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Overview of Substance Use Disorder (SUD) Care Clinical Guidelines: A Resource for States Developing SUD Delivery System Reforms
April 2017
For the past two years, the Medicaid Innovation Accelerator Program (IAP) has been providing a broad group of state Medicaid and behavioral health agencies with a variety of technical support resources to support the development of robust approaches for addressing substance use disorders (SUD). In addition, IAP has also been working directly with a small group of leader states on issues related to reducing substance use disorders, as well as with a number of states to assist with their planning and development of section 1115 demonstration proposals focusing on SUD.^1 Through our close work with states under various IAP SUD activities, we have developed tools and resources such as this one designed to support state efforts to introduce policy, program and payment reforms appropriate for a robust SUD delivery system.
The purpose of this resource is to support states in their ongoing efforts to introduce SUD service coverage and delivery system reforms by providing information about the preventive, treatment and recovery services and the levels of care comprising the continuum of SUD care. This document also provides an overview of nationally developed guidelines for SUD treatment criteria, including provider and service standards for each level of care. In addition, it provides useful tools and examples of state-based initiatives that can assist states in their efforts to ensure that care is delivered consistent with industry standard SUD treatment guidelines and that Medicaid beneficiaries receive the most appropriate services given their treatment and recovery needs.
(^1) Medicaid Innovation Accelerator Program Reducing Substance Use Disorders. “High Intensity Learning Collaborative fact sheet”. https://www.medicaid.gov/state-resource-center/innovation-accelerator-program/iap-downloads/learn-hilc- iap.pdf.
SUD TREATMENT CARE CONTINUUM AND PROGRAM STANDARDS
Needs assessments and other research have shown that not all state Medicaid programs offer the full continuum of services needed by individuals with a SUD.^2 3 The SUD continuum of services should include interventions that are capable of meeting the various types of individual’s needs, including various levels of care. As individuals move throughout the continuum in their recovery from SUD, they may need to transition to levels of care of greater or lesser intensity, depending on their clinical needs.
An example of patient flow throughout the SUD care continuum can illustrate how important service coverage of the full range of care is to appropriately treating SUD. An individual with SUD may be admitted to a medically managed withdrawal management or inpatient facility with acute physical health care needs requiring medical and nursing care. Once medically stable, the individual may next need a clinically managed adult residential program for treatment services or an intensive outpatient or outpatient program that includes medication assisted treatment (MAT).
Alternatively, an individual with SUD may begin treatment by receiving outpatient treatment services only to find that a more intensive level of care, such as intensive outpatient treatment, is more appropriate. Without the ability to transition to less or more intensive levels of care throughout treatment in response to changing clinical needs and treatment goals, individuals with SUD face higher risk of relapse and worse behavioral and physical health outcomes, including increased inpatient hospital utilization.^4
Through our work with states, we have found that comparing existing Medicaid SUD benefits side- by-side with the nationally developed SUD care continuum is a useful exercise for identifying how well service coverage aligns to the full continuum of SUD services. This will allow states to identify any gaps in their coverage and review their inventory of SUD providers that offer these services. Included in this document is a template that can be used to crosswalk state Medicaid coverage of SUD services with the continuum of care described in the American Society of Addiction Medicine (ASAM) Criteria (see Appendix One).
In addition to aligning benefits coverage with nationally accepted guidelines, states can also assess their program standards to ensure that SUD service provision adheres to the industry standards.
Specifically, states can review their licensure standards, regulations, policy, provider manuals and contracts, managed care contracts, or other program guidance to determine if requirements for SUD providers and services comport with important provider and service standards in the ASAM Criteria. This document provides a brief overview of these provider competencies, and includes optional resources that states can use to conduct such reviews (see Appendix Two).
