Presentation on the ASAM Dimensions and Treatment Planning

1. ASAM Overview and
Treatment Planning
By Elizabeth Kotkin, LMFT
Clinical Standards Coordinator
July 2008

2. Objectives
o To provide an introductory overview of the
six dimensions of ASAM Patient
Placement Criteria
o To describe the ASAM Levels of Care
o To explain how the ASAM Assessment
supports treatment planning

3. Overview of Key
Elements
• The assessment is multi-dimensional
• Each dimension is given a severity rating
• The severity ratings determine what areas
will be the focus of treatment (treatment
priorities)
• Treatment Assessments and Plans must be
individualized and tailored to that specific
client.

4. What is ASAM?
• American Society of Addiction
Medicine
• ASAM has developed Patient
Placement Criteria (PPC) for specific
levels of care for substance disorder
treatment

5. Six Dimensions Help to Classify and
Assess Treatment Need and Placement
• 1: Intoxication and withdrawal potential
• 2: Biomedical conditions and complications
• 3: Emotional behavioral conditions and
complications
• 4: Readiness for change
• 5: Relapse potential
• 6: Recovery environment

6. Let’s look at each
dimension

7. 1: Acute intoxication and/or
withdrawal potential
• What risk is associated with the patient’s
current level of acute intoxication?
• Is there significant risk of severe withdrawal
symptoms or seizures, based on the patient’s
previous withdrawal history and current use?
• Are there current signs of withdrawal?
• Does the patient have supports to assist in
ambulatory detoxification, if medically safe?

8. 2: Biomedical
conditions/complications
• Are there current physical illnesses, other
than withdrawal, that need to be addressed
because they create risk or complicate
treatment?
• Are there chronic conditions that affect
treatment?

9. 3: Emotional, behavioral or
cognitive conditions and
complications
• Are there current psychiatric illnesses or
psychological, behavioral, emotional, or cognitive
problems that need to be addressed because they
create risk or complicate treatment?
• Do any emotional, behavioral or cognitive problems
appear to be an expected part of the addictive
disorder or do they appear to be autonomous?
• Even if connected to the addiction, are they severe
enough to warrant specific mental health treatment?
• Is the patient able to manage the activities of daily
living?
• Can s/he cope with any emotional, behavioral or

10. 4: Readiness for Change
• Expect resistance to treatment
• Treatment resistance should not exclude a
person from receiving treatment
• It is the degree of readiness to change that
helps to determine the setting and intensity
of motivational strategies needed
• What things, if any, can be leveraged to help
enhance the patient’s readiness to change?

11. 5: Relapse, Continued Use
or Continued Problem
Potential
• Is the patient in immediate danger of continued
severe mental health distress and or AOD use?
• Does the patient have any recognition or
understanding of, or skills in coping with, his or her
addictive or mental disorder in order to prevent
relapse, continued use or continued problems such
as suicidal behavior?
• How severe are the problems or further distress that
may continue or reappear if the patient is not
successfully engaged in treatment at this time?
• How aware is the patient of relapse triggers, ways to
cope with cravings to use, and skills to control

12. 6: Recovery / Living
Environment
• Do any family members, significant others, living
situations, or school or work situations pose a threat
to the patient’s safety or engagement in treatment?
• Does the patient have supportive friendships,
financial resources, and educational or vocational
resources that can increase the likelihood of
successful treatment?
• Are there legal, vocational, social service agency or
criminal justice mandates that may enhance the
person’s motivation for engagement in treatment?
• Are there transportation, housing, childcare, or
employment issues that need to be clarified or

13. Severity Levels
• High Severity=Immediate need for treatment
on the dimension being assessed (as in
today, it is an emergency)
• Medium Severity=Treatment needs to
address this within the next two weeks
• Low Severity= Treatment needs to address
this within the next three months.

14. Levels of Service

15. Continuum of Care
ASAM describes treatment as a continuum
marked by five basic levels of care n ideal
ASAM continuum includes these levels of
care:
• Level 0.5 - Early Intervention
• Level I- Outpatient Services (OP)
• Level II - Intensive Outpatient Services
• Level III - Residential/Medically Monitored
Inpatient Services
• Level IV - Medically Managed Intensive Inpatient
Services (MM/IP)

16. Level 0.5: Early
Intervention
• Provides services for those who are
deemed to be at risk or those for
whom enough information is not
available to document a substance
use disorder.
• This is different from “prevention”
services.

17. Level I: Outpatient
Treatment
• Professionally-directed evaluation, treatment and
recovery services
• Delivered in a variety of settings
• Provided in regularly scheduled sessions
• Following a defined set of policies, procedures or
medical protocols
• Services address major lifestyle, attitudinal, and
behavioral issues that have the potential to
undermine the goals of treatment or inhibit the
individual’s ability to cope with major life tasks
without the non-medical use of alcohol or other
drugs.

