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DESIGN AND IMPLEMENTATION OF RESIDENTIAL TREATMENT ACROSS THE 3.1, 3.3 AND 3.5 ASAM LEVEL OF CARE IN THE
DMC-ODS
Presented by: Danielle Buckland, LCSW, Jim Klotzle, LMFT, and Rachael Ranney, LMFT
ABOUT PROTOTYPES WOMEN’S CENTER A PROGRAM OF HEALTHRIGHT 360
• Residential Facility• 164 beds for women and children.
• ASAM Designation 3.1, 3.2W, 3.3 and 3.5.
• Located next to Prototype’s Outpatient Behavioral Health Program including Department of Mental Health Services (DMH) and Outpatient Substance Use Disorder Program.
• Client Populations and Referral Sources• Criminal Justice referrals including: women’s re-entry, AB109, AB109 Co-occurring integrated
Network COIN, Community Prisoner Mother Program (CPMP), and other criminal justice court referrals.
• Co-Occurring Mental Health Disorders.
• Referrals from Department of Children and Family Services (DCFS).
THE DIFFERENCE BETWEEN CLIENT CLINICAL PRESENTATION AT THE 3.1,
3.3, AND 3.5 LEVEL OF CARE
THE PRIMARY DIFFERENCE BETWEEN 3.1 AND 3.5 IS FUNCTIONAL LIMITATION
• A Functional Limitation is a substantial difficulty or an inability to complete a range of activities, whether simple or complex. This can include difficulty completing simple daily activities such as self-care and communicating in a healthy manner, but can also impact major areas such as a client’s ability to maintain employment.
3.1 FUNCTIONAL LIMITATIONS ACCORDING TO ASAM CRITERIA
• According to the ASAM Criteria the primary functional limitation at the 3.1 level of care is “problems in application of recovery skills, self efficacy, or lack of connection to the community systems of work, education or family life” (Mee-Lee, Shulman, Fishman, Gastfriend, Miller, Provence, & American Society of Addiction Medicine, 2013)
3.1 EXAMPLES OF FUNCTIONAL LIMITATIONS
• What does this look like?
• Client may be able to sustain short periods of sobriety but is not able to sustain sobriety in the outpatient setting due to lacking the recovery environment or the recovery skills needed to be successful.
• Client requires daily availability of supports, including counseling and coaching, in order to maintain recovery.
• Client may present with ongoing urges and cravings, but is able to use coping skills to manage them for short periods of time.
• Client may have some coping skills and/or supports, but it is not enough to effectively stop using.
• Client has consistent difficulty applying recovery skills.
3.1 CASE PRESENTATION: MEET “MARIA”
• 23 year old Hispanic female with primary drug of choice methamphetamine secondary is alcohol and marijuana.
• Works intermittently with her mom cleaning houses. Mom’s business, emotional support, and stability is clear strength in the client’s life.
• Two daughters ages 2 and 4 who were recently removed by child welfare and placed in foster care.
• Presented with Major Depressive Disorder and some anxiety, but not enough to be the focus of treatment.
• Father of children is gang affiliated and is currently incarcerated pending trial. Client remains loyal to the children’s father.
• When the children were removed, Maria enrolled in Intensive Outpatient Treatment but has been unsuccessful with sustaining sobriety and clean time.
• Longest period without use was 12 days immediately after the children were removed. Sometimes she can make it through the weekdays while in treatment, but finds herself relapsing on weekends despite availability of weekend outpatient groups and 12 step meetings.
3.5 FUNCTIONAL LIMITATIONS ACCORDING TO ASAM CRITERIA
• According to the ASAM Criteria 3.5 level of care serves ”individuals who, because of specific functional limitations, need safe and stable living environments in order to develop and or/demonstrate the recovery skills so that they do not immediately relapse or continue to use in an imminently dangerous manner upon transfer to less intensive care”. (Mee-Lee, Shulman, Fishman, Gastfriend, Miller, Provence, & American Society of Addiction Medicine, 2013).
3.5 EXAMPLES OF FUNCTIONAL LIMITATIONS
• What does this look like?
• Client is not able to refuse substances or maintain sobriety time.
• Client experiences frequent cravings and urges to use that are difficult to resist resulting in a need for constant consistent support.
• Client lacks effective coping skills to resist urges to use.
