Continuum Care For Families
Overview of the ASAM Patient
Placement Criteria
Michael Ryan, LCSW, CASAC
February 2014
• In the past AOD treatment models have been
used as a “one size fits all” approach for almost
all patients who met the criteria for the treatment
of alcohol or other drug addiction.
• Today, in the AOD treatment field, there is a
movement toward using a variety of treatment
models to ensure access to quality treatment
and conserve healthcare resources. Now
clinicians must focus on matching patients to
appropriate, specific treatment, rather than on
placing patients in established programs.
• The success of clinically driven treatment
depends on the importance of an accurate
diagnosis.
• However, it is not only a diagnosis of an
AOD disorder, but also of the severity of
the disorder, that must determine the kind
of treatment an individual patient should
receive (Severity of Illness) (SI).
• This determination can result in:
placement of patients in the correct level
of care, movement to less intensive or
more intensive levels when appropriate,
and matching patients individually to a
variety of treatment modalities at all levels
of care.
• March 1991, the American Society of
Addiction Medicine published “Patient
Placement Criteria for the Treatment of
Psychoactive Substance Use Disorders”.
These criteria for admission, continued
stay, and discharge were described in
terms of four levels of care, for both adults
and adolescents.
• The American Society of Addiction
Medicine's (ASAM) Patient Placement
Criteria (ASAM PPC-2R) is the most
widely used and comprehensive national
guidelines for placement, continued stay
and discharge of patients with alcohol and
other drug problems.
Placement Criteria
• The overall intent of patient placement guidelines is to
place a person in the least intensive level of care that will
achieve AOD treatment objectives without sacrificing
safety or security
• They are also an attempt to establish patient placement
criteria that are acceptable to all treatment providers and
payers
• They support efforts to establish a common language for
AOD abuse treatment, to agree on consistent placement
decisions and provide a focus for future research
The ASAM PPC-2R
• The ASAM PPC-2R provides two sets of
guidelines, one for adults and one for
adolescents, and four broad levels of care for
each group.
• Level I Outpatient treatment
• Level II Intensive outpatient / partial
hospitalization
• Level III Medically monitored intensive inpatient
treatment
• Level IV Medically managed intensive inpatient
treatment.
•
Six Assessment Dimensions
• 1. Acute Intoxication and/or withdrawal
potential.
• 2. Biomedical conditions and complications.
• 3. Emotional, behavioral, or cognitive conditions
and complications.
• 4. Readiness to change, treatment acceptance /
resistance.
• 5. Relapse, continued use, or continued
problem potential.
• 6. Recovery / living environment.
• The ASAM criteria were designed to
provide guidelines for placing patients with
specific combinations of problems in
appropriate levels of safe and costefficient care.
• A strength of ASAM’s criteria is that they
characterize levels of care and patients in
some detail.
• This common language of levels of care,
multidimensional assessment of severity,
and specific placements of patients in a
level of care give the treatment field
systematic ways to describe the treatment
continuum and identify where patients
belong in the continuum.
Level I Outpatient
• Outpatient Treatment – organized nonresidential
treatment service or an office practice with
designated addiction professionals and
clinicians providing professionally directed AOD
treatment
• This treatment occurs in regularly scheduled
sessions usually totaling fewer than 9 contact
hours a week, includes both individual and
group therapy
Level II Intensive Outpatient
Treatment
• Includes partial hospitalization
• Organized service in which addiction
professionals and clinicians provide
several AOD service components to
clients
• Minimum of 9 treatment hours per week
• Patients attend a full spectrum of
treatment programming
Level III Medically Monitored
Intensive Inpatient Treatment
• Organized service conducted by addiction
professionals and clinicians who provide a
planned regimen of around-the-clock
professionally directed evaluation, care, and
treatment in an inpatient setting
• This level of care includes 24-hour observation,
monitoring, and treatment. A multidisciplinary
team functions under medical supervision
Level IV Medically Managed
Intensive Inpatient Treatment
• Organized service in which addiction
professionals and clinicians provide a planned
regimen of 24-hour medically directed
evaluation, care, and treatment in an acute care
inpatient setting
• Patients generally have severe withdrawal or
medical, emotional, or behavioral problems that
require primary medical and nursing services
Underlying Concepts of ASAM PPC
Biopsychosocial Perspective of Addiction
– Biopsychosocial in etiology, expression, Tx.
