessen the inevitable occurrence of misunderstandings and potential conflicts of interest.
• Support PHP policies and procedures.
• Allow PHPs sufficient clinical latitude in case management. Understand and respect confidentiality restrictions imposed on PHPs by State Statutes and Federal Regulations (See Public Policy #9 in this set of policy statements, “Public Safety and the Healthcare and Other Licensed Professional with Addictive Illness ”).
• Build relationships and trust with the PHP through mutually open, honest, direct communications.
• Allow the PHP in their jurisdiction to function as the licensing Board’s expert consultant in all matters relating to healthcare and other licensed professionals with potentially impairing illness.