• Client has multiple problems that may include but are not limited to substance use, homelessness, unemployment, chronic medical conditions, criminal activity, and psychological problems.
3.5 CASE PRESENTATION: MEET “KATIE”
• 31 year old Caucasian female with primary methamphetamine but reports a wide range of substance use and a willingness to use anything to get high.
• Intermittent homelessness since age 17 when her mother died of cancer. Katie’s biological father had a history of substance use and physical abuse of Katie and her brother. Katie reports she was asked to leave her biological father’s house due to conflict with her stepmom.
• History of trauma due to physical abuse, multiple sexual assaults as well as witnessing serious trauma while living on the streets. Meets full criteria for Post Traumatic Stress Disorder and has active symptoms of nightmares and flashbacks that make it difficult for her to sleep.
• 6 year old son was adopted 2 years ago after Katie was unsuccessful with sustained recovery despite multiple episodes in residential treatment.
• Katie recently learned she is pregnant which resulted in an renewed motivation for treatment. Katie came to Prototypes and told the intake counselor she was ready to enter treatment and was serious about completing this time.
THE 3.3 LOC IS POPULATION SPECIFIC AND HIGHLY DIFFERENT FROM THE 3.1 OR 3.5 LOC
• The ASAM designation of 3.3 is reserved for clients with significant cognitive impairments resulting from any of the following: traumatic brain injury, substance use, other co-occurring disorders, trauma, aging, developmental disabilities, intellectual disabilities, chronic brain syndrome, or other conditions such as Fetal Alcohol Spectrum Disorder (FASD).
• 3.3 LOC is unique because it is designed to treat a specific client population characterized by temporary or permanent cognitive impairment.
3.3 CASE PRESENTATION: MEET “DION”
• 23- year old, homeless, African American, female.
• History of multiple hospitalizations and is being referred for treatment by the hospital she is currently placed in. Client enters treatment with a diagnoses of Amphetamine Dependence and Unspecified Bipolar Disorder.
• Deon self-reports that she was a very hyper child and was first hospitalized at the age of 12. She states that she was kicked out of 3 Junior High Schools due to aggressive behaviors and she never completed high school. Deon has had multiple hospitalizations, one lasting for 5 months. Client began smoking marijuana at the age of 10 and meth at the age of 17. Client is currently on probation.
• Client demonstrates cognitive impairments due to her mental illness and substance use. Dion’s thinking skills are greatly impaired, she is very impulsive, she demonstrates impaired judgement, and is not able to correlate cause and effect. In addition, Dion is a poor historian. She has a very difficult time recalling accurate information about her past.
MENTAL HEALTH DISORDERS AND ASAM LEVEL OF CARE
• If a client has a co-occurring mental health disorder, which level of care would be most appropriate?
• Unfortunately there is no easy answer or simple formula to determine Level of Care based on mental health disorder diagnosis. Clients diagnosed with co-occurring mental health disorders may be appropriately placed at all different levels of care from outpatient, residential to withdrawal management.
• Keep in mind that client’s with more severe mental health symptoms will also rate higher severity and risk on ASAM Dimension 3 which includes emotional, behavioral or cognitive complications, which may result in higher prevalence of co-occurring mental health disorders and/or personality disorders in residential treatment.
• To further complicate things, some Mental Health Disorders are known to present with cognitive impairment.
MENTAL HEALTH DIAGNOSIS KNOWN TO PRESENT WITH COGNITIVE IMPAIRMENT
• Schizophrenia Spectrum and Other Psychotic Disorders
• Schizophrenia
• Schizoaffective Disorder
• Bipolar and Related Disorders
• Bipolar I Disorder
• Bipolar II Disorder
• Major Depressive Disorder with Psychotic Features
SCHIZOPHRENIA
• According to the DSM-5 “Impaired cognition is common, and alterations in cognition are present during development and precede the emergence of psychosis, taking the form of stable cognitive impairments during adulthood. Cognitive impairments may persist when other symptoms are in remission and contribute to the disability of the disease” (American Psychiatric Association, 2013).
• Cognitive impairments that show up consistently in individuals diagnosed with schizophrenia include: dysfunctions in working memory, attention, processing speed, visual and verbal learning with substantial deficit in reasoning, planning, abstract thinking and problem solving. (Heinrichs RW, Zakzanis KK. Neuropsychology. 1998 Jul; 12(3):426-45).
