For those who seek additional guidance in this area, a number of criteria sets have been developed to guide the process of matching patients to treatment settings. The Patient Placement Criteria for the Treatment of Psychoactive Substance Use Disorders (Hoffman, 1991), developed by the American Society of Addiction Medicine (ASAM) in 1991, are used by many programs. The ASAM criteria, which are intended for use as a clinical tool for matching patients to appropriate levels of care, reflect a clinical consensus of adult and adolescent treatment specialists and incorporate the results of a field review.
According to the ASAM Patient Placement Criteria, the three goals for management of detoxification are (1) avoidance of potential hazardous consequences of discontinuation of the drug of dependence; (2) facilitation of the patient’s completion of detoxification and timely entry into continued treatment; and (3) promotion of patient dignity and easing of discomfort during the withdrawal process.
The ASAM criteria describe levels of treatment that are differentiated by the following three characteristics:
- Degree of direct medical management provided
- Degree of structure, safety, and security provided
- Degree of treatment intensity provided
The ASAM levels of care range from outpatient treatment to medically managed intensive inpatient care. (The ASAM criteria do not provide for detoxification in social model programs.)
The ASAM criteria offer a variety of options, on the premise that each patient should be placed in a level of care that has the appropriate resources (staff, facilities, and services) to assess and treat the substance use disorder. While the criteria describe four levels of care, variations in staffing and support services may give some programs the capacity for more or less intense monitoring of detoxification than other programs at the same level of care.
The levels of care addressed by the ASAM Patient Placement Criteria are matched with the corresponding recommended detoxification settings described in Exhibit 2-1. The TIP titled The Role and Current Status of Patient Placement Criteria in the Treatment of Substance Use Disorders (TIP 13; Center for Substance Abuse Treatment, 1995) provides a framework to help providers understand the issues surrounding patient placement criteria and offers potential strategies that can be useful in developing criteria. This TIP represents an initial effort to develop criteria that are more consistent with the overall needs of the treatment field.
It provides an analysis of several sets of public and private criteria, including the ASAM criteria and those used by the States of Minnesota, Massachusetts, and Iowa. The TIP provides recommendations for filling in the gaps in existing criteria sets, so uniform criteria can be developed that are acceptable to both treatment providers and payers.
A managed care bibliography that includes information on patient placement criteria is available from CSAT. This bibliography, titled Annotated Bibliography: Substance Abuse Treatment Services and Health Care Reform, can be obtained by contacting CSAT’s Division of State and Community Assistance at (301) 443-8391.
Advantages and Disadvantages of Placement Criteria
In recent years, some States have begun to develop standards of care on the basis of models such as the ASAM Patient Placement Criteria. The move toward the development of standards of care and their subsequent application across a broad range of detoxification settings has advantages and disadvantages.
Properly developed and executed, such standards have the potential to ensure increased uniformity of treatment and improved appropriateness and cost-effective allocation of resources. A basic consideration is meeting these expectations while at the same time maintaining the focus on the patient’s clinical needs as the primary concern. Patient placement criteria can provide a safety net that protects patients from falling to the lowest level of care as a consequence of economic considerations or a lack of treatment alternatives. A major risk in the use of placement standards, however, is that they may be taken too literally by those not directly involved in patient care. This could result in a patient’s receiving an inappropriate level of care that does not meet his or her clinical needs.
Clinicians must exercise judgment in all cases. If a single approach to care is widely adopted and strictly adhered to as the “correct” approach, treatment innovation may be stifled. The chief value of any criteria set is the added power that it gives providers to identify specific patient needs by means of a consistent and detailed assessment process and to choose a level of care that will specifically address those needs.