Understanding Levels of Care

Determining where a consumer should be placed during a mental health or substance abuse crisis requires careful evaluation and consideration. Substance abuse professionals use evaluation criteria known as the ASAM PPC-2 (American Society of Addiction Medicine, Patient Placement Criteria, Revised) to help determine the most appropriate level of care based on the safety concerns and medical needs of each adult consumer (A similar tool, the CALOCUS, is used in evaluating children and adolescents). The ASAM is a multidimensional assessment model that takes the following six areas into consideration:

  1. Acute Intoxication and/or Withdrawal Potential
  2. Biomedical Conditions/Complications
  3. Emotional, Behavioral, or Cognitive Conditions/Complications
  4. Readiness to Change
  5. Relapse, Continued Use or Continued Problem Potential
  6. Recovery/Living Environment

Each of these area, or dimensions, is rated on a low to high scale. The substance abuse professional then determines an overall “score” based on the severity of each of these dimensions. The least restrictive placement is typically desired, with the potential to move to a more restrictive level of care if necessary after the current level proves ineffective in meeting the needs of the consumer. No diagnosis is given while a consumer is being screened for the appropriate level of care. Diagnoses are made following a thorough assessment by a licensed substance abuse professional when a consumer arrives at the facility deemed appropriate based on the ASAM evaluation. The following are descriptions and examples of the various levels of care alongside their respective “score”.

I.  Outpatient Services

Designed to treat the consumer’s assessed level of illness severity and to achieve permanent changes in a consumer’s substance using behavior. This service is provided in fewer than 9 contact hours per week.

Examples include: Community support teams, opioid treatment, substance abuse outpatient (SAOP)

II.1 Intensive Outpatient Treatment

Needs for psychiatric and medical services are addressed through consultation and referral arrangements. This service is provided in 9 or more hours of structured counseling and education services per week.

Examples include: Substance abuse intensive outpatient (SAIOP)

II.5 Partial Hospitalization

Ready access to psychiatric, medical, and lab services make this level of service a step up from the previous. This level of service seeks to address the concerns in Dimensions 1-3. Typically this level of service is for consumers who’s situation warrants daily monitoring or management but can be appropriately addressed in structured outpatient setting.

Examples include: Substance abuse comprehensive outpatient treatment (SACOT)

III.1 Clinically-Managed Low-Intensity Residential Services

Directed towards applying recovery skills, preventing relapse, promoting personal responsibility, and reintegration back into work and family life while living in a 24-hour structured environment. This also includes at least 5 hours of professional addiction services per week. Often, consumers enter this level of care upon completion of or with ongoing treatment in other levels of service.

Examples include: Halfway house

III.3 Clinically-Managed Medium-Intensity Residential Service        

Consumers enter this level of service when the effects of addition on the individual’s life are so significant and the level of addition-related impairment is so great that outpatient strategies alone would not be feasible or effective.  Programming and staffing address more severe medical, emotional, cognitive, and behavioral problems. Case management provides a “wrap-around” service.

Examples include: Therapeutic rehabilitation facility

III.5 Clinically-Managed High-Intensity Residential Services

This is a highly-structured 24-hour recovery environment provided in combination with medium-to-high intensity professional clinical services. Treatment is specific to maintaining abstinence and preventing relapse while vigorously promoting personal responsibility and positive character change in an intense therapeutic community.

Examples include: Substance Abuse Non-Medical Community Residential Treatment

III.7 Medically-monitored Intensive Inpatient Services

This is a medically-directed, but non-hospital, 24-hour level of care monitored by nurses, addiction physicians, and addiction credentialed clinicians in an acute care inpatient setting. Treatment includes a focus on co-morbid biomedical, emotional, and behavioral conditions.

Examples include: Substance abuse medically monitored community residential treatment

IV. Medically-Managed Intensive Inpatient Services

Treatment at this level is similar to level III.7, however, it is specific to the consumer’s substance dependence disorder and the consumer has full access to the resources in the acute care hospital or psychiatric hospital.

Examples include: Acute care general hospital, psychiatric hospital, psychiatric unit in an acute care hospital

 

I ——-II.1——-II.5——-III.1——-III.3——-III.5——–III.7——–IV

 

Resources:

Bolton, W. (2012). American Society of Addiction Medicine, Patient Placement Criteria for the Treatment of Substance-Related Disorders [Powerpoint slides].

Cigna Behavioral Health. (2009). Levels of Substance Abuse Care Descriptions. Retrieved at: http://apps.cignabehavioral.com/web/basicsite/consumer/educationAndResourceCenter/alcoholism/locDescSA.pdf