Low AMA Rate at Northbound – Therapy and Case Management

Edited by Living Sober

Last updated June 17, 2010

AMA stands for Against Medical Advice, whereas ASA stands for Against Staff Advice.  Often a drug rehab, or addiction treatment facility, is qualitatively assessed using AMA or ASA rates.  A high AMA or ASA rate means that a drug rehab has many clients leaving against the clinical recommendation of staff.  Often the client leaves treatment early (i.e., before their discharge date) and signs a paper stating that he or she has decided of their own volition and against clinical recommendations, to leave a treatment facility.

Having worked at many treatment facilities over the last 13 years, I have seen very high AMA rates.  In fact, I have worked at some facilities where most of the working hours in a day are spent just trying to keep clients at the facility. There are many reasons that clients leave a facility, but oftentimes if the AMA or ASA rate is high it means that there is something wrong with the program or staff at a facility and most likely the staff is spending most of their time just trying to get clients to stay at their facility.  It is inevitable that some clients will occasionally leave a drug rehab facility, but when this rate is high, you should be skeptical of the quality of treatment the drug rehab provides.

At Northbound we have an unusually low AMA or ASA rate.  I say unusual, because we expect it to be higher given that many people who enter drug rehabs in the United States do not want to be there.  One of the reasons why Northbound might have such a low AMA or ASA rate is because of the therapeutic model we use at Northbound.  Each client at Northbound has both a therapist and a case manager, which means that every client has two people working on their clinical care during their treatment stay.  I have found that the therapists are key to helping developing rapport with the clients, which equates to more successful outcomes.  Other drug treatment facilities have either a case manager (licensed drug and alcohol counselor) running a client’s case, or a therapist doing both therapy and case management, but no treatment center I know of assigns both a case manager and a therapist to each client.

Our therapists at Northbound are fortunate enough to focus primarily on therapy, whereas therapists who are also required to do case management must also focus on the daily management of a client’s case, which often means lots of paperwork and a lot of other daily monitoring of the client does not need a therapist’s level of expertise and is more suited for a drug and alcohol counselor.  By having the therapist be able to focus primarily on therapy and not case management, the quality of treatment is increased, leading to lower AMA or ASA rates.  Clients often come return to our facility after a relapse because of the relationship they formed with their therapist at Northbound.  I am not trying to minimize what case managers are able to accomplish with a client, but it is a different type of treatment.  When a drug and alcohol treatment facility only utilizes drug and alcohol counselors and not therapists for treatment, then often the drug and alcohol counselors end up attempting to do therapy with a client, which they are not qualified to do.  Likewise, therapists who double as case managers are faced with the daunting task of managing a client’s case while at the same time doing therapy with a client.  The relationship lines become blurred and often the quality of therapy is negatively effected.  Therapists who double as case managers in a residential drug treatment setting, often become the disciplinarian, and the level of rapport is reduced. When a therapist is seen as the disciplinarian by a client, clients treat their therapist as such, often rebelling and limiting the information they reveal to him or her for fear that they will “get in trouble.”

In a primary facility it is easier for therapists to double as case managers because the clients are more contained, but in a residential drug rehab setting, having therapists double as case managers puts the therapists in a tricky and often uncomfortable situation.

At Northbound we prefer our case managers to focus on the client’s 12-Step program , managing communication between the family and the client, and managing the client’s clinical chart, leaving our therapists to focus on what they should be focused on – therapy.

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