Modified Medical Model Detoxification for Drug Addiction
Social model programs that provide detoxification should have reliable and routine access to medical services to manage medical and psychiatric complications of their patients’ withdrawal. The access may be provided by a physician, nurse practitioner, or physician’s assistant. It has been suggested calling social model programs that provide medical detoxification services under medical supervision a “modified medical model.”
The purpose of the new name is to assist such programs in obtaining reimbursement under State health care reform and through managed care and third-party payers. The suggested name “modified medical model” has caused some controversy. Nonmedical critics noted that the new name could imply a “medical takeover” of social model programs. The critics with medical backgrounds and orientations pointed out that the current state of the art of detoxification, particularly from alcohol and other sedative-hypnotics and opiates, requires medical assessment and prescription of medications.
A closer alliance of the two models would provide better patient care and make some program services reimbursable by health care payers.
Advances in Alcohol and Other Drugs (AOD) abuse treatment over the past decade support this type of program, which may be described as a social model program backed up by all of the medical services needed to meet the physical needs of the patient undergoing detoxification. The essential characteristics of the ideal modified medical model are outlined under the following four headlines.
The “modified medical model” detoxification program is headed by a medical director who has knowledge of and skills in the treatment of addiction and who holds ultimate responsibility for patient care. The clinical responsibilities of the medical director include seeing patients when necessary and remaining on call for consultations. The director’s primary administrative duties are supervising detoxification staff and establishing clinical protocols.
Triage and ongoing patient evaluation are essential components of the proposed “modified medical model.” Staff regularly monitor each patient’s vital signs, and the decision to medicate or not to medicate is made by a physician. Such a routine stands in sharp contrast to that of traditional social model programs. Frequently, in these settings, no one is available to monitor patients’ vital signs. When crises occur, patients must be transported to a local emergency department. This practice is not cost-effective and does not ensure optimal patient care.
A nurse practitioner or a physician’s assistant manages day-to-day program operations. If the staff of the modified medical detoxification unit does not include a nurse practitioner or physician’s assistant, the medical director’s time in the program is expanded.
The nurse’s chief responsibilities are to monitor patients’ vital signs and to perform other nursing services. When an individual needs medical attention, the nurses call on a member of the medical team, if one is available to the unit, rather than referring the patient to an emergency department. However, if a member of the medical team is not available, the patient should be seen in an emergency department. A registered nurse should remain on call, and nurse’s aides (such as rehabilitation technicians or detoxification aides) should be on duty at all times. Appropriate support for the nurse’s aides includes, at a minimum, a nurse and a backup physician.
Staff Training, Certification, and Licensure
Ideally, all staff working in the program, including nurses, nurse practitioners, nurse’s aides, and physician’s assistants, are trained in detoxification and in the treatment of chemical dependency. Taking and interpreting vital signs constitute a minimal standard of care, and some staff members, such as nurse’s aides, might be trained to interpret signs relevant to AOD abuse issues, since such training is not provided in many standard curricula. Nurse’s aides undoubtedly would also require additional training in AOD abuse issues in order to serve as effective members of the care team in a detoxification unit. Program administrators should establish minimum standards for licensure and accreditation of modified medical programs and staff.