• Individuals diagnosed with schizophrenia show consistent brain changes in the following areas: prefrontal cortical areas, inferior parietal lobule, amygdala, superior temporal gyrus, medial temporal lobe, basal ganglia, thalamus, corpus callosum and cerebellum (Gourion D, Gourevitch R, Leprovost JB, Olié H lôo JP, Krebs MO Encephale. 2004 Mar-Apr; 30(2):109-180.)
ASAM ASSESSMENT AND PLACEMENT DECISIONS AND DOCUMENTATION TIPS
• Carefully assess the client’s six ASAM dimensions for severity ratings when determining the appropriate Level of Care.
• The placement decision should be made only after careful consideration and documentation of:
• What is the client’s preference?
• What are the client’s needs?
• What resources are available?
DIFFERENCE IN CLINICAL SERVICES AND DOCUMENTATION BETWEEN 3.1, 3.3 AND
3.5 LEVEL OF CARE
(AT PROTOTYPES A PROGRAM OF HEALTHRIGHT 360)
BACK TO THE BASICS: PURPOSE OF CLINICAL DOCUMENTATION
• Documentation illustrates the story of the client’s treatment and serves multiple purposes:
• It documents regular care so the treatment team can work together effectively.
• It provides a story of treatment, so any provider can work on the case during transitions.
• It demonstrates that providers fulfilled their legal and ethical obligations while providing treatment to clients.
• It serves as proof to federal, state, and local entities that the program provided accurate and ethical services.
• It serves as proof to third-party payers that services billed were provided and necessary.
The Golden Thread
Assessment•The ASAM Assessment and AIA Addendum helps identify and document the client’s problem areas that support the diagnosis and recommended ASAM level of care placement.
Treatment Plan•The Treatment Plan is written collaboratively with the client’s input, to create goals and action steps to address problem areas identified in the assessments.
Progress Notes•Progress Notes are written to document the Action Steps and interventions used to address the client’s problem areas. The Progress notes must include the client’s response to treatment.
Do not accidently cut the golden thread by writing a Progress Note or Treatment Plan that does not contain Short-Term
Goals or Action Steps that address the Problem Areas
identified in the Assessment.
The Golden Thread is the connection between the various parts of the client’s treatment. It is described in documents within the client’s record. Documentation should tell the story of each client’s unique treatment episode, with the thread of connection woven throughout the story, showing consistency of information across all forms and documents. This documentation thread establishes a written, legal record of the course of treatment. It provides the information needed for both guiding the treatment process and for billing purposes.
INTAKE AND TREATMENT AT PROTOTYPES A PROGRAM OF HEALTHRIGHT 360
• All clients are assessed at intake using the ASAM Continuum to determine initial Level of Care.
• Each client is assigned a Treatment Team consisting of a SUD Counselor, Clinical Therapist (LPHA) and a Case Manager.
• During the first week of treatment, the client is assessed by their Clinical Therapist (LPHA) and biopsychosocial known as the Adult Initial Assessment Addendum is completed.
• The Treatment Plan is written by the Clinical Therapist based on the ASAM Continuum, Adult Initial Assessment, and input from the client.
MULTIDISCIPLINARY TREATMENT TEAMS• Case Manager
• Requires registration or certification as a substance use disorder counselor with an approved accredited agency. Prototypes made the internal decision to also require a bachelors degree.
• Clinical Therapist (LPHA)• Requires a masters degree and registration or licensure with the Board of Behavior Sciences or
the Board of Psychology.
• SUD Counselor II/III• Requires registration or certification as a substance use disorder counselor with an approved
accredited agency.
• SUD Supervisor• A Supervisory position with registration or certification as a substance use disorder counselor
with an approved accredited agency.
• LPHA Supervisor • A Supervisory position that requires a masters degree and registration or licensure with the
Board of Behavior Sciences or the Board of Psychology.
