American Society of Addiction Medicine (ASAM)

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American Society of Addiction Medicine (ASAM)

• How and when to use the Criteria

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Definition of Terms

• 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.

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Dimensional Criteria Assessment

• Dimension 1 Acute Intoxication/Withdrawal
  Potential
• 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
• 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

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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
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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
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ASAM PPC-2R(Dimension 1- Detoxification Services)

• 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 On-site 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

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Residential/Inpatient Levels of Care

• 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

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The Differences Between Inpatient, Residential
and Outpatient with Supportive Living
Inpatient Residential O.P. w/Supportive Living
Provides 24-hour structure support Provides 24-hour access to medical nursing services Patients in Imminent Danger Provides 24-hour structure support (except III.1lt24 hrs) Primary medical services not necessary Patients in Immienent Danger (except III.1) Provides structure Support Primary medical services not necessary Patients not in Imminent Danger
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Levels of Care (PPC-2R)Overall Structure of
Levels of Care Services

• 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

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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
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Outpatient Levels of Care Services

• Level 0.5- Early Intervention
• Level I- Outpatient
• 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)

• It requires under two minutes to administer
• It requires no medial knowledge
• It provides you with a quantitative score that
  predicts the severity of withdrawal from alcohol

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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
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Managed Care

• A clinical Quality Process
• Rather than Simply A Way to Reduce Treatment Costs

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Individualized Treatment

• The four Ps
• Patient/Participant Assessment
• Problems/Priorities
• Plan
• Progress
• Match Severity or Level of Functioning (Assets
  and Obstacles to Improvement) With Intensity of
  Service (Treatment Modalities, Strategies and
  Site of Care)

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Level of Care Placement afterrelapseshould be
based on an assessment of history and here
now and NOTon the assumption that if a patient
relapsed after having been treated, then the
previous level of care was not intense enough!
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HOMELESSNESSalone is NOTsufficient reason for
Level III Placement!
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The more disadvantaged and complicated, the
more important isCASE MANAGEMENT

• Co-occurring medical and psychiatric disorders
• Adolescents
• Ex-Felons
• Older Adults
• Welfare/disability clients
• Financial problems needs
• Parenting needs
• Pregnant Women
• HIV- AIDS

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The Three Hs of Assessment

• History
• Here and Now
• How uncomfortable are you?

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A Discharge PlanIs ADeferred Treatment
PlanandShould Be As Specific and ConcreteAs A
Treatment Plan
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Discharge Planning is part of treatment
planning, NOT a discrete activity
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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
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Imminent Danger

• 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 ELEMENTS must be present

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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

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Immediate Need Profile (cont)

• 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

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Immediate Need Profile (cont)

• 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

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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

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Screening for Alcohol Problems

• 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

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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?

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CraftBrief Screening Test for AdolescentSubstanc
e Abuse 2 or more yes answers suggests a
significant problem

• 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?

Yes No