These two core features—offering service coverage for the full continuum of care and aligning
(^2) Clark RE, Samnaliev M, McGovern MP. Treatment for co-occurring mental and substance use disorders in five state Medicaid Programs. Pediatr Serv. 2007;58(7):942–948. (^3) Garnick DW, Lee MT, Horgan CM, et al. Adapting Washington Circle performance measures for public sector
substance abuse treatment systems. J Subst Abuse Treat. 2009;36(3):265–277. (^4) Magura S, Staines G, Kosanke N, et al. Predictive validity of the ASAM Patient Placement Criteria for
naturalistically matched vs. mismatched alcoholism patients. Am J Addict.2003;12(5):386–397. (^5) Sharon E, Krebs C, Turner W, et al. Predictive validity of the ASAM Patient Placement Criteria for hospital
utilization. J Addict Dis. 2003;22 Suppl 1:79–93.
Figure 1. ASAM Levels of Care
Definition of Treatment Terms
Throughout the ASAM Criteria, the following treatment terms are used to describe services within a specified level of care:
- Clinically managed services are directed by nonphysician addiction specialists rather than medical personnel. They are appropriate for individuals whose primary problems involve emotional, behavioral, cognitive, readiness to change, relapse, or recovery environment concerns. Intoxication, withdrawal, and biomedical concerns, if present, are safely manageable in a clinically managed service. This type of care is described under Level 3.1, 3.3 and 3.5 residential programs.
- Medically monitored services are provided by an interdisciplinary staff of nurses, counselors, social workers, addiction specialists, or other health and technical personnel under the direction of a licensed physician. Medical monitoring is provided through an appropriate mix of direct patient contact, review of records, team meetings, 24-hour coverage by a physician, 24-hour nursing and a quality assurance program. This type of care is described under Level 3.7 inpatient programs.
- Medically managed services involve daily medical care and 24-hour nursing. An appropriately trained and licensed physician provides diagnostic and treatment services directly, manages the provision of those services, or both. This type of care is described under Level 4 medically managed intensive inpatient programs.
Level 0.5: Early Intervention
Professional services targeting individuals who are at risk of developing a substance-related problem but may not have a diagnosed SUD are provided in Level 0.5. These early intervention services—including individual or group counseling, motivational interventions, and Screening, Brief Intervention, and Referral to Treatment (SBIRT)—seek to identify substance-related risk factors to help individuals recognize the potentially harmful consequences of high-risk behaviors. These services may be coverable under Medicaid as stand-alone direct services or may also be coverable as component services of a program such as driving under the influence or driving while intoxicated programs and Employee Assistance Programs (EAPs). Length of service may vary from 15 to 60 minutes of SBIRT, provided once or over five brief motivational sessions, to several weeks of services provided in programs. Medicaid coverage of services and component services, whether provided directly or through programs, must comport with all applicable rules, such as state plan benefit requirements.
- Setting: Early intervention services are often provided in nonspecialty settings including primary care medical clinics, hospital emergency departments, community centers, worksites, or an individual’s home. SBIRT may be conducted in a primary care physician’s office, mental health practice, trauma center, emergency department, school setting, or other nonaddiction treatment environments.
- Provider Type: Appropriately credentialed and/or licensed treatment professionals, including addiction counselors, social workers, or health educators may offer early
outpatient specialty providers, but may be delivered in any appropriate setting that meets state licensure or certification requirements. These programs have direct affiliation with programs offering more and less intensive levels of care as well as supportive housing services.
- Provider Type: Interdisciplinary team of appropriately credentialed addiction treatment professionals including counselors, psychologists, social workers, addiction-credentialed physicians, and program staff, many of whom have cross-training to aid in interpreting mental disorders and deliver intensive outpatient services.
- Treatment Goal: At a minimum, this level of care provides a support system including medical, psychological, psychiatric, laboratory, and toxicology services within 24 hours by telephone or within 72 hours in person. Emergency services are available at all times, and the program should have direct affiliation with more or less intensive care levels and supportive housing.
- Therapies: Level 2.1 intensive outpatient services include individual and group counseling, educational groups, occupational and recreational therapy, psychotherapy, MAT, motivational interviewing, enhancement and engagement strategies, family therapy, or other skilled treatment services.
Level 2.5: Partial Hospitalization Programs.
