Results for Criteria Code 0211

DIMENSION 1: Acute Intoxication and/or Withdrawal Potential

The adolescent who is appropriately placed in a Level 2.1 program is not experiencing or at risk of acute withdrawal. At most, the adolescent’s symptoms consist of subacute withdrawal marked by minimal symptoms that are diminishing (as during the first several weeks of abstinence following a period of more severe acute withdrawal).

The adolescent is likely to attend, engage, and participate in treatment, as evidenced by his or her meeting the following criteria:

a. The adolescent is able to tolerate mild subacute withdrawal symptoms.

b. He or she has made a commitment to sustain treatment and to follow treatment recommendations.

c. The adolescent has external supports (family and/or court) that promote engagement in treatment.

NOTE: If the adolescent presents for treatment after recently experiencing an episode of acute withdrawal without treatment (as opposed to stepping down from a more intensive level of care following a good response), it is safer to err on the side of greater intensity of services when making a placement decision. For example, a Level 2.5 setting may be indicated if the adolescent is doing poorly or if there are indications in other dimensions that he or she would benefit from that level of care.

Results for Criteria Code 0212

DIMENSION 2: Biomedical Conditions and Complications

In Dimension 2, the adolescent’s biomedical conditions and problems, if any, are stable or are being addressed concurrently and thus will not interfere with treatment. Examples include mild pregnancy-related hypertension, asthma, hypertension, or diabetes.

or

The adolescent’s biomedical conditions and problems are severe enough to distract from recovery and treatment at a less intensive level of care, but will not interfere with recovery at Level 2.1. The biomedical conditions and problems are being addressed concurrently by a medical treatment provider.

Results for Criteria Code 0213

DIMENSION 3: Emotional, Behavioral, or Cognitive Conditions and Complications

The adolescent’s status in Dimension 3 is characterized by at least one of the following:

a. Dangerousness/Lethality: The adolescent is at mild risk of behaviors endangering self, others, or property (for example, he or she has suicidal or homicidal thoughts, but no active plan), and requires frequent monitoring to assure that there is a reasonable likelihood of safety between IOP sessions. However, his or her condition is not so severe as to require daily supervision.

b. Interference with Addiction Recovery Efforts: The adolescent’s recovery efforts are negatively affected by an emotional, behavioral, or cognitive problem, which causes mild interference with, and requires increased intensity to support, treatment participation and/or adherence. For example, the adolescent requires frequent repetition of treatment materials because of memory impairment associated with marijuana use.

c. Social Functioning: The adolescent’s symptoms are causing mild to moderate difficulty in social functioning (involving family, friends, school, or work), but not to such a degree that he or she is unable to manage the activities of daily living or to fulfill responsibilities at home, school, work, or community. For example, the adolescent’s problems may involve significantly worsening school performance or in-school detentions, a circle of friends that has narrowed to predominantly drug users, or loss of interest in most activities other than drug use.

d. Ability for Self-Care: The adolescent is experiencing mild to moderate impairment in ability to manage the activities of daily living, and thus requires frequent monitoring and treatment interventions. Problems may involve poor hygiene secondary to exacerbation of a chronic mental illness, poor self-care, or lack of independent living skills in an older adolescent who is transitioning to adulthood, or in a younger adolescent who lacks adequate family supports.

e. Course of Illness: The adolescent’s history and present situation suggest that an emotional, behavioral, or cognitive condition would become unstable without frequent monitoring and maintenance. For example, he or she may require frequent prompting and monitoring of medication adherence (in an adolescent with a history of medication non-adherence) or frequent prompting and monitoring of behavioral adherence (in an adolescent with a conduct disorder or other serious pattern of delinquent behavior).

Results for Criteria Code 0214

DIMENSION 4: Readiness to Change

The adolescent’s status in Dimension 4 is characterized by (a) or (b):

a. The adolescent requires structured therapy and a programmatic milieu to promote progress through the stages of change, as evidenced by behaviors such as the following: (1) the adolescent is verbally compliant, but does not demonstrate consistent behaviors; (2) the adolescent is only passively involved in treatment; or (3) the adolescent demonstrates variable adherence with attendance at outpatient sessions or self or mutual help meetings or support groups. Such interventions are not feasible or are not likely to succeed in a Level 1 service;
or

b. The adolescent’s perspective inhibits his or her ability to make progress through the stages of change. For example, he or she has unrealistic expectations that the alcohol or other drug problem will resolve quickly and with little or no effort, or does not recognize the need for continued assistance. The adolescent thus requires structured therapy and a programmatic milieu. Such interventions are not feasible or are not likely to succeed in a Level 1 service.

