xxAACP Newsletter, Volume 11, Number 4, Autumn 1997
AACP Continues Development of LOCUS
Adult Version 1.5 Approved for Release
Principles Behind LOCUS
The task force developed several goals which they hoped to achieve with the level of care determination instrument. First, it must be easily understood and used. Second, it should incorporate, in a concise manner, the various factors clinicians normally use in making level of care decisions and it should reflect the interaction among those factors. Third, it must strike a balance between wise resource management and effective clinical care. Fourth, it should integrate factors relevant to both psychiatric and addictive problems and eliminate the need to determine which is the "primary" disorder. Fifth, it should be broadly applicable to a variety of systems and settings and preserve local autonomy in developing programming to meet the needs of unique populations. Finally, it should give reliable results with a variety of users and those results should reflect the consensus of experts in the field.
The Design LOCUS is divided into three sections. The fist section defines six evaluation parameters: 1) Dangerousness; 2) Functional Status; 3) Medical and Psychiatric Co-Morbidity; 4) Recovery Environment; 5) Treatment and Recovery History; and 6) Attitude and Engagement. A five point scale is constructed for each domain, and the criteria for assigning a given rating or score in that domain are elaborated. In dimension IV, two subscales are defined, while all other dimensions contain only one scale.
The second section of the document defines six "Levels of Care": I) Recovery Maintenance and Health Management; II) Outpatient; III) Intensive Outpatient; IV) Intensively Managed Non-Residential; V) Non-Secure Residential; and VI) Secure Residential. In addition, Prevention and Health Maintenance "Basic Services" are defined. Each level in the service continuum is defined in terms of four variables: 1) Physical Plant; 2) Clinical/Medical Services; 3) Support Services; and 4) Crisis Resolution and Prevention Services. Although the term "level" is used for simplicity, it is not meant to imply that the service arrays are static or linear. Rather, each level describes a flexible or variable combination of specific service types. Each level incompasses a multidimensional array of service intensities, combining crisis, supportive, clinical, and environmental interventions, which may vary independently. Patient placement criteria are then elaborated for each level of care. Separate admission, continuing stay, and discharge criteria are not needed in this system, as changes in level of care will follow from changes in ratings in any of the six parameters over the course of time.
The final section of LOCUS describes a proposed scoring methodology which facilitates the translation of assessment results into placement or level of care determinations. Both a grid chart and a decision flow chart are included for this purpose.
Early Experience
During the year of its release, LOCUS has been widely distributed and used in a variety of systems. The feedback obtained in these early applications has played a valuable role in guiding the first and second revisions on the instrument. The board of directors of the AAPC recently approved Adult Version 1.5 which has been available since May. Even prior to the revisions, the reception of LOCUS has been uniformly enthusiastic and it has been widely implemented by provider systems in Maine, Vermont, Pennsylvania, Michigan, Texas, Ohio, Oregon, and Washington and many other states. It has also drawn interest from several public sector managed behavioral heawlth companies and insurers. Several allied organizations have reviewed it and have expressed their interest in promoting its use.
There has been a general consensus that the task force met many of the goals it set out to accomplish. The instrument has been well received by both clinicians and administrators and has been useful not only for initial placement decisions, but also for internal utilization management, service planning, and clinical monitoring. Systems have found that their local needs can easily be accommodated by supplementing the standard framework LOCUS and that this can be accomplished without sacrificing the integrity of the instrument.
Recent Developments
With the early success of this instrument, a LOCUS Development Committee was formed at the last Board meeting which will be responsible for coordinating future initiatives with LOCUS and its derivatives. Having approved Adult Version 1.5, the committee has agreed to proceed with formal reliability and validity testing. The testing is targeted for completion by mid 1998. As part of the testing process, and in an effort to further improve the ease of use of the instrument, the AACP entered into a partnership with Deerfield Behavioral Health Network of Erie, Pennsylvania to develop a software version of LOCUS. Sales of computerized versions of the instrument will hopefully generate additional income for the AACP. The software version is expected to be available by the end of October 1997. In a separate agreement, Deerfield will also market a training program which will be promoted to assure reliability in its application by users and which will be part of the formal testing process.
A Child and Adolescent Version is also in production in partnership with the AACAP (American Academy of Child and Adolescent Psychiatry). It is hoped that the first draft of this version will be available before the end of the new year.
LOCUS Development Committee
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