ASAM 3.3 Decoded: The Nuts and Bolts of Clinically Managed, Population Specific, High Intensity Residential Services

The American Society of Addiction Medicine designates level 3.3 as the level of residential substance use disorder treatment delivered to those suffering from cognitive impairments. In May 2018, the California Institute of Behavioral Health Solutions invited Mardell Gavriel, Psy.D, the Vice-President of Mental Health Services at HealthRIght 360 to “decode” the ASAM 3.3 Level of Care. Dr. Mardell is a California licensed psychologist who has developed and directed clinical programs at HealthRight 360 since 1997 and has been instrumental in the implementation of evidence-based practices, workforce development, and programming for specific populations. This webinar was presented as a component of the DMC-ODS Waiver Forum, funded by the Blue Shield of California Foundation. The project’s aim is to provide a collaborative think tank for county administrators in the planning and implementation of the Drug Medi-Cal Organized Delivery System.  The fact that this level of care needs “decoding” speaks to the challenge of providing services that are robust enough to incorporate significant needs in this population’s other life areas while keeping the pace of the program at a level that ensures comprehension. HealthRIght360 operationalized this level of care in response to the increased presentation of individuals suffering not only from substance use disorders but significant cognitive impairments. Dr. Gavriel walks us through the complexities of this level of care, discussing the program requirements, appropriate screening tools, clinical accommodations, and staff training needs that are required for successful implementation of a level 3.3 clinical program.

As level 3.3 is designed to treat Substance Use Disorders (SUDs) in those with cognitive impairments, programs are required to provide specific services to meet the needs of this population. Most importantly, appropriate medical services must be in place—including the ability to consult with a physician or physician extender and to be able to access emergency services at any time. Medical, psychiatric, laboratory and toxicology services must be provided either on-site or through consultation/referral. Additionally, the program must provide resources to meet the other functional impairments this population may present with—key among those vocational and educational services. While those adjunctive services may be provided either on-site or by referral, core services, such as access to credentialed medical and mental health staff, the 24-hour presence of allied health professional staff, and ability to access a clinician trained in treatment of SUDs, all must be provided in-house.  Furthermore, staff must be trained in the biological and psychological dimensions of substance use and mental health disorders, and have training in behavior management.

In addition to the presence of a diagnosable SUD, appropriate patients for level 3.3 care must be medically stable but will require assistance to manage their mental stability as well as manage their substance use. There must also be the presence of a cognitive impairment—this may be a temporary impairment that may resolve after treatment, as in the case of some substance-induced impairments, or it may be a more permanent impairment, resulting from a neurological disorder like Parkinson’s or a result of Fetal Alcohol Spectrum Disorders. These impairments make treatment more difficult—contributing to already high dropout rates endemic to SUD treatment.

With some modifications, an existing 3.1 or 3.5 program could be adapted to serve a 3.3 population; Dr. Gavriel explains some of the modifications that were made in her agency to create an effective treatment program: one of the first was a routine screening for cognitive impairments. Using the Life History Screen, Dr. Gavirel and her team identified over 20% of the current patient population as eligible for the treatment modified level 3.3 program. In response, to create a modified program, the agency changed its policy on cell phone use, began assessing for reading ability and learning aptitudes, lowered the stimulation level in the environment, added memory aids, and began to constantly teach and coach the use of grounding techniques to manage arousal levels.

In addition to some of the overarching changes, staff were also trained to approach treatment differently; with some of the biggest changes coming in the delivery of manualized curricula. Curricula was “slowed down,” with sessions repeated more frequently, and groups shortened. Cards and other memory aids were created to ensure that skills could be practiced even if a participant struggled to remember group content. Staff were trained to incorporate kinesthetic activities and mindfulness skills in groups, and to more thoroughly assess the need for additional services (and provide the linkage).

Click here to hear the full webinar. The slides and operational tools are available in the attachments.


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