What Level of Care Does My Patient Need?

By David Mee-Lee MD 08/25/16

The Chief Editor of the American Society of Addiction Medicine (ASAM) criteria explains their clinical importance and clears up some misconceptions.

What Level of Care Does My Patient Need?
How much does a patient need?

The addiction treatment field has often been criticized for the inconsistency of approach used in treating the devastating disorders that present for treatment. Many years ago, when the fields of medicine and psychology still avoided the substance-using population, most treatment programs had little to go on, save 12-step concepts. Now, however, there is a substantial and growing literature supporting the evidence base of many interventions in addiction medicine, assessment and psychotherapy of addictive disorders. Despite that, many decisions about treatment continue to be made based on less-than-scientific grounds. The ASAM Criteria are a step in the right direction, and many states now require its use. Here, ASAM Criteria Chief Editor Dr. David Mee-Lee dispels some important misconceptions about how to use them in your work…Richard Juman, PsyD

Not Knowing What You Don’t Know about The ASAM Criteria 

As Chief Editor of the American Society of Addiction Medicine’s (ASAM) criteria since the beginning, I know what we were trying to achieve with the first edition published in 1991. The same guiding principles and goals have driven all subsequent editions, including the current and third edition: The ASAM Criteria - Treatment Criteria for Substance-Related, Addictive and Co-Occurring Conditions (2013). What is interesting—sometimes amusing, sometimes annoying—is what people have said about The ASAM Criteria over the years. Some have a pretty good understanding of the Criteria, but nevertheless have misconceptions about the nuances. Others think The ASAM Criteria is a two-page checklist of levels of care, and don’t even know there is a book, so they have requested: “Please fax me a copy of The ASAM Criteria as my two pages are getting a bit raggy.” (The current edition is a hardcover book of 460 pages and you can see more about it at www.ASAMcriteria.org.)

In the category of those who have a pretty good understanding are Jeannie Little and Patt Denning, who mentioned The ASAM Criteria in their November 19, 2015 piece “What's Under the Harm Reduction Umbrella? Part Two." They got it right that the Criteria “recommend that placement be determined based on severity across six dimensions … An important dimension is readiness to change, which recognizes that, despite high acuity, if people are not ready to change, high intensity placements might be wasted.” What they didn't fully grasp was their idea that "higher intensity treatment is recommended regardless of a person’s motivation to change." It is true that a more intensive level of care is recommended regardless of a person's stage of change, but only if the person is in imminent danger with some co-occurring complication. Once the imminent danger is over, The ASAM Criteria recommends less intensive levels of care and, more likely, outpatient services to attract a person into recovery at a pace that makes sense to the participant in their stage and readiness to change. The therapeutic alliance and empowerment are primary and are promoted by The ASAM Criteria—we agree that services should be “client-centered and directed” and that “respect for their autonomy was key to their cooperative and enthusiastic engagement.”

Why Knowing The ASAM Criteria is Relevant

Medicaid is playing an increasingly important role as a payer for services provided to individuals with addiction in the United States. There have been some exciting developments regarding The ASAM Criteria in Medicaid’s expanding role. In July 2015, the Center for Medicare and Medicaid Services (CMS) announced new opportunities for states to design service delivery systems for Medicaid beneficiaries with a substance use disorder (SUD). There are numerous federal authorities offering states the flexibility to implement system reforms that improve care, enhance treatment and offer recovery supports for SUD. The ASAM Criteria is mentioned in several places as integral to that service delivery design: “Enhancing provider competencies to deliver SUD services with fidelity to industry standard models, such as the American Society for Addiction Medicine (ASAM) Criteria.”

California is the first state approved by CMS for a demonstration project under section 1115 of the Social Security Act to ensure that a continuum of care is available to individuals with SUD. Section 1115 demonstration projects allow states to test innovative policy and delivery approaches that promote the objectives of the Medicaid program. Virginia, Massachusetts and other states are applying to reorganize their addiction treatment delivery system in keeping with The ASAM Criteria, as California is doing.