Level 2.5 partial hospital programs differ from Level 2.1 intensive outpatient programs in the intensity of clinical services that are directly provided by the program, including psychiatric, medical and laboratory services. Partial hospitalization programs are appropriate for patients who are living with unstable medical and psychiatric conditions. Partial hospitalization programs are able to provide 20 hours or more of clinically intensive programming each week to support patients who need daily monitoring and management in a structured outpatient setting.
- Setting: Structured outpatient setting that offers direct access to psychiatric, medical and laboratory services. Such programs may be freestanding or located within a larger healthcare system so long as the partial hospitalization unit is distinctly organized from the rest of the available programs. These programs have direct affiliation with programs offering more and less intensive levels of care as well as supportive housing services.
- Provider Type: Similar to Level 2.1, partial hospitalization services are delivered by an interdisciplinary team of providers, with some cross-training to identify mental disorders and potential issues related to prescribed psychotropic drug treatment in populations with SUD. Additionally, these programs must support access to more and less intensive programs as well as supportive housing services. One major distinction from Level 2.1 is the requirement for qualified practitioners in partial hospitalization programs to provide medical, psychological, psychiatric, laboratory, toxicology and emergency services.
- Treatment Goal: At a minimum, this level of care meets the same treatment goals as described for Level 2.1, with psychiatric and other medical consultation services available within 8 hours by telephone or within 48 hours in person.
- Therapies: Level 2.5 intensive outpatient services include individual and group counseling, educational groups, occupational and recreational therapy, psychotherapy, MAT, motivational interviewing, motivational enhancement and engagement strategies, family
therapy, or other skilled treatment services.
Level 3: Residential or Inpatient Programs
Level 3 programs include four sublevels that represent a range of intensities of service. The uniting feature is that these services all are provided in a structured, residential setting that is staffed 24 hours daily and are clinically managed (see definition of terms above). Residential levels of care provide a safe, stable environment that is critical to individuals as they begin their recovery process. Level 3.1 programs are appropriate for patients whose recovery is aided by a time spent living in a stable, structured environment where they can practice coping skills, self- efficacy, and make connections to the community including work, education and family systems.
Level 3.1: Clinically Managed Low-Intensity Residential Programs
- Setting: Services are provided in a 24-hour environment, such as a group home. Both clinic-based services and community-based recovery services are provided. Clinically, Level 3.1 requires at least 5 hours of low-intensity treatment services per week, including medication management, recovery skills, relapse prevention, and other similar services. In Level 3.1, the 5 or more hours of clinical services may be provided onsite or in collaboration with an outpatient services agency.
- Provider Type: Team of appropriately credentialed medical, addiction, and mental health professionals provide clinical services. Allied health professional staff including counselors and group living workers and some clinical staff knowledgeable about biological and psychosocial dimensions of SUD and psychiatric conditions support the recovery residence component of care.
- Treatment Goal: Patients receive individual, group, or family therapy, or some combination thereof; medication management; and psychoeducation to develop recovery, relapse prevention, and emotional coping techniques. Treatment should promote personal responsibility and reintegrate the patient to work, school, and family environments. At a minimum, this level of care provides telephone and in-person physician and emergency services 24-hours daily, offers direct affiliations with other levels of care, and is able to arrange necessary lab or pharmacotherapy procedures.
- Therapies : Level 3.1 clinically managed low-intensity residential services are designed to improve the patient’s ability to structure and organize the tasks of daily living, stabilize and maintain the stability of the individual’s substance use disorder symptoms, and to help them develop and apply recovery skills. The skilled treatment services include individual, group and family therapy; medication management and medication education; mental health evaluation and treatment; motivational enhancement and engagement strategies; recovery support services; counseling and clinical monitoring; MAT; and intensive case management, medication management and/or psychotherapy for individuals with co- occurring mental illness.
Level 3.5: Clinically Managed Residential Programs (high intensity for adults, medium intensity for adolescents)
This gradation of residential programming is appropriate for individuals in some imminent danger with functional limitations who cannot safely be treated outside of a 24-hour stable living environment that promotes recovery skill development and deters relapse. Patients receiving this level of care have severe social and psychological conditions. This level of care is appropriate for adolescents with patterns of maladaptive behavior, temperament extremes and/or cognitive disability related to mental health disorders.