Results for Criteria Code 0215

DIMENSION 5: Relapse, Continued Use, or Continued Problem Potential

The adolescent’s status in Dimension 5 is characterized by (a) or (b):

a. Although the adolescent has been an active participant at a less intensive level of care, he or she is experiencing an intensification of symptoms of the substance-related disorder (such as difficulty postponing immediate gratification and related drug-seeking behavior) and his or her level of functioning is deteriorating despite modification of the treatment plan;
or

b. There is a high likelihood that the adolescent will continue to use or relapse to use of alcohol and/or other drugs or gambling without close outpatient monitoring and structured therapeutic services, as indicated by his or her lack of awareness of relapse triggers, difficulty in coping, or in postponing immediate gratification or ambivalence toward treatment. The adolescent has unsuccessfully attempted treatment at a less intensive level of care, or such treatment is adjudged insufficient to stabilize the adolescent’s condition so that direct admission to Level 2.1 is indicated.

Results for Criteria Code 0216

DIMENSION 6: Recovery Environment

The adolescent’s status in Dimension 6 is characterized by (a) or (b) or (c):

a. Continued exposure to the adolescent’s current school, work, or living environment will render recovery unlikely. The adolescent lacks the resources or skills necessary to maintain an adequate level of functioning without the services of a Level 2.1 program;

or

b. The adolescent lacks social contacts, has unsupportive social contacts that jeopardize recovery, or has few friends or peers who do not use alcohol or other drugs. He or she also lacks the resources or skills necessary to maintain an adequate level of functioning without Level 2.1 services.

or

c. In addition to the characteristics for all programs, a third option is that the adolescent’s family or caretakers are supportive of recovery, but family conflicts and related family dysfunction impede the adolescent’s ability to learn the skills necessary to achieve and maintain abstinence.

NOTE: The adolescent may require Level 2.1 services in addition to an out-of-home placement (for example, at Level 3.1 or the equivalent, such as a group home or a non-treatment residential setting such as a detention program). If his or her present environment is supportive of recovery but does not provide sufficient addiction-specific services to foster and sustain recovery goals, the adolescent’s needs in Dimension 6 may be met through an out-of-home placement, while other dimensional criteria would indicate the need for care in a Level 2.1 program.

Results for Criteria Code 0251

DIMENSION 1: Acute Intoxication and/or Withdrawal Potential

The adolescent who is appropriately placed in a Level 2.5 program is experiencing acute or subacute withdrawal, marked by mild symptoms that are diminishing (as during the first several weeks of abstinence following a period of more severe acute withdrawal).

Withdrawal rating scale tables and flow sheets (which may include tabulation of vital signs) are used as needed.

The adolescent is likely to attend, engage, and participate in treatment, as evidenced by meeting the following criteria:

a. The adolescent is able to tolerate mild withdrawal symptoms.

b. He or she has made a commitment to sustain treatment and to follow treatment recommendations.

c. The adolescent has external supports (as from family and/or court) that promote treatment engagement.

Drug-specific examples follow:

a. Alcohol: Mild withdrawal; no need for sedative/hypnotic substitution therapy; no hyperdynamic state; CIWA-Ar score of ≤6; no significant history of regular morning drinking; the adolescent’s symptoms are stabilized and he or she is comfortable by the end of each day’s active treatment or monitoring.

b. Sedative/hypnotics: Mild withdrawal; the adolescent may have a history of near-daily sedative/hypnotic use, but no cross-dependence on other substances; no disturbance of vital signs; no unstable complicating exacerbation of affective disturbance; no need for sedative/hypnotic substitution therapy; the adolescent’s symptoms are stabilized, and he or she is comfortable by the end of each day’s active treatment or monitoring.

c. Opiates: Mild withdrawal; the adolescent may need over-the-counter medications for symptomatic relief, but does not need prescription medications or opiate agonist substitution therapy; he or she is comfortable by the end of each day’s active treatment or monitoring. The adolescent has sufficient impulse control, coping skills, and/or supports to prevent immediate continued use beyond the active treatment day.

d. Stimulants: Mild to moderate withdrawal (for example, involving depression, lethargy, or agitation), so that the adolescent is likely to need frequent contact and/or higher intensity services to tolerate symptoms, engage in treatment, and bolster external supports. The adolescent has sufficient impulse control, coping skills, and/or supports to prevent immediate continued use beyond the active treatment day.

