In the mid-90s, Wesley Sowers, MD, was the medical director for St. Francis Medical Center in Pittsburgh, the largest addiction treatment center in Pennsylvania at the time. Brewing was a tug-of-war between clinicians and managed care over who got to determine what was best for clients. Dr. Sowers, who is now the director for the Center for Public Service Psychiatry at the University of Pittsburgh, says clinicians showed considerable variability in decision making, which didn’t always include judicious use of resources and often resulted in more extensive hospital stays than people needed. “There wasn’t much thought about how we could use resources most effectively.” This began to manifest in burgeoning costs of care and was one of the reasons state and local governments, as well as private insurers, started to examine ways to control costs. The behavioral health community understandably feared that these limitations would harm treatment quality, and clinicians worried that managed care would eliminate their autonomy. “Both had a rationale behind what they were doing and why they were doing it. While managed care reforms were needed, many went too far.” Dr. Sowers, who had long been interested in systems, believed there was a sweet spot where balance could be achieved, and so he began to develop a mechanism that would determine best outcomes for people and systems of care. A win-win in facilitating person-centered care and cost-effective resource use.
Examining how to optimize treatment quality and manage costs, Dr. Sowers attempted to develop an integrated medical necessity tool to help match patient need with the appropriate service intensity. He also wanted to create a structure that was equally effective for people with addictive disorders as those with mental health issues, closing a divide perpetuated in behavioral health. “I was interested in co-occurring disorders and wanted to consider the interaction of mental illness, addiction, and physical issues that might affect people’s treatment response.” Dr. Sowers’ answer was to design a comprehensive system that focused on seven assessment dimensions: risk of harm; functional status; medical, addictive and psychiatric comorbidity; recovery environment (this dimension has two subscales: level of stress and level of support); treatment and recovery history; and engagement and recovery status. These became the core of the Level of Care Utilization System known as LOCUS. With input and support from the American Association of Community Psychiatrists (AACP), Dr. Sowers developed an algorithm in 1996 that makes it simple for clinicians to provide best-fit recommendations for care intensity. A rating in each dimension ranges from lowest to highest need: from 1 to 5, respectively. The clinician then adds the numbers for each dimension together, resulting in a composite score that indicates a person’s degree of need and the corresponding level of care required. Scores range from 7 as the lowest possible need and 35 as the highest.
Once LOCUS identifies the correct level of care in the continuum, providers can select from a menu of services tailored to a person’s particular needs. Menu items include clinical services, supportive services, crisis resolution and prevention services, and describe the conditions of the care environment. Dr. Sowers says that, on average, a person with a lower composite score wouldn’t have the same need-intensity as a person with a higher one, but that isn’t always the case. He says the first three dimensions—risk of harm, functional status, and comorbidity—include overriding concerns. If a person scores high in these critical areas, the algorithm will alter recommendations accordingly, pairing the person with an increased level of service. “There is a composite score and treatment grid that gives clinicians the correct placement. It’s easy to use.”
Dr. Sowers never anticipated it would work so well and has been pleasantly surprised at how widespread adoption has been, not just when it was developed in the 1990s but in the decades since. Unlike most innovations, LOCUS is a tool that is as applicable today as when it began. Since their inception, LOCUS and CALOCUS (the Child and Adolescent counterpart) have gone through revisions to improve accessibility and clarity. “Along the way, we have asked people to tell us what doesn’t work and what could be improved.” Interestingly, he says that over the years, there hasn’t been much need to change the rating system, but there have been minor adjustments to service intensity and level of care descriptions. “It has been a 20-plus-year process, and LOCUS is continually picking up momentum.” Part of the reason, he says, is that while many clinicians still use paper and pencil, the automated version is increasingly used and preferred, particularly as hospitals and treatment centers move toward electronic medical records.
Though the use of LOCUS is widespread, Dr. Sowers isn’t sure how comprehensively clinicians are using it. He built the system to span the service array and care continuum. The clinical structure translates from one level of care to the next and easily lends itself to a person-centered care and recovery paradigm. Dr. Sowers says there should be ongoing, continuous assessment throughout a person’s treatment experience. “Using surveys, we have tried to determine whether there is full LOCUS use, but it hasn’t yielded much information. Anecdotally, we can tell that many organizations only use it in a crisis setting, in some residential facilities, or in inpatient settings instead of along the entire continuum of care.”
Using LOCUS in limited settings doesn’t maximize its potential. Unlike alternative tools, the assessment takes into consideration prior responses to treatment and social and interpersonal determinants of functional impairment. Dr. Sowers says he and the AACP designed the system to guide continuous treatment planning, giving clinicians an indication of what needs to be improved upon to move a person down to a lower, less restrictive level of care. The objective is to follow the person as he or she moves through different care levels, tracking not only individual progress but also the entire system of clinical management. “It clarifies and unifies what we do in clinical settings, allowing us to identify the correct level of care for a person and most cost-effective measures that ensure the best outcomes.”