18. Level II: Intensive
Outpatient Treatment /
Partial Hospitalization
• Outpatient services that delivers treatment during
the day, before or after school or work, in the
evenings or on weekends for 6 hours (for
adolescents) of structured programming
• Provides essential education and treatment
components about substance-related mental health
problems
• Leaves room for “real-world” application of new skills
• Can arrange fore medical and psychiatric
consultation, medication management, and 24-hour
crisis services

19. Level III: Residential/Medically
Monitored Inpatient Services
• A planned regimen of care in a 24-
hour facility staffed by addiction and
mental health professionals.
• Highly structured with clearly-defined
policies and procedures
• Serve individuals who need safer,
more stable living environments in
order to develop their recovery skills

20. Level III: Residential/Medically
Monitored Inpatient Services
(con’t)
• Encompasses four types of programs
• Decimal numbers appearing after the ASAM level of care are
used to indicate the graduated intensity of levels of care
o Level III.1: Clinically-Managed Low-Intensity Residential
Treatment
o Level III.3: Clinically-Managed Medium-Intensity Residential
Treatment
o Level III.5: Clinically-Managed High-Intensity Residential
Treatment
o Level III.7: Medically-Monitored Inpatient Treatment

21. Level IV: Medically Managed
Intensive Inpatient Services
(MM/IP)
• Provides a planned regimen of 24-hour medically directed
evaluation, care and treatment of mental and substance-related
disorders in an acute care inpatient setting.
• Staffed by addiction-credentialed physicians, including
psychiatrists, as well as other mental health- and addiction-
credentialed clinicians.
• Provides care to patients whose MH and substance-related
problems are so severe that they require primary biomedical,
psychiatric and nursing care.
• Treatment is provided 24-hours/day and the full resources of a
general acute-care hospital or psychiatric hospital are available
to allow for the treatment of any co-occurring biomedical
conditions that need to be addressed.

22. Exceptions to the PPC
• Three factors that can override patient-treatment
match, with regard to levels of service:
o Lack of availability of appropriate, criteria-
selected care
o Failure of the patient to progress at a given level
of care, so as to warrant a reassessment of the
treatment plan
o State laws regulating practice of medicine or
licensure of a facility requiring criteria different
from these.

23. Treatment Assessment
• Purpose: To identify the client’s
specific area of concern (presenting
problems) and to determine the level
of severity in each area of concern.
• The treatment assessment helps the
counselor identify the client’s
immediate needs and provides a basis
for treatment.

24. Goals of Treatment
• Treatment should be individually tailored and guided
by an individualized treatment plan that is
developed in consultation with the client.
• The clinician’s referrals and recommendations
should be based on how that treatment and its
duration will affect client outcome and problem
resolution.
• The treatment goals should determine the methods,
intensity, frequency and types of services provided,
i.e. “In the process of completing a comprehensive
evaluation, making a placement decision is the last
step.”

25. Progress Through
Treatment
• As the person moves through treatment in any level
of service, his or her progress in all six dimensions
should be continually assessed.
• Degree of problem resolution or improvement in
treatment determines movement between levels of
care as the treatment plan is re-assessed.
• “Treatment failure” does not need to be a
prerequisite for approval of admission to a higher
level of care.

26. Individualized Treatment
Planning
• Writing Problem Statements
• Writing Goals
• Writing Action Plans (strategies)

27. Individualized Problem
Statement Includes:
• One Issue for each problem statement
• Briefly Stated
• For the correct dimension
• Stated as a problem that needs
improvement
• Stated as a correctable negative
consequence that is specific to this client
• What does the client think the problem is?

28. Problem Identification:
ABC’s
• Achievable: time, place, person
• Brief and Behavioral
• Caring: stated in accepting and non-
judgmental terms
• Different for each client

29. Individualized Goal
Statements Will:
• Be brief
• Relate the goal to the problem
• Relate the problem statement to the
goal which leads to the action plan
(strategies)
• Be appropriate to the client’s stage of
change
• What does the client want?

30. Short-Term Goals
• An expected result which takes a short time
to achieve
• Related to the identified clinical problem
• Stated in measureable terms
• Use action verb to illustrate direction of
change
• One goal per statement
• Appropriate to the client’s stage of change
• Provides guidelines for the direction of care

31. Individualized Action
Plan includes:
• Action steps must be directly related to the
matching problem statement
• Action steps must be stated in measurable terms
(observable, recordable, reportable and verifiable)
• Action steps must be stated as actions/tasks that
the client is willing and able to do
• Action steps must be specific to this client
• Action steps are realistic and achievable by this
particular client
• What is the client motivated to actually do?

32. Plan of Treatment:
• Describes the services or actions to meet the
stated goal
• Specifies the frequency of treatment interventions
or services
• Has a reasonable time for achievement
• Identifies who is responsible for the action or
strategy (client or staff or?)
• Takes into account the client’s degree of motivation
by applying appropriate strategies that specific to
the client’s stage of change.

33. Steps for Writing Short-
term Goals and
Strategies
• Write a problem for the client and ask what
about this is unique to this individual?
• Write a specific short-term goal
• Ask yourself: what behavior/action would
help this client achieve this goal, keeping in
mind the stage of change
• Make sure the strategy is observable so you
can track progress
• Is this something the client is willing and able
to do in the time specified?

34. Sample Strategies for
Treatment Plans:
• List two reasons the court sent you to treatment
• Write down the most recent thing that got you in
trouble when you were using alcohol or drugs
• What will happen if you don’t comply with probation
and report this to the treatment group
• List the pros and cons of your continuing to use
• Attend a meeting and see if you can relate to
anyone’s story. Report back to group.
• Share in group what has helped to prevent
relapsing and get other suggestions
• Any others?