It’s often difficult to understand, when you’re trying to get someone into treatment, why certain “levels” of care are recommended–or required.
For the most part, if you are hoping that insurance, Medicare or Medicaid, or another third-party payor will help with–or pick up entirely–the costs of treatment, you’ll be running into ASAM criteria that control who gets what kind of treatment.
ASAM (the American Society of Addiction Medicine) has developed criteria, used by many insurance programs, Employee Assistance providers, and most government payment programs. People who need treatment are assessed by a clinician against these criteria, and the appropriate type, or “level” of treatment auhorized is based on which criteria they meet.
Here’s a brief guide to the ASAM Patient Placement Criteria
Level 0.5: Early Intervention. This is for individuals believed to be at risk for substance problems but who don’t yet qualify for a diagnosable substance use disorder (such as abuse or dependence).
Level I: Outpatient Treatment. Generally for people who are assessed as likely to benefit from individual or group counseling for one to eight hours weekly, over a period of at least several months. In other words, someone in a fairly stable environment who will be able to succeed without a great deal of external structure and monitoring.
Level II: Intensive Outpatient Treatment/Partial Hospitalization. A somewhat higher level of outpatient treatment, usually nine hours or more per week over one to six months — daytime, or after work or school, or evening or weekends. This is for people who don’t require extended inpatient care but who do need additional structure to succeed in treatment.
Level III: Residential/Inpatient Treatment. All-day and all-night stay of varying lengths (days to months) in a supervised setting in order to provide a safe environment in which to establish and stabilize recovery. There are several different sublevels of residential programs.
For instance, there’s Clinically Managed Residential Treatment at Low, Medium, and High-Intensity levels to reflect differing degrees of supervision and care. Also, Medically Monitored Inpatient Treatment includes additional medical supervision. But all provide safety and security beyond the outpatient level, and the goal is always to help the patient establish stable recovery.
Level IV: Medically Managed Intensive Inpatient Treatment. As the name suggests, Level IV offers a much higher level of 24-hour medical evaluation and treatment, and in an acute care setting. This level almost always includes some mental health services and access to medical treatment for coexisting medical problems.
The ASAM criteria were developed by working clinicians and so recognize real-world considerations in placing a particular patient at a particular level of care. Commonly three considerations allow the clinician to bypass the criteria in making a placement decision. They are:
- The recommended level isn’t available. This happens quite often, particularly in less populated areas.
- The patient has already shown that he or she fails to progress at the recommended level. In other words, it’s been tried, and for one reason or another, it didn’t work. So another level of care should be considered.
- Welfare of the patient. Circumstances suggest that the patient should be treated at a different level of care for safety or security reasons. A co-existing medical condition, for instance, or a domestic abuse situation.