Methadone Treatment in Narcotic Addiction. Chapter 3

Introduction

The New York City Methadone Maintenance Treatment Program (NYC MMTP) comprises more than 40 clinical units located throughout the five boroughs, and staffed by employees of over a dozen contract agencies. Two factors have been instrumental in maintaining centralized control over this widespread network of facilities, and ensuring compliance with uniform policies and procedures. The first is the Program's organizational structure, in which one individual is assigned total responsibility for monitoring the on-going activities of several clinics (see "Management Analyst," Appendix 1). The second factor is the comprehensive data system, which evolved from a cumbersome, manual operation to an efficient, computer-based system designed to facilitate clinical as well as management functions.

Objectives of the NYC System

From a management standpoint, prompt, accurate, and comprehensive information regarding the Program's operation was indispensable. In the early years of the Program, it was necessary to know the demand for treatment, i.e., the number of applicants and their geographical distribution, in order to determine the need for expansion. Admissions from the waiting list (which at one time numbered over 8000) had to be scheduled in the order that applications were received, and the rate of admissions to the Program's treatment units had to be controlled on a day-by-day basis. While a few clinics accepted patients almost as quickly as they could be screened by the counseling and medical staff (as many as 50 clinic admissions weekly), the staff of most treatment units bad to be pushed to admit 10-15 patients per week until the census approximated the facility's capacity.

Since the capacity of each component clinic is a function of terminations as well as admissions, it was important for the Central Office to monitor attendance at each clinic and identify inactive patients who should be terminated. Optimal utilization of resources also required information regarding the pattern of scheduled visits in each treatment unit, to avoid an excessive patient load on any given day of the week (patients in the NYC MMTP are scheduled to attend the clinic from 2 to 6 days per week, depending upon length of time in treatment and demonstrated progress toward rehabilitation).

As the "Program Sponsor" of each of the NYC MMTP clinics, I was responsible for the accurate accounting of all methadone used by the Program. Consequently, the data system had to provide a reliable means for ensuring that only those individuals who were actively enrolled received medication, and for documenting the precise amount administered and dispensed to each. It also had to enable Central Office to identify any deviation from Program guidelines and Federal and State regulations governing methadone dosages and take-home medication.

Program evaluation was another critical function of the information system which was developed. Since the NYC MMTP is publicly funded and operated, there has always been an obligation to document the Program's experience in treating heroin addicts.

Methadone Accounting: The Foundation for Control

The ultimate control over all aspects of the NYC MMTP data system stems from the methadone accounting procedures which have been established. Physicians and nurses recognize that strict compliance with these procedures is a legal and professional obligation, as well as a programmatic requirement. For this reason, it has been possible to demand, and obtain, an accurate, day-by-day record of every patient visit to each clinic, and the amount of medication administered and dispensed to each individual.

A computer-printed "Medication Dosage and Pickup Schedule" (MDPS, Appendix II), based on orders written by the clinic physicians, is updated weekly (xvi); for each clinic, the schedule lists every active patient, and indicates the dose of methadone which is to be given each day of the following week. Any dosage order submitted by a clinic for an individual who is not an active patient (i.e., whose admission has not been processed by Central Office, or who has been terminated) will not appear on the MDPS.

In addition to its function as a prospective attendance and dosage schedule, the MDPS also serves as the primary methadone accounting document, providing Central Office with an historical record of actual clinic visits and dosages received by each patient. As each patient reports to the clinic, the precise amount of methadone administered and dispensed is recorded directly on the form, which is returned to Central Office at the end of the week for key-punching and analysis. Dosage and attendance information on patients admitted during the week, who were not included on the computer-printed MDPS, is entered by hand. Since the data system rejects hand-written entries for individuals who have not been cleared by the Central Office, the clinics are unable to account for medication given to anyone who is not an active patient.

