The following instructions may be used as a training document for WI-UPC and as a companion to the:
WI-UPC Adult Scoring Instrument (F-00115) (Word, 174KB)
WI-UPC Adult Scoring Instrument (F-00115S) Spanish (Word, 214KB)
WI-UPC Assets and Needs Criteria (PDF, 82KB)
As a companion to the Scoring Instrument, this section is helpful in providing more in-depth detail for evaluating patient characteristics in each of the dimensions. Additionally, the Assets and Needs Criteria should be reviewed on a regular basis in determining the need for continuing stay, level of care transfer and discharge.
Patient placement recommendations are determined by evaluating five dimensions of a patient’s condition or status. These dimensions are:
- Withdrawal Potential
- Physical / Mental Health Condition and / or Complication
- Emotional/Behavioral Condition and / or Complication
- Relapse Potential
- Recovery Environment
Appropriate placement is determined by matching individual patient characteristics within each of these dimensions with the frequency and intensity of services needed as indicated by the patient’s symptoms. The WI-UPC Scoring Instrument (Section III) is used for initial placement, while the Assets and Needs Criteria (Section II) outlined for each level of care is used to determine continued stay, level of care transfer or discharge.
The first step in recommending the appropriate level of care is to determine if the patient is intoxicated or incapacitated. If alcohol intoxication is present without incapacitation, and there is need for monitoring for the patient to safely resolve intoxication, the lowest appropriate level of care is Non-Medical, Non-Ambulatory Intoxication Monitoring Service (Level D-1). It should be noted that this level of care is non-medical in nature. If or when withdrawal symptoms develop, the patient should be evaluated for possible placement in a medically managed or monitored level of withdrawal service. The evaluation to determine the need for a more intensive placement is conducted by completing a withdrawal screen as defined in this section and in Section IV, and by completing Dimension #1 of the Scoring Instrument.
If incapacitation is present, the lowest appropriate level of service is Medically Monitored, Non-Ambulatory Withdrawal Service (Level D-3). If the patient’s condition is such that withdrawal potential can be adequately assessed, either directly or through history offered by reliable collateral sources, Dimension #1 of the Scoring Instrument should be completed. A patient’s withdrawal history under situations similar to what s/he is currently experiencing may provide information sufficient to indicate the need to increase the level of care.
There are a number of nationally recognized withdrawal screening instruments which produce a meaningful score. The CIWA-Ar, the SSA and the Narcotic Withdrawal Scale are examples of such instruments (samples may be found in Section IV of the manual). WI-UPC references a withdrawal severity scoring structure as follows: minimal, mild, moderate and severe. It is therefore important that the withdrawal screening instrument you select has a similar structure to determine the severity of the patient’s withdrawal symptoms. If the withdrawal screening and evaluation of Dimension #1 produce a recommendation for care in any level of withdrawal or intoxication monitoring service other than Ambulatory Withdrawal Service (Level D-2), a referral should be initiated as soon as possible. It is not necessary to evaluate the remaining four dimensions of WI-UPC before initiating the referral. The remaining four dimensions should be completed once his/her symptoms have cleared sufficiently to allow evaluation by the service in which the patient is placed. The detoxification service providing the withdrawal care is responsible for the determination of continued stay, transfer to a different level of care, or discharge from services.
If, however, initial screening and evaluation of withdrawal potential culminates in a recommended placement to Ambulatory Withdrawal Service, and such a service is available to the patient, the remaining WI-UPC dimensions should be evaluated prior to initiating a referral to the withdrawal service. Since it is possible for a patient to receive care in Ambulatory Withdrawal Service and a level of rehabilitation treatment service concurrently, any need for such a combination of services should be explored prior to a referral.
Step three in the WI-UPC process begins with evaluation of the seven Treatment service qualifying criteria. The qualifying criteria are used to determine if the patient presents a possible need for treatment services in the formal service delivery system (services certified under the Wisconsin Administrative Code). A substance abuse screening of the patient must be completed in order to obtain the necessary information to adequately respond to the seven qualifying criteria and the five dimension questions in WI-UPC. Any screening instrument may be used as long as it examines each of these areas. In Section IV of the manual, there are a number of sample screening questions. Information from the substance abuse screen is applied to the seven qualifying criteria. If the response to ANY of the qualifying questions is "Yes", the patient is determined to be in possible need of referral to some level of formal substance abuse treatment services, and the remaining four dimensions should be evaluated. If the response to ALL of the qualifying questions is "No", the patient is determined to not be in need of services in the formal treatment delivery system. If the need for formal services is not identified, it is important to determine whether the patient should be referred to informal community support groups, other community resources or to a service delivery system other than substance abuse treatment. The selected qualifiers (#1 - #7), should also be recorded on the Summary Sheet in the spaces provided.