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Case Manager
SUD Counselor
SUD Counselor
Case Manager
Clinical Therapist
LPHA
Clinical Therapist
LPHA
LPHA Supervisor
Orange TeamTotal Clients = 32
Caseload SizeSUD Counselor = 10
Clinical Therapist LPHA = 16Case Manager = 16
Staffing Pattern
7
Certified Counselor Supervisor
SUD Counselor
SUD Counselor
SUD Counselor
Case Manager
Case Manager
Clinical Therapist
LPHA
Clinical Therapist
LPHA
LPHA Supervisor
Red TeamTotal Clients = 32
Caseload SizeSUD Counselor = 10
Clinical Therapist LPHA = 16Case Manager = 16
SUD Counselor
SUD Counselor
SUD Counselor
Case Manager
Case Manager
Clinical Therapist
LPHA
Clinical Therapist
LPHA
Case Manager
Case Manager
SUD Counselor
SUD Counselor
SUD Counselor
Certified SUD Counselor Supervisor
LPHA Supervisor
Clinical Therapist
LPHA
Clinical Therapist
LPHA
Blue TeamTotal Clients = 32
Caseload SizeSUD Counselor = 10
Clinical Therapist LPHA = 16Case Manager = 16
Purple TeamTotal Clients = 32
Caseload SizeSUD Counselor = 10
Clinical Therapist LPHA = 16Case Manager = 16
Residential Multidisciplinary Color Teams
TYPES OF GROUPS OFFERED
• Core Groups-High intensity group counseling curriculum designed to provide Evidence-Based Practice interventions. All Core Groups in the 3.1 and 3.5 track of care have been recognized in the National Registry of Evidence-based Programs and Practices (NREPP) by the Substance Abuse and Mental Health Service Administration (SAMHSA).
• Supplemental Groups- include patient education and group counseling curriculum designed to prepare the client for life in the community. Groups include: Patient Education, 12 Step Education, 12 Step Meetings, Relapse Prevention, Parenting, Coping Skills, and Healthy Communication.
• Specialty Track Groups- Core Groups modified to meet the needs of a specialty population such as 3.3. The groups are modified to provide increased repetition, role play, verbal and visual presentation of the information, and pacing that slows the presentation of the material down. All specialty groups are facilitated by registered or licensed therapists (LPHA).
EBP’S SELECTED AS “CORE GROUPS”
• Seeking Safety
• Dialectical Behavioral Therapy
• Moral Reconation Therapy
• Beyond Anger and Violence
• Helping Women Recover
• Beyond Trauma
• Aggression Replacement Therapy
DOCUMENTING GROUP SERVICES
• All group counseling and patient education groups are documented using GIRP format and are individualized to demonstrate the client’s progress in treatment.
• Goal
• Intervention
• Response
• Plan
• All progress notes are individualized and include the client’s progress towards treatment goals (or barriers to progress) and demonstrate the golden thread.
CLINICAL DOCUMENTATION OF THE 3.1 LEVEL OF CARE
• The ASAM designation of 3.1 is appropriate for clients who need time and structure to practice and integrate their recovery and coping skills in a residential, supportive environment.
• The client’s assessment, treatment plan, and progress notes must document the balance of clinical support and application of coping and recovery skills. Ongoing assessment is needed to ensure the client is able to demonstrate safe recovery coping in the low intensity environment.
• Treatment Goals should challenge the client to strengthen and apply their coping skills, build strong relapse prevention, increase confidence in recovery, and prepare the client to transition to outpatient level of care.
SERVICES AT THE 3.1 LEVEL OF CARE
• Clients typically participate 1 high intensity ”Core Group” per day and 1-2 ”Supplemental Group” per day. The client’s group schedule may be adapted based on client need.
• Individual Counseling and Therapy sessions are scheduled once per week or as clinically indicated. Individual interventions are tailored to meet the client’s need and prepare them to leave residential and re-enter the community.
• Individual Case Management is scheduled as needed with typically an increase at client entrance and exit.
CLINICAL DOCUMENTATION OF THE 3.5 LEVEL OF CARE
• The ASAM designation of 3.5 is appropriate for clients who have specific functional limitations and need a safe and stable living environment in order to develop and/or demonstrate sufficient recovery skills to avoid immediate relapse or continued use of substances.
• The client’s assessment, treatment plan, and progress notes must document justification of the client’s need for a safe and stable living environment while engaging in treatment.
• Treatment Goals should include stabilizing the client and managing crises that may arise. The primary focus of interventions may be building motivation, teaching distress tolerance, emotion regulation, building coping skills, and case management.
• Ongoing assessment should continue to determine when the client has increased stability and coping skills and is ready to step down to 3.1 level of care.
