Understanding the ASAM Patient Placement Criteria

Four features characterize the ASAM Patient Placement Criteria: (1) individualized treatment planning, (2) ready access to services, (3) attention to multiple treatment needs, and (4) ongoing reassessment and modification of the plan.

Functionally, the criteria are used to match treatment settings, interventions, and services to each individual's particular problems and (often-changing) treatment needs. The ASAM criteria advocate for individualized, assessment-driven treatment and the flexible use of services across a broad continuum of care.

The criteria also advocate for a system in which treatment is readily available, because patients are lost when the treatment they need is not immediately available and readily accessible. By expanding the criteria to incorporate outpatient care, especially for those in early stages of readiness to change, the ASAM criteria have helped to reduce waiting lists for residential treatment and thus have improved access to care.

The criteria are based in a philosophy that effective treatment attends to multiple needs of each individual, not just his or her alcohol or drug use. To be effective, treatment must address any associated medical, psychological, social, vocational, and legal problems. Through its six assessment dimensions, the ASAM criteria underscore the importance of multidimensional assessment and treatment (Figure 2).

Objectivity. The criteria are as objective, measurable, and quantifiable as possible. Certain aspects of the criteria require subjective interpretation. In this regard, the assessment and treatment of substance-related disorders is no different from biomedical or psychiatric conditions in which diagnosis or assessment and treatment is a mix of objectively measured criteria and experientially based professional judgments.

Principles Guiding the Criteria. Several important principles have guided development of the ASAM criteria.

Goals of Treatment: The goals of intervention and treatment (including safe and comfortable detoxifi­ca­tion, motivational enhancement to accept the need for recovery, the attainment of skills to maintain abstinence, and the like.) determine the methods, intensity, frequency, and types of services provided. The health care professional's decision to pre­scribe a type of service, and subsequent discharge of a pa­tient from a level of care, are based on how that treatment and its duration will influence the resolution of the dysfunction and pos­itive­ly alter the prognosis for the patient's long-term outcome.

Thus, in addiction treatment, the treatment ­may extend beyond simple resolution of observable biomedical distress to the achievement of overall health­ier functioning. The patient demonstrates a response to treatment through new insights, attitudes and behaviors. Ad­diction ­treatment programs have as their goal not simply stabilizing the patient's condition, but altering the course of the patient's disease.

Individualized Treatment Plan: Treatment should be tailored to the needs of the individual and guided by an indi­vidualized treatment plan that is developed in consultation with the patient. Such a plan should be based on a comprehensive bio­psycho­social assessment of the patient and, when pos­sible, a comprehensive evaluation of the family as well.

The plan should list problems (such as obstacles to recovery, knowledge or skill deficits, dysfunction or loss), strengths (such as readiness to change, a positive social support system, and a strong connection to a source of spiritual support) and priorities (such as obstacles to treatment and risks, identified within the list of problems and arranged according to severity), goals (a statement to guide realistic, achievable, short-term resolu­tion or reduction of the problems), methods or strategies (the treatment services to be provided, the site of those services, the staff responsible for delivering treatment), and a timetable for follow-through with the treatment plan that promotes accountability.

The plan should be written so as to facilitate measurement of progress. As with other disease processes, length of service should be linked di­rectly to the patient's response to treatment (for example, attainment of the treatment goals and degree of resolution of the identified clinical problems).

Choice of Treatment Levels: Referral to a specific level of care must be based on a careful assessment of the patient. The goal that underlies the criteria is the placement of the patient in the most appropriate level of care. For both clinical and financial reasons, the preferred level of care is the least intensive level that meets treatment objectives, while providing safety and security for the patient. Moreover, while the levels of care are presented as discrete levels, in reality they represent benchmarks or points along a continuum of treatment services that could be used in a variety of ways, depending on a patient's needs and response. A patient could begin at a more intensive level and move to a more or less intensive level of care, depending on his or her individual needs.