- Setting: Services are often provided in freestanding, licensed facilities located in a community setting or a specialty unit within a licensed health care facility. Such programs rely on the treatment community as a therapeutic agent.
- Provider Type: Interdisciplinary team is made up of appropriately credentialed clinical staff including addictions counselors, social workers, and licensed professional counselors, and allied health professionals who provide residential oversight. Telephone or in-person consultation with a physician is a required support, but -on-site physicians are not required.
- Treatment Goal: Comprehensive, multifaceted treatment is provided to individuals with psychological problems, and chaotic or unsupportive interpersonal relationships, criminal justice histories, and antisocial value systems. The level of current instability is of such severity that the individual is in imminent danger if not in a 24-hour treatment setting. Treatment promotes abstinence from substance use, arrest, and other negative behaviors to effect change in the patients’ lifestyle, attitudes, and values, and focuses on stabilizing current severity and preparation to continue treatment in less intensive levels of care.
- Therapies : Level 3.5 clinically managed residential services are designed to improve the patient’s ability to structure and organize the tasks of daily living, stabilize and maintain the stability of the individual’s substance use disorder symptoms, to help them develop and apply sufficient recovery skills, and to develop and practice prosocial behaviors such that immediate or imminent return to substance use upon transfer to a less intensive level is avoided. The skilled treatment services include a range of cognitive, behavioral and other therapies administered on an individual and group basis; medication management and medication education; counseling and clinical monitoring; random drug screening; planned clinical activities and professional services to develop and apply recovery skills; family therapy; educational groups; occupational and recreational therapies; art, music or movement therapies; physical therapy; and related services directed exclusively toward the benefit of the Medicaid-eligible individual.
Level 3.7: Medically Monitored Inpatient Programs (intensive for adults, high-intensity for adolescents)
This level of care is appropriate for patients with biomedical, emotional, behavioral and/or cognitive conditions that require highly structured 24-hour services including direct evaluation, observation, and medically monitored addiction treatment. Medically monitored treatment is provided through a combination of direct patient contact, record review, team meetings and quality assurance programming. These services are differentiated from Level 4.0 in that the population served does not have conditions severe enough to warrant medically managed inpatient services or acute care in a general hospital where daily treatment decisions are managed by a physician.
Level 3.7 is appropriate for adolescents with co-occurring psychiatric disorders or symptoms that hinder their ability to successfully engage in SUD treatment in other settings. Services in this program are meant to orient or re-orient patients to daily life structures outside of substance use.
- Setting: Services are provided in freestanding, appropriately licensed facilities located in a community setting or a specialty unit in a general or psychiatric hospital or other licensed health care facility.
- Provider Type: Interdisciplinary team is made up of physicians credentialed in addiction who are available on-site 24 hours daily, registered nurses, and additional appropriately credentialed nurses, addiction counselors, behavioral health specialists, clinical staff who are knowledgeable about biological and psychosocial dimensions of SUD and psychiatric conditions who have specialized training in behavior management techniques and evidence- based practices.
- Treatment Goal: Patients with greater severity of withdrawal, biomedical conditions, and emotional, behavioral, or cognitive complications receive stabilizing care including directed evaluation, observation, medical monitoring, 24-hour nursing care and addiction treatment.
- Therapies : Daily clinical services, which may involve medical and 24-hour nursing services, individual, group, family and activity services; pharmacological, cognitive, behavioral or other therapies; counseling and clinical monitoring; random drug screening; health education services; evidence-based practices, such as motivational enhancement strategies; medication monitoring; daily treatment services to manage acute symptoms of the medical or behavioral condition; and related services directed exclusively toward the benefit of the Medicaid-eligible individual.
Level 4: Medically Managed Intensive Inpatient Programs
This level of care is appropriate for patients with biomedical, emotional, behavioral and/or cognitive conditions severe enough to warrant primary medical care and nursing care. Services offered at this level differ from Level 3.7 services in that patients receive daily direct care from a licensed physician who is responsible for making shared treatment decisions with the patient (i.e. medically managed care). These services are provided in a hospital-based setting and include medically directed evaluation and treatment.