SERVICES AT THE 3.5 LEVEL OF CARE
• Clients receive high intensity treatment with an emphasis on “Core Groups”. Clients at the 3.5 LOC are typically assigned 2-3 sessions of Core Groups per day.
• When client’s are not participating in ”Core Groups” they may engage in lighter activities (“Supplemental Groups”) such as Therapeutic Services, 12 Step Education, Relapse Prevention, Leisure Activities, or Individual Services.
• Individual services at the 3.5 level of care typically consist of a weekly individual sessions with their SUD Counselor and Clinical Therapist. Individual Interventions tailored based on clinical need.
• Case management is scheduled as needed with typically an increase at client entrance and exit.
CLINICAL DOCUMENTATION OF THE 3.3 LEVEL OF CARE
• The ASAM designation of 3.3 is reserved for clients with significant cognitive impairments resulting from any of the following: traumatic brain injury, substance use, other co-occurring disorders, trauma, aging, developmental disabilities, intellectual disabilities, chronic brain syndrome, or other conditions such as Fetal Alcohol Spectrum Disorder (FASD).
• Don’t be afraid to slow treatment down, increase repetition, and use multiple methods to teach coping skills. Use of role play and practice sessions may be beneficial. While providing interventions continue to assess the clients progress and document in ongoing progress notes.
• Treatment Goals may focus on increasing use of supports and establishing routines that support sobriety/clean time.
• Goal of increasing use of supports…
• Goals of increasing use of ADL’s..
• Goals increasing use of communication skills..
• Goal to manage health/mental health symptoms..
SERVICES AT THE 3.3 LEVEL OF CARE
• 3.3 clients are placed on a specialty track to ensure to meet each individual client’s needs. Clients receive 5 core EBP groups, 3 patient education groups, individual services and 2 weekend groups.
• The 3.3 Core EBP groups are led by a Clinical Therapist LPHA and include one hour of work and 30 minutes of either physical activity or art as it relates to the EBP. Facilitator will Increase interventions such as role play and present information verbally and visually rather than requiring reading; provide short breaks to prevent cognitive fatigue or frustration.
• 3.3 clients are referred to and opened in DMH within 48 hours intake. The client’s are seen by the psychiatrist within 72 hours of intake. This will ensure that the clients mental health needs are at the forefront of their treatment.
• Individual treatment is critical to the 3.3 LOC. Clients will receive at least 30 minutes of one on one time with treatment team 5 days a week. This ensures that clients needs are being met and staff are able to triage any issues that may arise.
• Treatment for 3.3 client’s moves at a slower pace with increased repetition because the client is likely to have difficulty with abstract thought and interventions. Client’s are likely to benefit from basic life skills, social skills, and basic coping skills, groups will be designed to increase ability to tolerate frustration.
PANEL QUESTIONS & ANSWERS
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REFERENCES
• American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
• Barch DM, Sheffield JM. Cognitive impairments in psychotic disorders: common mechanisms and measurement.World Psychiatry (2014) 13(3):224–32. 10.1002/wps.20145
• Gourion D, Gourevitch R, Leprovost JB, Olié H lôo JP, Krebs MO. [Neurodevelopmental hypothesis in schizophrenia]. Encephale. 2004;30:109–118. doi: 10.1016/S0013-7006(04)95421-8. French. [PubMed] [CrossRef] [Google Scholar]
• Heinrichs RW, Zakzanis KK. Neurocognitive deficit in schizophrenia: a quantitative review of the evidence. Neuropsychology. 1998;12:426–445. doi: 10.1037/0894-4105.12.3.426.
• Mee-Lee, D., In Shulman, G. D., In Fishman, M., In Gastfriend, D. R., In Miller, M. M., In Provence, S. M., & American Society of Addiction Medicine,. (2013). The ASAM criteria: Treatment for addictive, substance-related, and co-occurring conditions.
• Lima, I., Peckham, A. D., & Johnson, S. L. (2018). Cognitive deficits in bipolar disorders: Implications for emotion. Clinical psychology review, 59, 126–136. doi:10.1016/j.cpr.2017.11.006
• Reichenberg A, Harvey PD, Bowie CR, et al. Neuropsychological function and dysfunction in schizophrenia and psychotic affective disorders. Schizophr Bull. 2009;35:1022–9.
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