Transcript American Society of Addiction Medicine (ASAM)

American Society of
Addiction Medicine (ASAM)
How and when to use the Criteria
Definition of Terms
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Clinically managed: Directed by non physician addiction specialist rather
than medical personnel. Appropriate for individuals whose primary
problems involve emotional, behavioral, cognitive, readiness to change,
relapse or recovery environment concerns.
Intoxication/withdrawal/biomedical concerns are all minimal if they exist at
all.
Medically Monitored: Services provided by an interdisciplinary staff of
nurses, counselors, social workers, addiction specialist and other health and
technical personnel under the direction of a licensed physician. Medical
monitoring is provided through appropriate mix of direct patient contact,
review of records, tram meetings, 24 hour coverage by a physician and a
quality assurance program.
Medically Managed: Services that involve daily medical care, where
diagnostic and treatment services are directly provided an/or managed by
an appropriately trained and licensed physician.
Dimensional Criteria Assessment
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Dimension 1: Acute Intoxication/Withdrawal Potential
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Dimension 2: Biomedical Conditions and Complications
Dimension 3: Emotional/Behavioral/Cognitive Conditions and Complications
Dimension 4: Readiness to Change
Dimension 5: Relapse/Continued Use/Continued Problem Potential
Dimension 6: Recovery Environment
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ASAM Criteria should be utilized to:
1. Assign the appropriate level of service and level of care
2. Do effective treatment planning and documentation
3. Make decisions about continued service or discharge by ongoing assessment and
review of progress notes
Relationship Between ASAM PPC-2R and ASI-MV
ASAM PPC-2R
Dimensions
ASI-MV Domains
*ASAM Dimension 1:
Acute
Intoxication/Withdrawal
Potential
*Drug/Alcohol Use
*ASAM Dimension 2:
Biomedical Conditions &
Complications
*Medical Status
*ASAM Dimension 3:
Emotional, Behavioral &
Cognitive Conditions &
Complications
*Psychiatric Status
Relationship Between ASAM PPC-2R and ASI-MV
ASAM PPC-2R
Dimensions
ASI-MV Domains
*ASAM Dimension 4:
Readiness To Change
*Legal System?
*ASAM Dimension 5:
Relapse, Continued Use, Continued
Problem Potential
*Drug/Alcohol Use
*Psychiatric Status
*ASAM Dimension 6:
Recovery Environment
*Employment/Support
*Legal System
*Family/Social Relationships
ASAM PPC-2R
(Dimension 1- Detoxification Services)
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Level I.D: Ambulatory Detoxification without Extended
On-site Monitoring (e.g., physician office practice/home
health care)
Level II-D: Ambulatory Detoxification with Extended Onsite Monitoring (e.g., detoxification on partial
hospitalization program)
Level III-D: Residential/Inpatient Detoxification
 Level III.2D: Clinically Managed Residential
Detoxification (e.g., social detox)
 Level III.7D: Medically Monitored Inpatient
Detoxification
Level IV-D: Medically Managed Inpatient Detoxification
Residential/Inpatient Levels of Care
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Level III: Residential/Inpatient Services
 Level III.1- Clinically Managed Low-Intensity
Residential Services (e.g., halfway house)
 Level III.3- Clinically Managed Medium- Intensity
residential Services (e.g., Therapeutic Rehabilitation
Facility)
 Level III.5- Clinically Managed High-Intensity
Residential Services (e.g., Therapeutic Community,
Residential Treatment Center)
 Level III.7- Medically Monitored Intensive Inpatient
Treatment
Level IV: Medically Managed Intensive Inpatient
Treatment
The Differences Between Inpatient, Residential
and Outpatient with Supportive Living
Inpatient
Provides 24-hour
structure & support
Provides 24-hour
access to medical &
nursing services
Patients in
“Imminent Danger”
Residential
Provides 24-hour
structure & support
(except III.1<24 hrs)
Primary medical
services not necessary
Patients in
“Immienent Danger”
(except III.1)
O.P. w/Supportive
Living
Provides structure &
Support
Primary medical
services not necessary
Patients not in
“Imminent Danger”
Levels of Care (PPC-2R)
Overall Structure of Levels of Care & Services
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Level 0.5- Early Intervention
Level I- Outpatient
Level II- Intensive Outpatient/Partial
Hospitalization
Level III- Residential/Inpatient Treatment
Level IV- Medically Managed Intensive Inpatient
Treatment
Level 0.5 is NOT a level of care or treatment
but the combination of psycho-education
and assessment. If the assessment
indicates the need for treatment, the
individual may receive treatment at the
conclusion of the 0.5 service or concurrently
Outpatient Levels of Care & Services
Level 0.5- Early Intervention
 Level I- Outpatient
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Less that 9 contact Hours/Week
Level II- Intensive Outpatient/Partial
Hospitalization
Level II.1- 9 or More Contact Hours/Week in a
Structured Program (6 hrs. for adolescents)
 Level II.5- 20 or More Contact Hours/Week in
a Structured Program
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The CIWA-Ar
(Clinical Institute Withdrawal Assessment of Alcohol,
Revised)
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It requires under two minutes to administer
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It requires no medial knowledge
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It provides you with a quantitative score
that predicts the severity of withdrawal
from alcohol
Types of Managed Care Reviews
For the MCO
For the Provider
Pre-certification
Intake & Initial
Assessment
Concurrent Review
Treatment Plan Update
Retrospective Review
Case Review
Managed Care
A clinical Quality Process
Rather than Simply A Way to Reduce
Treatment Costs
Individualized Treatment
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The four P’s
Patient/Participant Assessment
 Problems/Priorities
 Plan
 Progress
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Match Severity or Level of Functioning
(Assets and Obstacles to Improvement)
With Intensity of Service (Treatment
Modalities, Strategies and Site of Care)
Level of Care Placement after
relapse
should be based on an assessment
of history and “here & now” and
NOT
on the assumption that if a patient
relapsed after having been treated,
then the previous level of care was
not intense enough!