Each of the remaining four dimensions are then evaluated using the information from the substance abuse screening. Next to the Severity Indicator Questions which are located directly below each of the dimension questions, a number is underlined. If the response to the question is "Yes", this number should be recorded in the appropriate place on the grid found on the Summary Sheet. These numbers represent the level of care indicated by the severity indicator. When each of the dimension questions have been reviewed, the scoring grid should be completed. Instructions on the Summary Sheet ask that the single highest number for Dimension #1 be recorded as Score 1. The single highest number in all of the remaining dimensions collectively should then be recorded as Score 2. Please note that scores are not to be added or averaged; the single highest number under each of the two categories (Withdrawal/Detoxification and Treatment) should be selected and recorded.
Any extenuating circumstances should be explored for each patient on an individual basis. For instance, the recommended level of service may be Day Treatment Service according to the Scoring Instrument, but that specific addiction service may not be available in the patient’s geographic area, or funding for the recommended level of care may not be available. This would necessitate some adjustment in the referral for services, and the reason should be documented in the "Interviewer’s Comments" section of the Summary Sheet.
You may note that Transitional Residential Services are not included in the initial scoring process as a level of care. The reason for this is because a patient may not be admitted to this level of care unless they have previously been treated in one or more of the other levels of rehabilitation care (Level 1 - Level 4). In most instances, this level of care will be used in a transfer process and the criteria will be identified in the Assets and Needs from Section II. The exception to this rule is if a patient is being initially placed in either Day Treatment or Outpatient, they may additionally be placed in Transitional Residential Treatment Service if there is sufficient need, even though it may be the patient’s first placement for substance abuse rehabilitative care. If this exception is sought, specific language from the Assets and Needs in Section II for this level of care should be included in the Interviewer’s Comments Section.
Another reason for selecting an alternative level of care may be the identification of availability of additional resources to the patient. For instance, a patient may be able to address identified needs through accessing available resources such as community, friends or family members. The important thing to consider in selecting an alternative level of care is that the indicator identified in the scoring process, which produces the recommendation for level of care, must be addressed in a manner that safely and effectively meets the needs of the patient.
The patient’s willingness to accept and participate in the recommended level of care should be considered. For instance, if the patient has transportation or child care issues which prohibit the recommended placement, there may be a need to adjust the referral. Additionally, a patient may simply be unmotivated to participate in the recommended intensity of service. Consideration should be given to decreasing the service intensity and focusing treatment planning on the issue of the patient’s motivation, and providing the patient with assistance in self determination of any existing problems associated with their substance use.
In any situation which necessitates deviation from the level of service recommended by the Scoring Instrument, sufficient documentation must be included.
Finally, the recommendations should be recorded on the final page of the Summary Sheet and signatures collected. At a minimum, the Summary sheet should be transferred to the patient’s clinical record, and a copy should be provided to the referring agency. The information from the Summary Sheet may be included in alternative format, provided that all information is included
The Assets and Needs Criteria is found in Section II of the manual. This criteria, which is specific for each of the eight levels of care, should be reviewed and the results recorded on a regular basis to determine the need for continued stay, level of care transfer or discharge. When the criteria is reviewed, all of the assets listed, plus one or more of the needs must apply in order for the level of care to be appropriate. It is not necessary to identify a need for each of the identified dimensions, but rather one need identified in any dimension for a level of care is sufficient to determine appropriateness. Recording this information in the patient’s record may be accomplished in a number of ways, however all of the information must be included in the clinical record.
|LEVEL OF CARE KEY|
|D-1||Non-Medical, Non-Ambulatory Intoxication Monitoring Service|
|D-2||Ambulatory Withdrawal Service|
|D-3||Medically Monitored, Non-Ambulatory Withdrawal Service|
|D-4||Medically Managed Inpatient Detoxification Service|
|1||Outpatient Treatment Service|
|2||Day Treatment Service|
|3||Residential Treatment Service|
|4||Inpatient Treatment Service|