1. American Society of Addiction Medicine (ASAM) How and when to use the Criteria

2. 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. 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 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. 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.

3. Dimensional Criteria Assessment Dimension 1: Acute Intoxication/Withdrawal Potential Dimension 1: Acute Intoxication/Withdrawal Potential Dimension 2: Biomedical Conditions and Complications Dimension 2: Biomedical Conditions and Complications Dimension 3: Emotional/Behavioral/Cognitive Conditions and Complications Dimension 3: Emotional/Behavioral/Cognitive Conditions and Complications Dimension 4: Readiness to Change Dimension 4: Readiness to Change Dimension 5: Relapse/Continued Use/Continued Problem Potential Dimension 5: Relapse/Continued Use/Continued Problem Potential Dimension 6: Recovery Environment 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

4. Relationship Between ASAM PPC-2R and ASI-MV ASAM PPC-2R Dimensions ASI-MV Domains *ASAM Dimension 1: AcuteIntoxication/WithdrawalPotential *Drug/Alcohol Use *ASAM Dimension 2: Biomedical Conditions & Complications *Medical Status *ASAM Dimension 3: Emotional, Behavioral & Cognitive Conditions & Complications *Psychiatric Status

5. 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

6. 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 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 II-D: Ambulatory Detoxification with Extended On- site Monitoring (e.g., detoxification on partial hospitalization program) Level III-D: Residential/Inpatient Detoxification Level III-D: Residential/Inpatient Detoxification Level III.2D: Clinically Managed Residential Detoxification (e.g., social detox) Level III.2D: Clinically Managed Residential Detoxification (e.g., social detox) Level III.7D: Medically Monitored Inpatient Detoxification Level III.7D: Medically Monitored Inpatient Detoxification Level IV-D: Medically Managed Inpatient Detoxification Level IV-D: Medically Managed Inpatient Detoxification

7. Residential/Inpatient Levels of Care Level III: Residential/Inpatient Services Level III: Residential/Inpatient Services Level III.1- Clinically Managed Low-Intensity Residential Services (e.g., halfway house) 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.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.5- Clinically Managed High-Intensity Residential Services (e.g., Therapeutic Community, Residential Treatment Center) Level III.7- Medically Monitored Intensive Inpatient Treatment Level III.7- Medically Monitored Intensive Inpatient Treatment Level IV: Medically Managed Intensive Inpatient Treatment Level IV: Medically Managed Intensive Inpatient Treatment

8. The Differences Between Inpatient, Residential and Outpatient with Supportive Living InpatientResidential 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.1<24 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”

9. Levels of Care (PPC-2R) Overall Structure of Levels of Care & Services Level 0.5- Early Intervention Level 0.5- Early Intervention Level I- Outpatient Level I- Outpatient Level II- Intensive Outpatient/Partial Hospitalization Level II- Intensive Outpatient/Partial Hospitalization Level III- Residential/Inpatient Treatment Level III- Residential/Inpatient Treatment Level IV- Medically Managed Intensive Inpatient Treatment Level IV- Medically Managed Intensive Inpatient Treatment

10. 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

11. Outpatient Levels of Care & Services Level 0.5- Early Intervention Level 0.5- Early Intervention Level I- Outpatient Level I- Outpatient Less that 9 contact Hours/Week Less that 9 contact Hours/Week Level II- Intensive Outpatient/Partial Hospitalization 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.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 Level II.5- 20 or More Contact Hours/Week in a Structured Program

12. The CIWA-Ar ( Clinical Institute Withdrawal Assessment of Alcohol, Revised) It requires under two minutes to administer It requires under two minutes to administer It requires no medial knowledge It requires no medial knowledge It provides you with a quantitative score that predicts the severity of withdrawal from alcohol It provides you with a quantitative score that predicts the severity of withdrawal from alcohol

13. 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

14. Managed Care A clinical Quality Process Rather than Simply A Way to Reduce Treatment Costs

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

16. Level of Care Placement after relapse should be based on an assessment of history and “here & now” and NOT on the assumption that if a patient relapsed after having been treated, then the previous level of care was not intense enough!

17. HOMELESSNESS alone is NOT sufficient reason for Level III Placement!

18. The more disadvantaged and complicated, the more important is CASE MANAGEMENT Co-occurring medical and psychiatric disorders Co-occurring medical and psychiatric disorders Adolescents Adolescents Ex-Felons Ex-Felons Older Adults Older Adults Welfare/disability clients Welfare/disability clients Financial problems needs Financial problems needs Parenting needs Parenting needs Pregnant Women Pregnant Women HIV- AIDS HIV- AIDS

19. The Three H’s of Assessment History History Here and Now Here and Now How uncomfortable are you? How uncomfortable are you?

20. A Discharge Plan Is A Deferred Treatment Plan and Should Be As Specific and Concrete As A Treatment Plan

21. “Discharge Planning” is part of treatment planning, NOT a discrete activity

22. Assessing for “Lapse” vs. “Relapse” Lapse Impulsive Impulsive Short Duration Short Duration Accompanied by Guilt Accompanied by Guilt Small Amount of Use Small Amount of Use Relatively Low Consequences Relatively Low Consequences Desire to Return to Abstinence Desire to Return to AbstinenceRelapse Planned Planned Long Period of Use Long Period of Use High Defensiveness High Defensiveness Large Amount of Use Large Amount of Use Relatively High Consequences Relatively High Consequences Uncertainty About Desire to Return to Abstinence Uncertainty About Desire to Return to Abstinence

23. “Imminent Danger” 1. A strong probability that certain behaviors will occur (e.g., continued alcohol or drug use or relapse or non-compliance with psychiatric medications) 2. 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) 3. 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

24. 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

25. Immediate Need Profile (con’t) 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

26. Immediate Need Profile (con’t) 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

27. 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

28. Screening for Alcohol Problems 1. Have you ever felt the need to CUT down on your drinking? __Yes __No 2. Have you ever felt ANNOYED by someone criticizing your drinking? __Yes __No 3. Have you ever felt GUILTY about your drinking? __Yes __No __Yes __No 1. Have you ever felt the need for an EYE OPENER to get you started in the morning? __Yes __No

29. 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?”

30. Craft Brief Screening Test for Adolescent Substance 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? YesNo