Comprehensiveness and Continuity of Care
I believe that the development and three subsequent revisions of The ASAM Criteria (Mee-Lee et al., 2013), along with motivational interviewing (MI) and medication-assisted treatment (MAT), have made the greatest contributions to assessment and placement for people with substance use disorders (SUDs). The five levels of ASAM’s withdrawal management—they used to be called “detoxification” because livers do the detoxification and clinicians manage the process, but it was changed to “withdrawal management”—and the eight levels of treatment (including three levels of outpatient care, three levels of residential treatment, and two levels of inpatient treatment) provided the field with a common language and description of the different intensities of treatment.
Unfortunately, these levels of care and the programs in each began to be seen as distinct and separate entities by some (Vanderplasschen, De Bourdeaudhuij, & Van Oost, 2002), rather than waypoints in a continuum of care. Some clinicians considered admission to their programs as a discrete event rather than admission into a continuum of care through their program. This has resulted in a series of disconnected treatment services. This is not only true when considering different programs at different sites, but sometimes different levels of care offered by the same program at the same site. This disconnect has implications for both clinical care and costs.
Some patients with less severe SUDs may require only a single, low intensive level of care as their total treatment such as Level 1, outpatient. But others may require multiple levels of care, starting with a more intensive level and then moving down in intensity as they make progress. Conversely, some will require an increase in intensity for such things as the development or worsening of a co-occurring medical or mental health problem (e.g., acute suicidality). One current disturbing issue contributing to the disconnect is the practice of treating patients in more intensive levels of care, such as ASAM Level 3.7 in areas far from home followed up by inadequate care when they return. These treatment programs and their staff view their treatment, whether verbalized or not, and even whether thought consciously or not, as patients’ treatment rather than as only a part of the continuum (Lee et al., 2014).
A true continuum of care is characterized by three things:
1. Seamless transfer between levels of care or programs
2. Philosophical congruence between programs
3. Rapid transfer of patient information between levels of care
A continuum of care can be provided by multiple providers in some predetermined arrangement that facilitates movement through the continuum, but this is more difficult unless all the treatment providers are in the same geographic area. It can also be accomplished through a single program and when done creatively, costs less to provide and enhance clinical care.
I would like to share an example of an acute care, hospital-based, addiction treatment program that provided three levels of withdrawal management services with a twenty-three-hour observation bed, seven levels of treatment, and two levels of transitional care, all at the same site (see Figure 1).
A word about names for some of the levels of care in Figure 1. Because this was “new ground” about twenty-five years ago, some of today’s language for levels of care did not quite fit or was cumbersome, so I have included a legend for certain levels’ names.
This was “ambulatory withdrawal management with extended on-site monitoring withdrawal” (ASAM Level 2-WM), combined with supportive housing for those patients who were deemed at risk for using substances overnight when home, for not returning the following day, or whose recovery environment was too toxic to support their recovery.
Superintensive Partial Hospitalization
This was ASAM partial hospitalization Level 2.5 (PHP) combined with supportive housing for those patients who did not require the twenty-four-hour care of a clinically managed, high-intensity residential program or medically monitored intensive inpatient program, but had issues like lack of transportation, homelessness, being at risk for using overnight when home, not returning the following day, or having an environment that was too toxic to support recovery. This model, from twenty-five years ago, is common practice today.
While this does not show on the chart, it was used primarily for assessment prior to the selection of level of care. It was an element that was particularly attractive to payers since the use of the twenty-three-hour bed provided an assessment option that resulted in some patients being admitted to a less intensive level of care that they would have been without the twenty-three-hour bed.
I previously stated that this could be done at lower costs than would be necessary if each level of care was a discrete program. For example, in this model patients in all three levels of withdrawal management went through their detoxification together, with the patients in inpatient detoxification and those in subacute detoxification remaining in the program overnight while those in ambulatory detoxification went home each evening. Similarly, patients in inpatient rehabilitation, superintensive partial hospitalization, and partial hospitalization all went through treatment together with those in the PHP program, going home at night and returning the next morning.
How did this model reduce costs? It would be very expensive if we had to staff up each level of care separately. However, by combining the different programmatic elements we were able to staff to volume. Interestingly, the hospital was only about 50 percent occupied, which led to severe financial problems. In order to control costs, hospital management required each hospital service to perform a weekly productivity analysis that compared staff expenses with income. The addiction service was the most productive service in the hospital.
As another example of this approach, we had two evening IOP programs which were well utilized. We received requests to start a day IOP, but our analysis indicated that it would run a census of only three to five patients. With the clinical staff’s input, we rearranged the schedules for the full-day programs so that the people in the day IOP could get program elements they needed in the morning with the other patients and leave at lunch time.
Knowing the value of aftercare in helping achieve and maintain positive outcomes, we decided to attempt a one-year aftercare program (Schaefer, Ingudomnukul, Harris, & Cronkite, 2005), but did not know how we were going to fund it. Again, using the clinical staff’s ideas, we reached out to people we knew who were in counselor training programs or who worked at other SUD treatment programs and offered to provide them with weekly clinical supervision for one year and a certificate of completion at the conclusion of the year if they would provide us with one evening a week for the year to facilitate an aftercare group. One of our clinicians offered to change his schedule to provide the supervision. Our cost was for coffee and cookies for the volunteer facilitators during the group supervision, which occurred after the conclusion of the aftercare groups.
I previously stated that this approach also had positive clinical implications. On the fifth floor of the building where the detox and inpatient patients lived there was a nursing station, behind which was a large whiteboard with each patient’s name written in a color that corresponded to their level of care. Patients became motivated to move toward less intensive levels of care and would often ask the nurses, “What do I need to do to get to the next less intensive level of care?”
In conclusion, providing a more comprehensive continuum of care, increasing continuity of care, helping motivate patients, and doing all of this at lower costs was a win-win scenario.
About the Author
Gerald Shulman, MA, MAC, FACATA, is a clinical psychologist and fellow of the American College of Addiction Treatment Administrators. He has been providing treatment or clinically or administratively supervising the delivery of care to alcoholics and drug addicts since 1962.
Lee, M. T., Horgan, C. M., Garnick, D. W., Acevedo, A., Panas, L., Ritter, G. A., . . . Reynolds, M. (2014). A performance measure for continuity of care after detoxification: Relationship with outcomes. Journal of Substance Abuse Treatment, 47(2), 130–9.
Mee-Lee, D., Shulman, G. D., Fishman, M. J., Gastfriend, D., Miller, M. M., & Provence, S. M. (2013). The ASAM criteria: Treatment criteria for addictive, substance-related, and co-occurring conditions. Carson City, NV: The Change Companies.
Schaefer, J. A., Ingudomnukul, E., Harris, A. H., & Cronkite, R. C. (2005). Continuity of care practices and substance use disorder patients’ engagement in continuing care. Medical Care, 43(12), 1234–41.
Vanderplasschen, W., De Bourdeaudhuij, I., & Van Oost, P. (2002). Coordination and continuity of care in substance abuse treatment. An evaluation study in Belgium. European Addiction Research, 8(1), 10–21.