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– Lee Gartner, Ph.D., Planner, Chemical Dependency Program Division, Minnesota Department of Human Services. Lee Gartner is co-chair of CSAT 's TIP on Patient Placement Criteria.

Minnesota implemented patient placement criteria for public pay clients in 1986. Each year, 15,000 admissions are made to various forms of treatment using the criteria known as Rule 25. In Minnesota, the following definite benefits have resulted from implementing these client placement criteria:

• All Minnesotans now have access to a continuum of treatment services.

• Halfway house services, in particular, were not previously available to many clients, because funding these services was a local option.

• The use of residential primary treatment has decreased by 26 percent. These clients have been diverted to outpatient or combination programs with no decrease in completion rates (outcome data for this period are not available).

• Perhaps most significantly, the rise in cost of alcohol and drug abuse treatment has consistently been well below the rise of health care costs generally.

Through the 1970s and into the 1980s, Minnesota provided treatment for its public pay clients through six separate funding mechanisms. That meant we dealt with six sets of eligibility criteria and six benefit sets. Placement decisions were more a reflection of the clients ' financial condition than their treatment needs. The largest funding mechanisms had a bias toward residential and inpatient hospital care.

Additionally, placement decisions were frequently made by treatment providers who obviously had a financial interest in what treatment the client received. That problem was amplified by Minnesota 's historical investment in 28-day residential treatment.

The Consolidated Chemical Dependency Treatment Fund

In 1986, all the funding sources were pooled to form the Consolidated Chemical Dependency Treatment Fund. The premise was that public treatment dollars would be most effectively used if the type of treatment provided was based on the clients ' alcohol and drug use and resulting problems, rather than on their finances. To work, the consolidated fund required a mechanism to assure that placements would be unaffected by the financial interests or personal bias of an assessor, and that the clients – regardless of where they lived – would receive the same type of placement for the same client profile.

That mechanism was Rule 25, which is a set of placement criteria coupled with a requirement that the assessors be free of shared financial interest with a treatment provider. Rule 25 is an administrative rule developed by the Single State Agency working with a task force. The task force was representative of public and private agencies, the various levels of treatment, and diverse demographic groups. To reduce the influence of counselor bias, there was an effort to rely on objective factors whenever possible. Criteria were developed for:

• Outpatient treatment

• Residential treatment, whether freestanding or inpatient hospital, with specific criteria for situations when a hospital must be used

• Extended residential care

• Halfway house placements

In 1990, using a study commissioned by the Single State Agency, the criteria were revised to divert more clients to outpatient treatment and to add specifications for short residential stays that would be followed by outpatient treatment.

The Future of Rule 25

While Rule 25 predates the American Society of Addiction Medicine 's Patient Placement Criteria (ASAM-PPC), the major goals are the same. They are both attempts to standardize placement decisions and to make those decisions based on individual client need, to differentiate between levels of care, and to consider multiple dimensions of the client' s current condition in making the determination.

Rule 25 is less subjective than ASAM-PPC and clearer and easier to use. The Rule 25 continued stay criteria, however, are not objective enough to be transferable. Because the Rule was written in 1986, it does not build on Diagnostic and Statistical Manual (DSM) diagnoses. Neither set of criteria addresses all the levels of care available to public and private pay clients, nor do these criteria separate residential placement from type and intensity of service.

Minnesota is now moving toward universal health care coverage. The major cost containment mechanism will be Integrated Service Networks (ISNs). The requirement to make placements for alcohol and drug abuse treatment according to Rule 25 is written into the law governing the ISNs.

Eventually, Rule 25 will determine placement for most private as well as public pay clients. It will have to be updated to improve the continued stay criteria, add levels of care, incorporate DSM-IV diagnostic criteria, and unbundle service and setting. Planners in Minnesota are hopeful that, by the time they are working on a new Rule 25, the next edition of ASAM-PPC will have solved most of these problems for them.

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