HOMELESSNESS
alone is
NOT
sufficient reason for Level III
Placement!
The more disadvantaged
and complicated,
the more important is
CASE MANAGEMENT
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Co-occurring medical and psychiatric disorders
Adolescents
Ex-Felons
Older Adults
Welfare/disability clients
Financial problems needs
Parenting needs
Pregnant Women
HIV- AIDS
The Three H’s of Assessment
 History
 Here
and Now
 How
uncomfortable are you?
A Discharge Plan
Is A
Deferred Treatment Plan
and
Should Be As
Specific and Concrete
As A Treatment Plan
“Discharge Planning” is part of
treatment planning, NOT a
discrete activity
Assessing for “Lapse” vs. “Relapse”
Lapse
Impulsive
Short Duration
Accompanied by Guilt
Small Amount of Use
Relatively Low
Consequences
Desire to Return to
Abstinence
Relapse
Planned
Long Period of Use
High Defensiveness
Large Amount of Use
Relatively High
Consequences
Uncertainty About
Desire to Return to
Abstinence
“Imminent Danger”
1.
2.
3.
A strong probability that certain behaviors will occur (e.g.,
continued alcohol or drug use or relapse or non-compliance with
psychiatric medications)
The likelihood that these behaviors will present a significant risk of
serious adverse consequences to the individual and/or others (as
in a consistent pattern of driving while intoxicated)
The likelihood that such adverse events will occur in the very near
future
In order to constitute “imminent danger” ALL THREE ELEMENTSmust
be present
Immediate Need Profile
Dimension #1: Acute Intoxication/Withdrawal
Potential:
(a) Have you ever has life-threatening
withdrawal signs or symptoms? ___ No ___Yes
(b) If yes, are you currently having similar
withdrawal symptoms? ___No ___Yes
Dimension #2: Biomedical Conditions and Complications:
Do you have any current, untreated severe
physical problems? ___No ___Yes
Dimension #3: Emotional/Behavioral Conditions & Complications:
Do you feel that you are imminently in danger and could harm
yourself or someone else? ___No ___Yes
Immediate Need Profile (con’t)
Dimension #4: Treatment Acceptance/Resistance:
(a) Do you feel that you are in immediate need of
alcohol/drug treatment? __No __Yes
(b) Have you been referred or required to have an
assessment and/or enter treatment by the criminal
justice system, health or social services,
work/school, or family/significant other? __No __Yes
Immediate Need Profile (con’t)
Dimension #5: Relapse/Continued Use Potential
(a) Are you currently under the influence? __No __Yes
(b) Are you likely to continue use of alcohol and/or other
drugs, or to relapse, in an imminently dangerous
manner? __No __Yes
Dimension #6: Recovery Environment:
Are there any dangerous family, significant others,
living/working situations threatening your safety,
immediate well-being and/or sobriety? __No __Yes
Responses to Immediate Need Profile
Yes to Dimension 1, 2, and/or 3 Questions:
Requires that the caller/client immediately receive medial or
psychiatric care
Yes to Dimension 4 Alone:
Caller/client to be seen for an assessment within 48 hours, and
perferably earlier, for motivational strategies, unless patinet
imminently likely to walk out and needs containment strategies
Yes to Dimension 5, Question (a):
Requires the caller/client receive assessment for withdrawal
potential
Yes to Dimension 5 and/or 6 without Yes in Dimensions 1, 2, and/or 3:
Requires the caller/client be referred to a safe or supervised
environment
Screening for Alcohol Problems
1.
2.
3.
1.
Have you ever felt the need to CUT down on your
drinking?
__Yes __No
Have you ever felt ANNOYED by someone criticizing
your drinking?
__Yes __No
Have you ever felt GUILTY about your drinking?
__Yes __No
Have you ever felt the need for an EYE OPENER to
get you started in the morning?
__Yes __No
UNCOPE
U “In the past year, have you ever drank or used drugs
more that you intended to?”
N “Have you ever neglected some of your usual
responsibilities because of using alcohol or drugs?”
C “Have you felt you wanted or needed to cut down on your
drinking or drug use in the last year?”
O “Has anyone objected to your drinking or drug use?”
P “Have you ever found yourself preoccupied with wanting
to use alcohol or drugs?”
E “Have you ever used alcohol or drugs to relieve
emotional discomfort?”
Craft
Brief Screening Test for Adolescent
Substance Abuse
* 2 or more yes answers suggests a significant problem
Yes
C- Have you every ridden in a CAR when driven by
someone (including yourself) who was “high” or had
been using alcohol or drugs?
R- Have you ever used alcohol to RELAX, feel better
about yourself or fit in?
A- Do you ever use alcohol/drugs while you are by
yourself, ALONE?
F- Do your family or FRIENDS ever tell you that you
should cut down on your drinking or drug use?
F- Do you ever FORGET things that you did while
using alcohol or drugs?
T- Have you gotten into TROUBLE while you were
using alcohol or drugs?
No