Continuum of Care: In order to provide the most clinically appropriate and cost-effective treatment system, a continuum of care must be available. Such a continuum may be offered by a single provider or multiple providers. For the continuum to work most effectively, it is best distinguished by three characteristics: (1) seamless transfer between levels of care, (2) philosophical congruence among the various providers of care, and (3) timely arrival of the patient’s clinical record at the next provider. It is most helpful if providers envision admitting the patient into the continuum through their program rather than admitting the patient to their program.

Many providers of treatment services offer only one of the many levels of care described. In such situations, movement between levels might mean referring the patient out of the provider's own network of care. While lack of reimbursement for some levels of care, or lack of availability of other levels of care may render this impossible at present, the goal of these criteria is to stimulate the development of efficient and effective services that can be made available to all patients.

Progress Through the Levels of Care: As a patient moves through treatment in any level of care, his or her progress in all six dimensions should be contin­ually assessed. Such multidimensional assessment ensures comprehensive treatment. In the process of patient assessment, certain problems and priorities are identified as justifying admission to a particular level of care. The resolution of those problems and priorities determines when a patient can be treated at a different level of care or discharged from treatment. The appearance of new problems may require services that can be effectively provided at the same level of care, or that require a more or less intensive level of care.

Each time the patient's response to treatment is assessed, new priorities for recovery are identified. The intensity of the strategies incorporated in the treatment plan helps to determine the most efficient and effective level of care that can safely provide the care articulated in the individualized treatment plan. Patients may, however, worsen or fail to improve in a given level of care or with a given type of program. When this happens, changes the level of care or program should be based on a reassessment of the treatment plan, with modifica­tions to achieve a better therapeutic response.

Length of Stay: The length of stay or service is determined by the patient’s progress toward achieving his or her treatment plan goals and objectives. Fixed length of stay or program-driven treatment is not individualized and does not respond to the particular problems of a given patient. While fixed length of stay programs are more convenient and predictable for the provider, they may be less effective for individuals.

Clinical versus Reimbursement Considerations: The ASAM criteria describe a wide range of levels and types of care. Not all of these services are available in all locations, nor are they covered by all payers. Clinicians who make placement decisions are expected to supplement the criteria with their own clinical judgment, their knowledge of the patient, and their knowledge of the available resources. The ASAM criteria are not intended as a reimbursement guideline, but rather as a clinical guideline for making the most appropriate placement recommendation for an individual patient with a specific set of symptoms and behaviors. If the criteria only covered the levels of care commonly reimbursable by private insurance carriers, they would not address many of the resources of the public sector and, thus, would tacitly endorse limitations on a complete continuum of care.

Treatment Failure: Two incorrect assumptions are associated with the concept of "treatment failure." The first is that the disorder is acute rather than chronic, so that the only criterion for success is total and complete amelioration of the problem. Such expectations are recognized as inappropriate in the treatment of other chronic disorders, such as diabetes or hypertension. No one expects that simply because a patient has been treated on one occasion for his or her hypertension, there will never be another episode. The same recognition of chronicity should be applied to the treatment of addictive disorders, for which appropriate criteria would involve reductions in the intensity or severity of symptoms, the duration of symptoms, and the frequency of symptoms.

The second assumption is that responsibility for treatment “failure” always rests with the patient (as in, “The patient was not ready”). However, poor treatment outcomes also may be related to a provider's failure to provide services tailored to the patient's needs.

Finally, there is a concern that some benefit managers require that a patient "fail" at one level of care as a prerequisite for approving admission to a more intensive level of care (for example, "failure" in outpatient treatment as a prerequisite for admission to inpatient treatment). In fact, such a requirement is no more rational than treating every patient in an inpatient program or using a fixed length of stay for all. Such a strategy potentially puts the patient at risk because it delays care at a more appropriate level of treatment, and potentially increases health care costs if restricting the appropriate level of treatment allows the addictive disorder to progress.

The ASAM Criteria and State Licensure or Certification. The ASAM criteria contain descriptions of treatment programs at each level of care, including the setting, staffing, support systems, therapies, assessments, documentation, and treatment plan reviews typically found at that level. This information should be useful to providers who are preparing to serve a particular group of patients, as well as to clinicians who are making placement decisions. Nevertheless, the descriptions are not requirements and are not intended to replace or supersede the relevant statutes, licensure or certification requirements of any state.