Understanding PPC requires an awareness of the following underlying assumptions. The PPC is an evolutionary process - a work in progress. How it applies to the wide variety of chemical dependency services available, as well as to other healthcare providers, the insurance industry and the criminal justice system is an on-going scenario that will take years to fully develop. The PPC are not a set of rules carved in concrete.

In order to even use the criteria (except for Level 0.5), the patient must first be assessed as meeting the diagnostic criteria of a substance-related disorder. The treatment of individual patients requires professional evaluation and the exercise of independent judgment on a case-by-case basis. The PPC are a format for professional decisions and a way to objectively share those decisions with others.

Treatment "failure" at a given service level should not be used as an admission criteria to another level. The "failure" of a patient at a particular level of service should not be attributed to the patient alone. Often there are contributing factors, such as the appropriateness of the treatment level, quality of treatment and treatment planning, logistics and financial considerations.

The ideal length of service is focused on the fact that patient needs and the goals of the individual treatment plan determine the level of service, not program content, finances or the criminal justice system. The PPC recognizes that availability of appropriate services, progress in treatment and state laws may require exceptions.

Spirituality is inherent in all the dimensions. Due to the difficulty in measurement, it is not a separate dimension. Self-help recovery groups, such as Alcoholics Anonymous, are encouraged by the PPC, but not considered a formal treatment level due to the lack of "formal programming."

The goal of the criteria is placing the patient in the most appropriate level of service based on patient needs and response to treatment goals. Unlike earlier versions of the ASAM PPC, treatment services are "unbundled," i.e., the type and intensity of service are determined by the individual treatment plan and not limitations imposed by the treatment setting.

The primary impact of PPC for the clinician is in treatment planning and the chief challenges to treatment planning seem to be twofold. The first is the switch to a specific focus on patient needs and goals (rather than "programs and content"). The second challenge is clinical writing that is behavioral and measurable, as well as clear and understandable. This becomes a matter of practice and patience, and can be solved over time by the use of the suggestions that follow:

• Treatment plan review and team staffing of patients on a frequent basis are essential, for the value of learning, mutual support and to provide the creativity needed to use the PPC.

• Each treatment team should develop a shared master book of clinical writing that works for that agency. Sentences and phrases (and whole treatment plans) that are developed by the staff should be readily available for use so they can be adapted to the individual patient. It is much quicker to adapt a pre-written sentence than to sit at a desk trying to put the whole thing together. This is not the same thing as having pre-printed treatment plans, which should be avoided.

• Providers must have clinical supervision that focuses on meaningful and consistent review of treatment planning and placement decisions, to include continual training.

• Forms should be as easy to use as possible. Computer software can help, especially to keep staff schedules networked and to process routine letters, but is not a substitute for professional judgment.

• A thorough analysis of the entire treatment system, with line staff participation. In order to provide the time for treatment planning and continuous assessment, each portion of the system must be looked at to eliminate duplication and unnecessary forms.

Finally, the use of Patient Placement Criteria requires time, training, practice and patience. Criteria for patient placement, like other sets of criteria we use, are tools to increase our professional judgment as well as the efficiency and effectiveness of treatment.