– Comprehensive assessment and treatment
– Explains clinical diversity with commonalities
– Promotes integration of knowledge
Multidimensional Assessment
1. Acute Intoxication and/or Withdrawal Potential
2. Biomedical conditions and complications
3. Emotional/Behavioral/Cognitive conditions and
complications
4. Readiness to Change
5. Relapse/Continued Use/Continued Problem
potential
6. Recovery Environment
Treatment Levels of Service
• I Outpatient Treatment
• II Intensive Outpatient and Partial
Hospitalization
• III Residential/Inpatient Treatment
• IV Medically-Managed Intensive Inpatient
Treatment
Level 0.5 and OMT
– Level 0.5: Early Intervention Services Individuals with problems or risk factors
related to substance use, but for whom an
immediate Substance -Related Disorder
cannot be confirmed
• Opioid Maintenance Therapy (OMT) Criteria for Level I Outpatient OMT, but
OMT in all levels
Detoxification Services for
Dimension 1
• I-D - Ambulatory Detoxification without
Extended On-site Monitoring
• II-D - Ambulatory Detoxification with
Extended On-Site Monitoring
Detoxification Services Dimension I
• III.2-D - Clinically-Managed Residential
Detoxification
• III.7-D - Medically-Monitored Inpatient
Detoxification
• IV-D - Medically-Managed Inpatient
Detoxification
• Level I and II Services
– Level I Outpatient Treatment
– Level II.1 Intensive Outpatient Treatment
• Level II.5 Partial Hospitalization
Level III Residential/Inpatient
• Level III.3 Clinically-Managed, Medium
Intensity Residential Treatment (Adult
Level only
• Level III.3 Clinically-Managed, Medium
Intensity Residential Treatment (Adult
Level only)
Level III Residential/IP
(Continued)
• Level III.5 Clinically-Managed,
Medium/High Intensity Residential
Treatment
• Level III.7 Medically-Monitored Intensive
Inpatient Treatment
Level IV Services
• Level IV Medically-Managed Intensive
Inpatient Treatment
Cost Benefit
• A strength of the ASAM criteria is the potential
for cost savings. A major difference in cost is
spanned in distinguishing between Level III and
Level IV treatment (medically managed vs.
medically monitored; acute vs. subacute care).
• Previously, Level III (short term, medically
monitored, residential treatment) was frequently
provided in hospital settings at acute-care rates.
• The codification of a continuum of care
although limited to four levels of care
provides PPC that can help move the
treatment field toward more
comprehensive and cost-effective
continuums of care.
• Uniform criteria can bring stability and
consistency to the field of AOD treatment,
allowing diverse disciplines and organizations to
work together. Once implemented, they can
provide a common agenda, a common
language, and shared expectations about
treatment across different groups of
multidisciplinary service providers, payers,
policymakers, and others.
• Most third-party insurance plans limit coverage
to services and supplies that are “medically
necessary.” While plans may define the term
differently, the intent is to exclude from coverage
unnecessary treatment services, equipment, and
supplies.
• Most plans’ definition of medically necessary
services include, at a minimum, the following
elements:
• 1. The service must be ordered by a
professional whose license qualifies him or
her to diagnose and deliver treatment.
• 2. It must be of the proper quantity,
frequency, and duration for the condition
being treated.
• 3. It must not be experimental or
investigative.
• Failure to satisfy the second element is
generally the issue in disputes between
AOD treatment providers and third-party
payers.
PERIODS OF RECOVERY
TRANSITIONS
Stabilization
Early Recovery
Middle Recovery
Late Recovery
Maintenance
• Stabilization major task: recovering from withdrawal,
overcoming preoccupation with chemicals, learning to
cope without using AOD’s, and developing hope and
motivation for long-term recovery.
