Commentary: Peeling the Layers of Confidentiality in Addiction Treatment

As addiction treatment providers become integrated into the larger health care system as part of health care reform, it will become especially important for addiction professionals to understand issues of patient confidentiality in this new environment.

The Patient Protection and Affordable Care Act (the health care legislation signed into law in March 2010, known as ACA) is centered on the idea that the client/patient controls his or her own health care. So the question becomes, what does the client/patient want to follow them in their records that move from substance abuse treatment to primary care and potentially to mental health care?

The foundational piece of the client/patient record is their diagnosis or diagnostic impression. The client/patient will want to be assured that the “least restrictive” diagnosis is applied to their specific condition. This has not always been the practice in some treatment centers that use a “one size fits all” diagnosis and treatment planning. In some treatment centers, the intake, screening and evaluation process is performed by new or inexperienced interns and addiction professionals due to the economics of the facility and treatment budgets. With more complex clients/patients (co-occurring and co-morbid disorders), it is even more important that the professional performing the screening and evaluation process is seasoned and trained in addictive and co-occurring disorders and is knowledgeable in performing a mental health status.

To measure the performance of individual clinicians in following confidentiality procedures, clinical supervision will need to be enhanced and more available. Currently, there is little to no reimbursement for clinical supervision and therefore, it is a low priority for many treatment programs. Ongoing supervision through case studies, multi-disciplinary team reviews, documentation reviews and training will need to be expanded in most treatment systems in order to meet this need and reduce the risk of malpractice lawsuits.

The ACA expands treatment to family members. For years, addiction providers emphasized how important family treatment is to the whole family system. However, few programs have been able to implement consistent and integrated family programs. While integrating families will improve outcomes, the expected growth of family treatment will push up against confidentiality boundaries. Issues of how and what to share of the primary client/patient’s progress, along with how much to share from the family members to the primary client/patient, need to be resolved. Training in ethics and confidentiality will become a higher priority to reduce perceived trust issues and potential malpractice claims.

Due to integration of primary care with addictive disorders and mental health, more use of QSOAs, or Qualified Service Organizational Agreements, will be helpful. A qualified service organization (QSO)  is a person or organization that works with an addiction service provider, either in providing services or in storing records. Clear examples of different types of QSOAs and individual/family releases of confidentiality will be helpful to all systems of providers. Cross training of records management will also be necessary for the addiction professional who has not worked in a primary care setting that includes documentation in that particular system. Understanding what should go into a medical chart and what should not will be important for the addiction professional to know.

Preventing relapse is another issue that will present challenges in the new health care environment. Addiction professionals know that a relapse can be used to promote the recovery process and not used in a punitive fashion by sending the patient/client to jail or removal of children from the home or other such penalties. We will have to figure out the best way to mitigate relapse with appropriate documentation, releases of information and treatment plan review in the child welfare and legal systems.

In the professional worlds of the primary care, mental health and addictive disorder, I believe that “no malice intended” is one part of a code we all live. However, as we transition to this new environment, there will be some trial and error that will result in negative experiences. We must work together to discuss how to protect the people who have been entrusted to our care, and their families. Building trust through communication and release of information systems will enhance client/patient protection and build stronger relationships among the health care and helping professionals.

For more information, visit the NAADAC website. Also posted on our website are the Substance Abuse and Mental Health Services Administration’s (SAMHSA) FAQs regarding confidentiality.

Cynthia Moreno Tuohy serves as the Executive Director of NAADAC, the Association of Addiction Professionals. To contact her directly on this or any other issue, email her at cmoreno@naadac.org.