During the past few weeks I have worked on two cases that required me to make referrals to treatment, and in both cases, I found myself very frustrated. What should be a fairly straightforward and easy thing to do, is far from it. And when I make a bad referral, I feel responsible when the person I am trying to help actually gets worse. So I take referrals very seriously.
Why do I find referring people to treatment so challenging? Let me count the ways…. While, how about I just provide you my top six reasons:
- No treatment available. In 55 percent of counties in the US there are no licensed providers of addiction treatment according to SAMHSA’s 2013 workforce survey. While most of these are rural counties, it turns out some of the most serious addiction problems occur in small communities, particularly those with high poverty. But even in cities that have licensed providers, many have wait lists. So at times I struggle finding help for someone because there simply is no local help available. This means my client must travel to a city that has available treatment, which means more financial and logistical challenges.
- Clinician Variability. Programs don’t treat people, people treat people. The most important thing I do in making a referral is to spend time really understanding who will be delivering care. You would think vetting degrees, licenses, and scope of expertise would be sufficient, but it’s not. Most clinicians are average, and for many people and problems, average works just fine. But when I seek help for someone, I want better than average, I want the best I can find. And that means going beyond credentials on paper and finding those rare individuals – masters – who consistently produce positive outcomes. And this often means looking for a needle in a haystack, which as you might imagine, can be frustrating.
- Minimum stay requirements. I recently called The Menninger Clinic, Cottonwood de Tucson, and The Meadows – three high-end residential programs – wanting to admit a client for 1-2 weeks of care, and all three said “No”, they had minimum stay requirements that started at 30 days. But my client did not need a month of residential treatment, and doing so would have meant irreversible consequences from being away from work for so long. It irritates me to no end that the treatment industry continues to ignore the customer and their needs, and operate programs to optimize revenues rather than patient outcomes.
- Lack of coordinated care. Many patients need a team of people to get better (see my post on heroin addiction), which may include: primary care physicians, nurse practitioners, counselors, psychologists, case managers, pastors, dentists, social workers, psychiatrists, dieticians, and the list goes on. In my experience working on referrals, among the biggest challenges is getting everyone on the same page, with signed releases, working together as a team. Individually, providers are on board with the idea of collaborative care, but in actual practice, there is still much room for improvement! Case management takes time, often time that no one wants to pay for. The hope for the future is that technology can help connect the dots, but that day has yet to come because of numerous barriers including how protected health information is across providers.
- One size does not fit all. Most often people who struggle with problems like addiction and trauma require different interventions, at different times, done by different people. The idea that one person or program can sufficiently provide all the help a person needs is unrealistic. So a critical component of my referral work is determining where a person is at on their road to healing, what interventions make sense given where they are at, and who is the best person(s) to do the clinical work. If you are unfamiliar with my 5 Actions framework, I encourage you to check it out as it help explains this point in more detail.
- Patients are unpredictable. While us clinicians (and researchers) would like to believe we can use screening and assessment tools to identify and categorize patient problems, and then apply evidence-based practices with predictable results, those who have been in the clinical trenches long enough know that counseling is messy and unpredictable. No matter how thorough a job I do in vetting out the fit between a client and referral provider, I have learned from experience that patients are as unpredictable as life. I do my best to get it right, and then back away from the outcome and trust that whatever is supposed to happen, happens.
Finding the Right Fit: Enter Case Managers
The point of the previous points is to hit home that matching patients to providers can be a challenging endeavor! It requires careful evaluation, thoughtful patient input as to their motivations, needs, and desires, and skillful selection of professionals who have a track record of delivering positive outcomes. I wish I could provide you a formula that makes the process easier, but patient matching is both art and science.
Who are the most skilled at making referrals? In my experience, case managers are the best trained professionals to do this kind of work. There are approximately 37,000 certified case management professionals throughout the US, and while not all of them make referrals, most are quite good at it.
Recently, I wrote an article for the journal Care Management about how Case Managers could play a key role in transforming addiction and mental health treatment throughout the country. The article, Case Managers as Change Agents for Improving the US Addiction Treatment System, is really worth the read if you are interested in this topic (and even a good read if your not)!
Doug McCullough says
Hey Dr. John!
Very interesting article! I agree that those individuals who may need treatment and are living in rural communities are underserved in regards to treatment. I’d be curious to hear your thoughts on E-therapy and whether it can be an effective way to help those with substance abuse issues? In my opinion I feel it can be helpful but not as a stand-alone approach. Also, when you’re searching for a clinician to refer a client to, what are some of the things that you look for? I feel that credentials are not enough; passion for helping people and a proven track record of success using evidence-based practices are essential in my opinion!
John Fitzgerald says
Thanks Doug for the comment. Here is a link to my thoughts on e-therapy: http://addictionmanagement.org/online-cloud-based/. As to what I look for in a counselor, I agree with you – passion, proven track record, and I would add an ability to really listen and work with the body and emotions.
KayLynn Gesner says
I found this post especially interesting because I am studying to be a social worker, and I often think about these sort of things. Your post made some great points that referrals are sometimes misguided or impossible to make. You mentioned collaborative care, which is the basis for my career path: as a social worker, I should work with many people to make sure that the patient/client is receiving the best care for them. The system needs to change from a “one size fits all” to a system that values the differences in each person and is flexible enough to work with that person. I think about just the example you gave of the person who need residential care for 1-2 weeks, which seems reasonable, but facilities said no because they had a minimum stay, which is ridiculous. The length of stay should be up to the person, and agreed upon by all basis.
Thanks for a great post!
John Fitzgerald says
Thanks for the kind feedback!