This methadone accounting system is integrally related to all other components of the data system, and is the basis for ensuring compliance with the Program's admission, termination, and patient-evaluation procedures. Before a patient can be admitted (i.e., administered the first dose of methadone), the clinic must telephone the central staff, which immediately verifies that the individual's application has been received and that he (she) has been notified to report for admission screening to that particular clinic. Preadmission clearing with the Central Office prevents a patient from simultaneously enrolling in more than one NYC MMTP facility. It also allows central monitoring to ensure that applicants are scheduled for admission to the clinic nearest their home, in chronological order of application. In addition, the Central Office is able to follow up in the case of applicants who are not admitted, and determine the reason for clinic rejection of those who appear to meet the basic requirements of age, duration of addiction, and residence. Above all, the system guarantees that the Central Office knows at all times the precise census of every clinic. This accuracy, which is built into the daily operation at the clinic level, in turn permits the other components of the data system to operate more effectively (xvii).

Since an admission can be accomplished only if the Application Form (Appendix III) is processed by Central Office, all applicant information is available for analysis.

Central Office is able to identify every new patient for whom an Admission Screening Form (Appendix IV), with demographic, social, and drug-use history information, has not been submitted.

Computer-generated billing of Medicaid for every clinic visit by eligible patients is based on the historical record of attendance contained on the MDPS.

Bimonthly Patient Progress Reports (Appendix V) indicating current medical or psychiatric problems, drug abuse, legal problems, employment, schooling, welfare status, and other information relevant to patient assessment are the basis for Program evaluation. Reports are initiated centrally for every patient on the active census, providing computer-printed dosage and attendance history, and the results of all urinalyses performed during the two-month reporting period (xviii). These forms are sent to the treatment units for completion by the counseling staff, and are then returned to Central Office for keypunching and analysis of the clinical information. By correlating the number of reports sent to each clinic with the number returned, it is possible to achieve a degree of completeness approaching 100%.

Before the Patient Progress Reports are sent to the clinics, the dosage and attendance records printed on the forms are reviewed by the central staff to identify patients who have received no methadone for the entire 2-month period. The appropriate clinics are contacted, and terminations are instituted when indicated. This process prevents patients remaining "active" when they are no longer receiving medication.

By processing all terminations centrally, uniform definitions of the reasons for discharge from the Program can be applied, based on a thorough review of the patient's clinical record. The last date of methadone administration is known for all patients, and can be used as an objective date of termination, in order to eliminate the distortion in retention data associated with delays in initiating and completing the processing of terminations.

The Integration of Administrative and Clinical Functions
of the NYC MMPT Data System

Although the NYC MMTP data system was developed by the Program's managerial staff primarily to meet management needs, it was designed to be an integral component of patient care. Every data form serves a critical clinical function, in addition to providing data relevant to the administration of the Program. The Admission Screening Form, for example, contains questions which identify potential problem areas of new patients, and which are important in the planning of appropriate treatment services. The Patient Progress Report, in addition to permitting assessment of clinic and Program performance, ensures that the narrative record in every patient's chart is complemented by a concise, readily accessible, bimonthly summary of progress and problems, as well as a record of the patient's attendance and dosage history and urinalysis results. The weekly medication schedule, which serves ultimately to control and monitor the entire operation of the Program, also guides the nursing staff in the accurate administration and dispensing of methadone, and is simultaneously the primary methadone accounting document.

This integration of management and clinical objectives has proved the key to obtaining consistently accurate and timely data. Providing information intended solely for Program administration and evaluation, without direct and immediate relevance to the treatment services, would inevitably have received low priority by those who must collect the data. By addressing the needs of clinic staff, the data system of the NYC MMTP has, at the same time, made it possible for the Program to develop as a single organizational entity, operating according to uniform policies and procedures, with central accountability.

Notes

xvi. The turnaround time is 36 hours; medication orders received from the clinics each Wednesday are reflected in the computer printouts delivered to each clinic on Friday, for use during the following week.

xvii. An alternative means of achieving the benefits of centralization involves the establishment of "central intake units." The advantage of the NYC MMTP approach is that papers, and not patients, are processed centrally; applicants have contact only with staff directly involved in the delivery of treatment services.

xviii. Urinalysis results are entered into each patient's computerized file on a weekly basis, from reports submitted to Central Office directly by the laboratory.