- Setting: Services may be provided in an acute care general hospital, an acute psychiatric hospital, or a psychiatric unit within an acute care general hospital, or through a licensed addiction treatment specialty hospital.
- Provider Type: Interdisciplinary team is made up of appropriately credentialed clinical staff including addiction-credentialed physicians who are available 24 hours daily, nurse practitioners, physicians’ assistants, nurses, counselors, psychologists, and social workers. Some staff are cross-trained to identify and treat signs of comorbid mental disorders.
- Treatment Goal: Addiction services including medically directed acute withdrawal management are provided in conjunction with intensive medical and psychiatric services to alleviate patients’ acute emotional, behavioral, and cognitive distresses associated with the SUD whose acute medical, emotional, behavioral and cognitive problems are so severe that
WITHDRAWAL MANAGEMENT LEVELS OF CARE
The ASAM Criteria includes five levels of withdrawal management services, which are described as if they were provided separately from the aforementioned level-of-care services available to manage SUDs. However, these services are routinely provided concurrently with other addiction services, by the same clinical staff, and in the same treatment setting. A brief description of withdrawal management services is provided in Figure 2.
Figure 2. Withdrawal Management Levels of Care
Staffing requirements differ according to the level of withdrawal management services required. For example, readily available physicians and nurses are required for outpatient withdrawal management, whereas social residential withdrawal management requires only that such personnel be available for consultation if protocols are in place and the care setting is staffed by appropriately credentialed and trained counselors.^8
OPIOID TREATMENT SERVICES
Opioid treatment services (OTS) is a broad term describing MAT options for opioid use disorders and the psychosocial supports and services provided in concert with pharmacological treatment. Two categories of MAT options exist for opioid use disorders–opioid agonists and antagonists.
Opioid agonist medications such as methadone and buprenorphine occupy and partially activate opioid receptors in the brain. These medications reduce opioid cravings and relieve withdrawal symptoms without producing a state of intoxication. As agonist medications, methadone and buprenorphine are covered under the Controlled Substances Act, which means that providers must meet certain regulatory requirements to prescribe them. Conversely, opioid antagonist medications such as naltrexone are not covered by the Controlled Substances Act. These medications occupy, but do not activate opioid receptors, thereby preventing the brain from responding to opioids and preventing intoxication when opioids are used.
Health care facilities that provide access to opioid agonists like methadone and buprenorphine are categorized as either opioid treatment programs (OTPs) or office-based opioid treatment (OBOT) models.
Opioid Treatment Programs
OTPs, commonly known as methadone maintenance treatment clinics or opioid maintenance therapy clinics, directly administer MAT (primarily methadone) to patients on a daily basis. Thus individuals receiving medication from OTPs are not required to take a prescription to any outpatient dispensing pharmacy. Due to this organizational structure, OTPs are heavily regulated by federal and state agencies. OTPs are appropriate for individuals who are assessed as meeting the diagnostic criteria for a severe opioid use disorder.
- Setting: Dispensing of methadone is conducted in licensed permanent, freestanding clinics, community mental health centers, community health centers, hospital medication units or satellite clinics, mobile units attached to permanent clinic sites, or inpatient settings that meet criteria set by 42 CFR 8. These facilities are highly structured, ambulatory addiction treatment service centers, such as Level 1 outpatient settings, that may require patients’ daily attendance to receive medication. Patients more established in their treatment eventually may receive “take home” medication supplies for limited durations, such as a weekend.
(^8) More information on specific withdrawal management levels of care is available from Mee-Lee D, ed. The ASAM Criteria: Treatment Criteria for Addictive Substance-Related, and Co-Occurring Conditions. Chevy Chase, MD: American Society of Addiction Medicine; 2013. http://www.asam.org/quality-practice/guidelines-and-consensus- documents/the-asam-criteria/text. Accessed March 28, 2016.
- Treatment Goal: MAT is integrated into patients’ general medical and psychiatric care. Stabilized patients, including those referred from OTPs, continue to receive pharmacological treatment and ancillary psychosocial treatment services as needed.
