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.