STATE OF MINNESOTA

OFFICE OF ADMINISTRATIVE HEARINGS

 

FOR THE DEPARTMENT OF HUMAN SERVICES

 

 

In the Matter of the Proposed Rules Governing the Licensure of Treatment Programs for Chemical Abuse and Dependency and Detoxification Programs, Minnesota Rules, Chapter 9530

DEPARTMENT OF HUMAN SERVICES FIRST RESPONSE TO COMMENTS AND HEARING TESTIMONY

            The Minnesota Department of Human Services (“Department”) submits this response as its initial response to written comments and hearing testimony. 

 

General Comments:

1. Comments:  A number of individuals testifying at the public hearing supported the overall direction of the proposed rules.  Those testifying specifically praised the flexibility afforded providers, the client focus, and the setting of minimum standards without being too prescriptive.

 

A number of individuals also criticized the overall direction of the rules.  Criticisms included too much flexibility, lack of clarity and prescriptive standards.  A major theme, however, was that the Department failed to show that the current licensing rules were inadequate.

 

Response:  Approximately 300 providers treat Minnesotans for chemical abuse or dependency.  Provider programs range from flexible and innovative to highly standardized.  Accordingly, the Department cannot make generalizations regarding the adequacy of current rules for every provider.  The Department has, however, identified a number of factors that support its decision to repeal current rules and adopt the proposed rules.

 

First, the current rules support the more rigid approach to treatment delivery and require providers with more flexible programs to seek variances, which increase the administrative burden for both the providers and the Department. With the proposed rules, the Department seeks to shift that arrangement so that the rules support not only providers with standardized programs, but also providers with flexible and individualized programs.

 

Second, the current rules do not recognize the chronic illness model of treatment, and therefore, may have detrimental effects on client treatment and recovery.  Chemical dependency is aptly compared to other chronic illnesses like diabetes.  Not every diabetic patient can be successfully treated with the same program. Treatment may change depending on a client’s progress and response to current treatments.  In the period immediately following diagnosis, contact with health care providers is typically frequent.  As stability is achieved the intensity decreases, and, as the patient develops the skills and commitment to manage his or her own illness, the involvement of health care professionals may be reduced to a check-in schedule.  If, at any time, conditions change or something goes wrong, additional services can be added until stability is reestablished.  This health care response to a chronic illness provides a service delivery model that is responsive to each patient’s current situation.

 

Under the current rules, which do not recognize the chronic illness model, the chemical dependency treatment system is designed to treat clients’ discrete episodes.  Follow-up, if provided, is time-limited.  A change in condition, such as a relapse, signals a new episode, which requires starting treatment again rather than building on previous treatment experience.  If, during the course of a treatment episode, the client is recognized to need more intensive or less intensive services, the current rules require that the client be discharged from the program, even though that program recognized and was responsive to the client’s newly identified need.  The client must then be admitted to a different program at the appropriate level of care.  The change in programs requires the client to form a new counselor/client relationship, learn new rules and expectations, adjust to a new peer group, and work out a new treatment plan.  The period of adjustment sets back therapeutic progress.  The proposed rules will create continuity of care by allowing the provider that recognized the client’s change in condition to simply adjust the client’s treatment plan.

 

Third, the current rules do not support providers that seek to improve treatment efficacy.  Again, a comparison may be drawn between chemical dependency and other chronic illnesses.  As long as individuals continue to experience the affects of their illnesses, their caregivers have a responsibility to seek more responsive or effective ways of delivering service.  Because health care professionals have sought better services for their patients, individuals with diabetes now have new ways of administering insulin, more precise and individualized medication dosing, and greater control of their disease through a better understanding of the interaction of diet, exercise and medication.

 

In contrast, the outcomes for chemical dependency treatment have not changed significantly over the past five years.  The following are the chemical dependency treatment completion rates for chemical dependency provider programs in Minnesota:[1]

 

1998:   63.7%

1999:   64.4%

2000:   64.2%

2001:   63.7%

2002:   65.1%

 

Completion rates are used to track positive treatment outcomes because program completion is the single most important indicator of client abstinence six months after discharge. Many of the provisions of the proposed rule were incorporated to address the factors that keep individuals from successfully completing treatment. The proposed rule should help providers better meet the needs of individuals who currently do not complete treatment.