- Therapies: Individualized, patient-centered evaluation and treatment includes assessing, prescribing, administering, reassessing, and regulating medication type and dose levels as well as providing or referring for psychosocial treatments. OBOT providers may perform medication management for comorbid physical and mental health disorders if they are the patient’s primary care physician or psychiatrist.
EXAMPLES OF STATE SUBSTANCE USE DISORDER PROGRAM STANDARDS
As discussed above, the levels of care described in the ASAM Criteria may be used as a basis for designing Medicaid SUD benefits as part of a strategy to provide service coverage for the full continuum of care. In addition, the provider and service recommendations corresponding to each ASAM level of care can be used as a basis for designing Medicaid SUD program standards as part of a strategy to promote quality of addiction care. A number of state policy levers are available for this purpose, including licensure standards, regulations, policy guidance, provider manuals and contracts, managed care contracts, and other program guidance.
We have found that comparing existing Medicaid SUD program standards side-by-side with the specific provider and service recommendations for each level of care described in the ASAM Criteria is a useful step that states can take to ensure that care is delivered consistent with industry standard criteria. This exercise may be especially valuable for clinically intensive services such as residential treatment. Appendix Two includes a template that can be used to compare existing state protocols for SUD providers with the provider competencies recommended in the ASAM Criteria for Adult Level 3.1 services.
Many states have incorporated residential treatment into the SUD care continuum in a way that is designed to improve care quality while monitoring excessive use and expenditures. These states have articulated SUD provider and program standards to reflect with fidelity the ASAM Criteria recommendations for Adult Level 3 services. The examples below highlight select state mandates, licensure standards, program guidance, and managed care administration designs that specify SUD treatment, facility and provider requirements in line with the industry standard.
State Regulations and Licensure Standards
California received approval for a section 1115 demonstration to pilot test a new program for the organized delivery of services to treat SUDs. California’s program, called the Drug Medi- Cal Organized Delivery System (DMC-ODS) aims to simultaneously increase access to SUD services, including residential treatment and withdrawal management, while decreasing programmatic costs to Medicaid. The DMC-ODS aims to provide Medicaid beneficiaries with the continuum of care modeled after the ASAM Criteria for SUD services.
California has taken several steps efforts to ensure that providers and treatment facilities participating in the DMC-ODS pilot are delivering care in accord with the ASAM criteria, including implementing strategies to assess short-term residential treatment providers as delivering care consistent with the ASAM Level 3.1, 3.3 and 3.5 levels of care. Providers operating at each level of care are required to achieve specific licensure or alcohol and other drug (AOD) certification. Provider applications for new licenses and certifications must show that the provider’s staffing plans, use of training to ensure evaluations, services, and referrals are conducted
in accordance with ASAM requirements. The California Department of Health Care Services also conducts onsite evaluations of residential programs to ensure that they are appropriately staffed and have the necessary services in place to be certified as Level 3.5 programs.^11
The Maine Department of Health and Human Services issued regulations for licensing and certifying substance abuse treatment programs in 2008. These mandates clearly adopt the ASAM level-of-care requirements for residential services including residential withdrawal management. Provider credentials also are clearly stated in accordance with ASAM Criteria.^13
Program Standards
Several states have developed and issued guidance to support SUD treatment programs to provider care in accordance with key benchmarks from the ASAM Criteria. For example, in 2013 Michigan released a treatment policy formally establishing requirements for residential services to be in line with those set forth by the ASAM Criteria.^14 The document outlines specific provider, service and staffing requirements in accordance with key benchmarks from the ASAM Criteria descriptions for Level 3 programs, and carefully directs providers through the dimensions of care and gradations of intensity for residential services.
Several states have developed crosswalks between their locally developed patient placement criteria and the ASAM criteria to guide the use of residential services. For example, the Arizona Department of Health Services has developed a practice protocol to help Tribal and Regional Behavioral Health Authorities and providers better understand and implement the ASAM Criteria.^18 This protocol highlights criteria that would make beneficiaries eligible for continued stay, transfer, or discharge from residential treatment.
