Susan Musetti, MFT accepts Twin Town Clinical Director Position/ Ethical Standards Restated!

Doing the right thing is not easy but it is what we’re about

Media coverage of addiction treatment leads the public and some professionals to conclude that service providers will take inappropriate measures to increase revenues.

Twin Town distinguishes itself by:

• Refusing to accept/ pay referral fees or contract with referral mills (internet websites) to increase rates of patient enrollment. The patient and family geographic location, and the clinical needs expressed by the patient and their family are always considered when forming disposition/ referral plans.

• Refusing to mislead patients and their families with statements such as, “We’ll take your insurance and we will accept payment arrangements for the unpaid balance”. In situations where the patient and their family are misled at enrollment, they are later shocked by bills which may exceed tens of thousands of dollars. The reality all along was that the insurance would have only paid for only a few days of residential or out-of-network treatment.

• Refusing to contract with the patient or family for a “flat case-rate” for the entire course of treatment. Under flat case rate agreements refunds are frequently refused and the unused funds are pocketed.

Twin Town sets ethical and quality standards that in many ways exceed the norm:
 Twin Town provides only cost-effective treatment which is quality monitored.
 Before admission, we provide full financial and service disclosure, and we secure voluntary informed consent. We avoid surprises.
 Our staff seeks to protect the dignity and confidentiality of each client patient and their family members.
 Documentation and billings for outpatient treatment goes towards the provision of outpatient treatment. Twin Town does not provide residential treatment- outpatient treatment is billed and is what is offered.
 Clinical relationships with current and/or prior caregivers are respected and protected. Twin Town will not transfer clients from care of therapists, counselors, psychiatrists and/or physicians. Twin Town COORDINATES care with community professionals rather than setting up competitive or fragmented systems of care.
Substance Use Disorder Services, Department of Healthcare Services and the Joint Commission certify and accredit the services rendered by Twin Town Treatment Centers. Twin Town contracts with most insurance, managed care companies and employee assistance programs.
Commercial media coverage of addiction treatment leads the public and some professionals to conclude that treatment entails residential room and board.
“Treatment” was once synonymous with twenty-eight or more days “in rehab”- away from home, family and job. Clinical outcome research, cost-effectiveness studies, competitive pricing, and purchaser/ consumer demand for choice have challenged the old paradigms. No conclusive or credible finding has changed the receding tide of residential treatment admissions and lengths of stays.

“Treatment on an outpatient basis allows a more valid assessment of environmental, cognitive and emotional antecedents of drinking episodes and drinking urges on the part of the patient, and allows the patient to test new coping strategies while still within a supportive counseling relationship. These conditions would be expected to foster greater generalization of learning in treatment to the patient’s natural environment” (Annis, 1986, p. 183).

Outpatient treatment mobilizes available supports (family, family doctor, and mutual support organizations) rather than creating temporary and artificial supports that will be removed once the residential experience ends. Indigenous recovery supports are identified and activated during the course of outpatient treatment. The transition from active treatment into aftercare is much less abrupt and gains are generalized. Clinical changes, recovery supportive resources and relationships are likely to be maintained.

Outpatient treatment provides a much greater “take-home” advantage.

“Compared to those receiving no treatment, those receiving nonresidential treatment took longer to fail or recidivate. However, those receiving residential treatment did not differ from those who received no treatment in time to failure. In the treatment-only model, nonresidential treatment participants took longer to fail than their matched residential treatment counterparts” (Krebs et al. 2009).

Longer durations and greater intensity of treatment episodes have been tied to more successful treatment outcomes. Regardless of whether the treatment is provided in residential or outpatient settings, if the patient is satisfied and remains involved with treatment, their outcome will likely be better than shorter or sporadic episodes of care (Hser, et al.).

Do outpatient services of “full-service” treatment programs provide only steps into and out of the more lucrative residential level of care if financial resources exist?

Residential treatment will produce better profit/ development margins if critical business volumes can be achieved. The higher operating costs, administrative time, and professional oversight of residential components draw decision-makers to focus on their residential treatment at the expense of their less complex and less lucrative outpatient services. It is clear to the margin-oriented administrator that short-term financial gains will be best made from a residential model if only the beds can be filled.

If your principal stakeholder is the consumer or payer of care, cost-effectiveness must take priority. Outpatient treatment, whenever clinically feasible, is the primary access point for both private and public addiction treatment. When higher acuity conditions warrant intensive supervision at the beginning of a treatment episode, “step-down” outpatient treatment provides the necessary duration of care and the sober adaptation to a normative living environment.

In our time of cost cutting and efficiency planning, outpatient treatment coordinated with detoxification, residential stabilization, medical and mental health care, and sober living answers clinical and fiscal problems. Coupled with sober living accommodations, outpatient treatment emerges as the cost-effective and accessible venue of care for many who are in need of recovery and who require a sober living condition and structure.


“Subjects benefited equally from outpatient and residential aftercare, regardless of the severity of their drug/alcohol problem.” Differential effectiveness of residential versus outpatient aftercare for parolees from prison-based therapeutic community treatment programs. William M Burdon1, Jeff Dang2, Michael L Prendergast1, Nena P Messina1 and David Farabee 1, *Corresponding author: William M Burdon, 1University of California, Los Angeles, Integrated Substance Abuse Program, Substance Abuse Treatment, Prevention, and Policy 2007, 2:16 doi:10.1186/1747-597X-2-16

“Previous reviews have concluded that there was no evidence for the superiority of inpatient over outpatient treatment of alcohol abuse, although particular types of patients might be more effectively treated in inpatient settings. We consider the implications of our findings for future research, especially the need to examine the conceptual rationales put forward by proponents of inpatient and outpatient treatment, i.e. mediators and moderators of setting effects.” The effectiveness of inpatient and outpatient treatment for alcohol abuse: the need to focus on mediators and moderators of setting effects, JOHN W. FINNEY, ANNETTE C. HAHN, RUDOLF H. MOOS Article first published online: 24 JAN 2006 DOI: 10.1046/j.1360-0443.1996.911217733.x Addiction Volume 91, Issue 12, pages 1773–1796, December 1996

National studies indicate significant reductions in recidivism following outpatient treatment
Pre-treatment Post-treatment, Drug Abuse Reporting Program (DARP), National Treatment Improvement Evaluation Study (NTIES), Treatment Outcome Prospective Study (TOPS)

Outpatient treatment more effective than residential treatment for drug-involved probationers (Krebs et al., 2009) and during reentry and can reduce likelihood of re-incarceration by 63% (Burdon et al., 2004)

Greater benefits for the cost for outpatient treatment in non-offender samples (CALDATA, French et al., 2000, 2002)

Aftercare services among drug-involved offenders can significantly reduce substance use and re-arrest (Butzin et al., 2006)

Aftercare services provide $4.4 – $9 return for every dollar invested (Roman & Chafing, 2006)