Content and Spirit of The ASAM Criteria

Previous editions of The ASAM Criteria were named ASAM “Patient Placement” criteria. With this latest edition, we removed “placement” in the title, as too many thought of the Criteria as just being about assigning a person to a level of care in their program, and then carrying on with business as usual. However, this has to do with much more than a checklist to place a person in a program. If you truly embrace the spirit and content of The ASAM Criteria, it will change how you “use” the criteria to: 

• engage and attract people into recovery

• collaborate on a person-centered, individualized treatment plan

• design, deliver and pay for levels of care and the continuum of services

• manage and move people through the continuum of care in an ongoing disease management process

A Sampling of Misconceptions

1. Because about 30 states mandate the use of The ASAM Criteria in some way, it is easy to think of the Criteria as just paperwork to be tolerated every 30 or 60 days when required to review and update the treatment plan. But reviewing a person’s multidimensional assessment should be a regular part of ongoing evaluation of progress and outcomes in treatment. If a client is progressing well in treatment, then assess what needs to be done next. If outcomes are not good, then reviewing The ASAM Criteria’s six dimensions guides what changes need to be made to the treatment plan.  

2. Another misconception is that The ASAM Criteria is a medical model and requires everyone to hire a medical director. Certainly, the first three dimensions often require some medical or nursing care; and anti-addiction medications may be helpful for Dimension 5 for some people. But psychosocial assessment and services are relevant to all six dimensions and especially Dimensions 4, 5 and 6.

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

So, The ASAM Criteria is not based on a medical model, but on a biopsychosocial-spiritual model. Or, as ASAM would say in its 2011 definition: “Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations…”

3. Another concern is that The ASAM Criteria must require more staff, expense and administration to provide all the levels of care. It is true that if all you have in your agency is one or two levels of care, then to add several more levels is going to cost more—but not as much as you might think, if you use economies of scale. In other words, if you can overlap levels of care, not only is that good for continuity of care—where a person can move flexibly and seamlessly through levels of care—it is good for resource utilization, because you can use the same treatment milieu to deliver a variety of services and levels of care. For example, a person could leave after one group session because they are in Level 1 Outpatient services, stay for a three-hour session and then leave because they are on Level 2.1, Intensive Outpatient, or stay there all day because they are in Level 2.5, Partial Hospital. If they sleep there in 24-hour living support, Level 3.1 as well, then they are getting even more intensity within the same milieu. It’s time to get more innovative about how we design and deliver services, so we can be efficient—but also effective—in smooth transitions between levels of care that support continuity and recovery.

4. Some inpatient and residential providers have criticized The ASAM Criteria for being biased towards outpatient services. When we developed criteria for five levels of withdrawal management, inpatient providers complained that now, managed care would require more ambulatory and outpatient services for people in withdrawal. Some managed care companies complained that with five levels of residential and inpatient services, we were biased towards 24-hour services. If we are being hit from both sides, we figure we might be in the right place. In reality, The ASAM Criteria is focused on matching a person’s severity of illness and level of function to the most efficient, effective and safe intensity of service and level of care, just as in any other illness. If you are so severely depressed and suicidal that you keep trying to jump out the window or hang yourself, your family appreciates that there is an intensive, secure inpatient level available. But you only need that for the relatively brief time it takes to stabilize the impulsivity, and gratefully, there are outpatient levels available in which to continue care. The same principles that we suggest for addiction are mirrored in the standards of care for diabetes, asthma and hypertension.

Final Misconceptions

I’m sometimes amazed how many people “use” The ASAM Criteria, but have never really read or reviewed the guiding principles, goals and intent of the Criteria. That is understandable if you didn’t even know there was a book, or if the one your agency got you was in 2001, or worse—1996 or 1991. “You are so last century!” And by the way, while it has been good for name recognition for people to say “Do you use the ASAM?”, you may know that ASAM is an organization of about 3,500 physicians committed to helping people with addiction—and you can be an Associate member too, even if you are not a physician. So, asking “Do you use The ASAM Criteria?” is not the equivalent of asking “Do you use the ASI (Addiction Severity Index)?” because The ASAM Criteria is not purely an assessment instrument. Additionally, there is now standardized ASAM Criteria assessment software branded as CONTINUUM – The ASAM Criteria Decision Engine ™ (see www.asamcontinuum.org). 

So, thanks for using The ASAM Criteria. We hope that you are truly using it in the spirit and for the purposes for which it was intended.

David Mee-Lee, M.D., is Chief Editor of The ASAM Criteria - Treatment Criteria for Substance Related, Addictive and Co-Occurring Conditions (2013). He is a Senior Vice President at the Change Companies and can be reached at [email protected] 

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David Mee-Lee, M.D., is Chief Editor of The ASAM Criteria - Treatment Criteria for Substance Related, Addictive and Co-Occurring Conditions (2013). He is a Senior Vice President at the Change Companies and can be reached at [email protected]. You can also find David on Linkedin.