 

Fourth, the current rules assume that some clients live in environments that are detrimental to recovery.  As a result, the current rules may not allow a client to receive an appropriate level of treatment services on an outpatient basis and may require their admission to an inpatient program, which is more costly and intrusive.

 

Conversely, the current rules assume that a client lives in a safe and appropriate environment if they need relatively low intensity treatment services, which the rules prescribe as outpatient treatment.  Under the proposed rules, providers can assess a client’s need for housing support independently from the client’s need for treatment.

 

While the Department recognizes that some providers have been able to accomplish these goals under the current rules, the current rules are not designed to support these goals.  The proposed rules are intended to support providers in developing individualized responsive treatment programs for their clients. 

 

In summary, the proposed rules do not require that every provider offer an infinite array of services, service intensities, or housing options.  The proposed rules simply support providers in either continuing with their current program practices or developing innovative and responsive treatment approaches.  The Department, by offering the proposed rules, is not saying the system does not work.  Rather, the point is that the Department’s licensing rules should not be the barrier that limits the system’s opportunities to improve.

 

2. Comments: A number of individuals questioned the relationship between the proposed rule and the assessment of the need for chemical dependency treatment.

 

Response: The proposed rule will establish the standards for programs licensed to provide treatment services.  It will not change the manner in which assessments are performed. The Department will continue to assess and authorize services on the basis of the levels of care in the assessment rule, which is found at Minnesota Rules, Parts 9530.6600 - 9530.6655.  Although the Department is considering modifications of the assessment rule, the proposed conforming changes at 9530.6605 ensure that the language of the assessment rule is compatible with the proposed changes to the licensing standards.   

 

 

 

 

 

3. Comments: Individuals expressed concerns about the relationship between the proposed rule and Chapter 2960 and the lack of notice to providers regarding the adoption of Chapter 2960.

 

Response:  The Department is working on language to amend the proposed rules to clarify the relationship between the proposed rules and Chapter 2960.  This amended language will be provided in the Department’s second response to comments.  The hearing record for Chapter 2960 documents the notice provided to chemical dependency treatment providers. On January 3, 2003, all licensed residential chemical dependency programs were sent notification of the hearing, which was held on February 11, 12 and 13, 2003. Representatives from two licensed residential chemical dependency programs were on the advisory committee that developed Chapter 2960.  Further Chapter 2960 will not be fully effective until July 1, 2005.  The Department intends to provide numerous training and information sessions for providers operating programs licensed under this Chapter.

 

4.  Comments:   There were several comments expressing concern about the haste with which the proposed rules were developed. 

 

Response:  As evident in the record, including 3 published Requests for Comment, the development of these regulations has taken years.  The Department nonetheless recognizes that some period of time is needed to transition to the revised standards.   The Department estimates that it will take from 6 to 9 months to develop training on the new standards and to offer this training to providers throughout the state.  We further anticipate that providers will need several months to analyze the impact of the rules on their organizational structures and to make necessary adaptations.  The Department proposes the following amendment in order to allow an efficient transition to the new rules before implementation.

 

Effective Date.  Minnesota Rules, parts 9530.6405 to 9530.6590 are effective September 1, 2004.  The Repealer would also be effective September 1, 2004.

 

Comments regarding proposed part 9530.6417

 

Comments: A number of individuals indicated that the proposed rule requirements concerning capacity management, which is found at 9530.6417, were unduly burdensome.

 

Response: The Department drafted the capacity management portions of the proposed rule to comply with the Federal Substance Abuse Prevention and Treatment Block Grant mandates for programs serving IV drug users and programs serving pregnant women.  In response to public comment, the Department has determined, based upon its understanding of the federal mandates, that the language of 9530.6500, subpart 2 is sufficient to meet the federal requirements of 45 CFR 96.126. concerning programs for IV drug users.

 

The Department also has federally imposed capacity monitoring responsibilities with respect to availability of programs serving pregnant women.  The federal regulations allow these responsibilities to be accomplished in a number of ways.  The Department has determined that given the flexibility offered under the federal regulations and the limited populations involved, the potential burden imposed on providers by 9530.6417 is not necessary.  The Department will develop an alternative mechanism for gathering the information necessary to monitor and manage the availability of these services.  Accordingly, the Department proposes to delete part 9530.6417.