• Early Recovery major goal is to change attitudes and
beliefs about AOD use that put client at risk of relapse:
changing ones understanding of AOD use and role it has
played in ones life, exploring the purpose of AOD use,
learning to cope with life without AOD use by learning
new life skills.
• Middle Recovery goal is usually the repair of damage to
life caused by AOD use: focusing on normal life issues
rather than focusing on using AOD’s, making changes
that support life balance and ongoing personal growth.
• Late Recovery goal is attaining lifestyle balance by
overcoming problems that may have existed before
AOD: recognizing problems form childhood that may be
affecting quality of life and recovery, making connections
between early problems and current problems, breaking
the cycle of family dysfunction by restructuring habits of
thinking, feeling, and to support healthy living, moving
past long-term obstacles to live lifestyle of choice.
• Maintenance goal is to live productively and
enjoy life: maintaining some kind of program of
recovery that helps a client recognize limitations
imposed by AOD disorder, continuing to take
personal inventory, improving conscious contact
with some sort of higher power, coping with
normal life problems and complications,
continuing to grow and develop in all areas of
life, coping with “stuck” points in recovery
process.
Change
• Any change means that something is different,
something (habit or way of daily life) must be left
behind and a new way learned.
• Changing social habits may mean that some of
client’s friends will not understand and may not
relate to client as they have in the past. Clients
leave behind some lifestyle activities and friends
that they may have felt were important to them.
• Feelings of loss are understandable, all new
skills are important tasks in adjusting to life
without what the client has lost.
Identifying Feelings
• The biggest problem most clients have in
identifying feelings is that they don’t have
words that describe their inner experience.
There is something happening inside of
them, but they don’t have words to tell
someone else. Sometimes an exercise is
created called a “feelings list” that client’s
can go over to help identify feelings and
put a name to them.
Life Management Evaluation
• To determine what needs to change in a client’s life, it is
important to look at the whole life. A life-management
evaluation takes a look at four basic areas of life:
intimate / family life; work life (voc/ed); social life; and life
skills.
• Intimate/family Life: applies to the people with whom a
client lives with or is in close day-to-day contact with.
People with whom a client spends significant amounts of
time with.
• Work/Career Life: applies to people with whom the client
must interact with in meeting voc/ed goals.
• Social Life: people with whom the client is involved in
social activities but who are not part of their intimate or
family life.
• Life Skills: these are skills or activities a client has to
perform to keep life “functioning”, tasks a client needs to
accomplish to keep problems from arising in ones life.
Life skills in problem solving, time management, financial
management etc.
• Sometimes a life management areas chart can be done
with the client to give direction as to what life areas need
to be addressed.
• Many life-management skills have been lost or never
mastered during the periods of AOD use. Clients may
need to learn organizational skills to provide structure to
their lives. Clients may need help in developing lifemanagement skills.
• Impairments in thought and emotional processes are
common in treatment. Retraining the impaired function
is possible. One method of structured practice of
behavioral skills is called role playing. In role playing the
client is asked to recreate in a safe place (group or
individual sessions) the actual situations that demand
the use of a skill he/she is attempting to learn or relearn.
• The client is then observed while trying to
learn/relearn the skill and an appropriate
sequence of work-up steps is developed.
• The most complex of life tasks can be broken
down into the simple component steps
necessary to get there. Skills training simply
means breaking down skills into their simplest
components and systematically learning each
component and then assembling them into a
more complex skill.
Problem Solving
• Problem identification – identifying what is causing the
difficulty.
• Problem clarification – being specific, is this the real
problem, or is there a more fundamental problem?
• Identify alternatives – what are the options in dealing
with the problem? Clients can make a list and see them
on paper, this can increase the clients chances of
choosing the best solution.
• Projected consequences – what are the probable
outcomes of each option. What is the best or worst case
scenario from chosen option?
• Decision - which option offers the best outcomes
and seems to be the most reasonable choice for
a solution based upon the alternatives.
• Action – Once a client decides on a solution to a
problem they need to plan how they will carry it
out. A plan is a map to achieve a goal.
• Follow-up – Carrying out of the plan is evaluated
on how it is working. The plan can always be
revised when a client realizes that another plan
might work better.