Conclusion
We hope this document is valuable to states interested in introducing SUD benefit design, program and administrative reforms, as it provides general information about key benchmarks from nationally developed SUD treatment guidelines. The information and resources included in this document can also serve as a helpful reference for states that are developing a comprehensive benefits package covering the full continuum of care, and incorporating industry-standard benchmarks for defining medical necessity criteria, covered services and provider qualifications.
(^11) California Department of Health Care Services. Substance Use Disorder Services, Facility Certification. http://www.dhcs.ca.gov/provgovpart/Pages/Facility_Certification.aspx. Accessed March 18, 2016. (^12) State of California—Health and Human Services Agency, Department of Health Care Services. DHCS American Society of Addiction Medicine (ASAM) Residential Level of Care Designation Questionnaire. http://www.dhcs.ca.gov/provgovpart/Documents/ASAM_Designation_Questionnaire_8-19-15.pdf. Accessed March 23,
(^13) Michigan Department of Community Health, Behavioral Health and Developmental Disabilities Administration,
Bureau of Substance Abuse and Addiction Services. Treatment Policy #10. Residential Treatment Continuum of Services. May 3, 2013. http://www.michigan.gov/documents/mdhhs/Residential_TX_Policy_10_549861_7.pdf. Accessed March 23, 2016. (^14) Arizona Department of Health Services, Division of Behavioral Health Services. DBHS Practice Protocol: Comprehensive Assessment and Treatment of Adults With Substance Use Disorders. Effective July 1, 2012. http://www.azdhs.gov/bhs/guidance/comprehensive-assessment.pdf. Accessed March 23, 2016.
ASAM
Level of Care
Service Title [State] Description (^) Existing [State] Medicaid Service?
New [State] Medicaid Service?
Medicaid Authority Needed?
3.1 Clinically Managed Low- Intensity Residential Services
24 hour structure with trained personnel; at least 5 hours of clinical service/week and prepare for outpatient treatment
Yes (limited to subpopula tions)
Yes (to expand to all population s)
demonstration
3.3 Clinically Managed Population Specific High Intensity Residential Services
24 hour structure with trained counselors to stabilize multi- dimensional imminent danger; Less intense milieu; and group treatment for those with cognitive or other impairments unable to use fill active milieu or therapeutic community and prepare for outpatient treatment
No Yes 1115 demonstration
3.5 Clinically Managed High Intensity Residential Services
24 hour care with trained counselors to stabilize multi- dimensional imminent danger and prepare for outpatient treatment.
No Yes 1115 demonstration
3.7 Medically Monitored Intensive Inpatient Services
24 hour nursing care with physician availability for significant problems in Dimensions 1, 2 or 3. 16 hour/day counselor availability
Yes No State Plan
4 Medically Managed Intensive Inpatient
24 hour nursing care and daily physician care for severe unstable problems in Dimensions 1, 2 or 3. Counseling available to engage patient in treatment
Yes No State Plan
OTP Opioid Treatment Program
Daily or several times weekly opioid agonist medication and counseling to maintain multidimensional stability for those with severe opioid use
No Yes State Plan
ASAM
Level of Care
Service Title [State] Description (^) Existing [State] Medicaid Service?
New [State] Medicaid Service?
Medicaid Authority Needed?
OBOT Office-Based Opioid Treatment
Daily or several times weekly opioid agonist medication and counseling to maintain multidimensional stability for those with severe opioid use
Yes No State Plan
1 - WM Ambulatory Withdrawal Management Without Extended on- Site Monitoring
Mild withdrawal with daily or less than daily outpatient supervision
No Yes State Plan
2 - WM Ambulatory Withdrawal Management with Extended On-site Monitoring
Moderate withdrawal management and support and supervision; at night has supportive family or living situation
Yes No State Plan
WM
Clinically Managed Residential Withdrawal Management
Moderate withdrawal, but needs 24 hour support to complete withdrawal management and increase likelihood of continuing treatment or recovery
No Yes 1115 demonstration
WM
Medically Monitored Inpatient Withdrawal Management
Severe withdrawal, 24-hour nursing care and physician visits; unlikely to complete withdrawal management without medical monitoring.
No Yes 1115 demonstration
