The ASAM Criteria

ASAM Textbook Chapter 4-5 - Placement Dilemmas

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Placement Dilemmas

Even those using the ASAM criteria regularly encounter "real world" dilemmas surrounding access, reimbursement, funding, resource allocation, and availability of services, particularly for patients with co-occurring medical or psychiatric disorders.

Co-Occurring Disorders. When the first edition of the ASAM criteria was published in 1991, the criteria were designed for programs that offered only addiction treatment services. However, even that early edition also acknowledged that some patients come to treatment with medical (Dimension 2) and psychiatric (Dimension 3) disorders that coexist with their substance-related problems. Clinical reality suggests that programs and practitioners who are committed to meeting the total needs of the patients they serve must be able to meet the needs of these "dual diagnosis" patients. This concept is particularly relevant today, as the range of patient needs and clinical variability continues to broaden.

Factors contributing to this clinical reality include the expansion of substance use and substance-related disorders in younger populations; greater sensitivity to substance use problems in the mental health, welfare, and criminal justice systems; and increased commitment to earlier intervention in substance use disorders in preference to fragmented services and incarceration. A major factor has been the growing body of scientific evidence pointing to addictive disorders as diseases of the brain; another is the development of pharmacotherapies for addiction. Greater understanding of the uses and effects of psychosocial and cognitive-behavioral strategies also has heightened awareness of a broadened range of modalities to meet individual needs.

The ASAM PPC-2R thus incorporates criteria that address the large subset of individuals who present for treatment with co-occurring Axis I substance-related disorders and Axis I/Axis II mental disorders. Individuals with such co-occurring disorders (often referred to as "dual diagnoses") can be conceptualized as belonging to one of two general categories:

Moderate Severity Disorders: Such persons present with stable mood or anxiety disorders of moderate severity (including resolving bipolar disorder), or with personality disorders of moderate severity (although some persons with severe levels of antisocial personality disorder may be appropriately placed in this group), or with signs and symptoms of a mental health disorder that are not so severe as to meet the diagnostic threshold.

High Severity Disorders: Such persons present with schizophrenia-spectrum disorders, severe mood disorders with psychotic features, severe anxiety disorders, or severe personality disorders (such as fragile borderline conditions).

Individuals whose co-occurring mental disorders best fit within the category of moderate severity disorders are appropriately treated in programs designed to treat primary substance use disorders. Those with concurrent high severity mental disorders, on the other hand, generally are best managed in dual diagnosis specialty programs that can offer integration mental health and addiction treatment approaches. Some patients may require immediate stabilization of their psychiatric symptoms before they can be engaged in ongoing addiction treatment and recovery. Depending on the severity of their symptoms, such patients may require referral to medical and/or psychiatric services outside the ASAM PPC-2R levels of care (see Table 1).

Once stabilization has been achieved, the initial placement for recovery services should reflect an assessment of the patient's status in all six dimensions. The principle here is that the highest severity problem (particularly those in Dimensions 1, 2 or 3) should determine the patient's initial placement. Subsequent resolution of this problem creates an opportunity to transfer the patient to a less intensive level of care. Addressing the individual's recovery needs thus may involve a sequence of services across several levels of care (involving a "step down" or "step up process"). For example, a patient who is assessed in Dimension 2 as hypertensive should be placed in a Level III.7 or Level IV program to stabilize his or her medical condition, before being transferred to a Level I program for treatment of the addictive disorder.

What should be avoided is the notion of "averaging" severity across dimensions to arrive at a placement determination.

Patients whose biomedical or psychiatric disorders are so severe that stabilizing them is the highest priority are most appropriately treated in a medical or psychiatric facility or unit before addiction treatment is initiated.

Assessment of Imminent Danger. If a patient has problems in Dimensions 4 and 5 that require 24-hour supervision and treatment interventions (such as boundary setting), without which treatment services cannot be effectively delivered, and/or the individual is in imminent danger, then the mere addition of room and board would be inadequate to meet the individual's needs. Such a patient needs placement in a residential program that offers clinical staff and services 24 hours a day in order to respond to the patient's issues that pose the imminent danger. Assessment of risk should guide the decision.

Mandated Level of Care or Length of Service. In some cases, an individual is referred for treatment at a specific level of care and/or for a specific length of service (for example, an offender in the criminal justice system may be given a choice of a prison term or a fixed length of stay in a treatment center). Such mandated or court-ordered referrals may not be based on clinical considerations and thus may be inconsistent with a placement decision arrived at through the ASAM criteria. In such a case, the provider should make reasonable attempts to have the order amended to reflect the assessed clinical level or length of service.

If the court order or other mandate cannot be amended, the individual may be continuing treatment at a level of care or for a length of stay greater than is clinically indicated. The resident's readiness for discharge or transfer and the staff's attempts to implement a clinically appropriate placement should be noted in the clinical record, and the treatment plan should be updated in a manner that provides the resident with the opportunity to continue the recovery process at the same level of care even though it could be continued at a less intensive level of care.

Logistical Impediments. Logistical problems can arise anywhere, but are found most frequently in rural and underserved inner-city areas. When logistical considerations are an impediment to the indicated services (for example, lack of available transportation is a barrier to a patient's access to an indicated outpatient program), an outpatient service combined with unsupervised/minimally supervised housing may be an appropriate treatment intervention. In cities or towns, such a domiciliary option might be found in a group living situation (such as a Salvation Army program, motel accommodations, YMCA/YWCA or mission). In rural and other underserved areas, options could include (1) the creation of a supervised housing situation by using unused treatment beds, (2) assertive community treatment models in which the treatment is brought to rural areas (such as Native American settlements) and provided in weekend intensive models at sites such as community centers and churches, (3) vans that are sent out to pick up patients and bring them to a treatment site, and (4) using a van or motor home as an office or group therapy room

Need for a Safe Environment. When a patient lives in a recovery environment that is so toxic as to preclude recovery efforts (as through victimization or exposure to an active addict) and a Level I or II outpatient service is indicated, the patient may need referral to a safe place to live while in treatment, as well as to treatment itself.

Assuring Individualized Treatment. Many programs claim to provide individualized care, but how is the referring clinician to know that such care actually is provided? There are at least three efficient ways to determine whether a program is providing truly individualized treatment:

1. Take 10 closed clinical case records and compare the treatment plans. If the reviewer cannot clearly distinguish patients by their treatment plans, the treatment is not individualized.

2. Review the progress notes and determine whether they relate back to the objectives or strategies to the treatment plan.

3. For programs that receive reimbursement from multiple payers, compare lengths of service with sources of payment. If the lengths of stay correspond to payer type, then the program is payment-driven rather than offering individualized treatment.

Exceptions to the Patient Placement Criteria. In making treatment placement decisions, three important factors override the patient‑treatment match with regard to levels of care:

1. Lack of availability of appropriate, criteria‑selected care;

2. Failure of a patient to progress at a given level of care, so as to warrant a reassessment of the treatment plan with a view to modifying the treatment approach. Such situations may require transfer to a specialized program at the same level of care or to a more intensive or less intensive level of care to achieve a better therapeutic response; and State laws regulating the practice of medicine or licensure of a facility that require the use of different criteria.

Unique clinical presentations or extenuating circumstances require some flexibility in application of the criteria to ensure the safety and welfare of the patient.

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