e. Inhalants: Mild subacute intoxication (involving cognitive impairment, lethargy, agitation, and depression), such that the adolescent is likely to need frequent contact and/or higher intensity services to tolerate symptoms, engage in treatment, and bolster external supports. The adolescent has sufficient impulse control, coping skills, and/or supports to prevent immediate continued use beyond the active treatment day.

f. Marijuana: Moderate withdrawal (involving irritability, general malaise, inner agitation, and sleep disturbance) or sustained subacute intoxication (involving cognitive disorganization, memory impairment, and executive dysfunction), such that the adolescent is likely to need frequent contact and/or higher intensity services to tolerate symptoms, engage in treatment, and bolster external supports.

g. Hallucinogens: Mild chronic intoxication (involving mild perceptual distortion, mild suspiciousness, or mild affective instability). The adolescent has sufficient compensatory coping skills to support engagement in treatment.

Results for Criteria Code 0252

DIMENSION 2: Biomedical Conditions and Complications

The adolescent’s biomedical conditions and problems are severe enough to distract from recovery and treatment at a less intensive level of care, but will not interfere with recovery at Level 2.5. Examples include unstable diabetes or asthma requiring medication adjustment, or physical disabilities that distract from recovery efforts.

Such problems require medical monitoring and/or medical management, which can be provided by a Level 2.5 program either directly or through an arrangement with another treatment provider.

Results for Criteria Code 0253

DIMENSION 3: Emotional, Behavioral, or Cognitive Conditions and Complications

The adolescent’s status in Dimension 3 is characterized by at least one of the following:

a. Dangerousness/Lethality: The adolescent is at mild risk of behaviors endangering self, others, or property (for example, he or she has suicidal or homicidal thoughts, but no active plan), and requires frequent monitoring to assure that there is a reasonable likelihood of safety between PHP sessions. However, his or her condition is not so severe as to require 24-hour supervision.

b. Interference with Addiction Recovery Efforts: The adolescent’s recovery efforts are negatively affected by an emotional, behavioral, or cognitive problem, which causes moderate interference with, and requires increased intensity to support, treatment participation and/or adherence. For example, cognitive impairment or significant attention deficit hyperactivity disorder prevents achievement of recovery tasks or goals.

c. Social Functioning: The adolescent’s symptoms are causing mild to moderate difficulty in social functioning (involving family, friends, school, or work), but not to such a degree that the adolescent is unable to manage the activities of daily living or to fulfill responsibilities at home, school, work, or community. For example, the adolescent’s problems may involve recent arrests or legal charges, or non-adherence with probation, progressive school suspensions or truancy, risk of failing the school year, regular intoxication at school or work, involvement in drug trafficking, or a pattern of intentional property damage.

Alternatively, the adolescent may be transitioning back to the community as a step down from an institutionalized setting.

d. Ability for Self-Care: The adolescent is experiencing moderate impairment in ability to manage the activities of daily living, and thus requires near-daily monitoring and treatment interventions. Problems may involve disorganization and inability to manage the demands of daily self-scheduling, a progressive pattern of promiscuous or unprotected sexual contacts, or poor vocational or prevocational skills that require habilitation and training provided in the program.

e. Course of Illness: The adolescent’s history and present situation suggest that an emotional, behavioral, or cognitive condition would become unstable without daily or near-daily monitoring and maintenance. For example, signs of imminent relapse may indicate a need for near-daily monitoring of an adolescent with attention deficit hyperactivity disorder and a history of disorganization that becomes unmanageable in school with substance use; or an initial lapse indicates a need for near-daily monitoring in an adolescent whose conduct disorder worsens dangerously within the context of progressive use.

Results for Criteria Code 0254

DIMENSION 4: Readiness to Change

The adolescent’s status in Dimension 4 is characterized by (a) or (b):

a. The adolescent requires structured therapy and a programmatic milieu to promote treatment progress and recovery because motivational interventions at another level of care have failed. Such interventions are not feasible or are not likely to succeed in a Level 2.1 program;
or

b. The adolescent’s perspective and lack of impulse control inhibit his or her ability to make behavioral changes without repeated, structured, clinically directed motivational interventions. (For example, the adolescent has unrealistic expectations that his or her alcohol, other drug, or mental health problem will resolve quickly, with little or no effort, or the adolescent experiences frequent impulses to harm himself or herself. He or she is willing to reach out but lacks the ability to ask for help.) Such interventions are not feasible or are not likely to succeed in a Level 1 or Level 2.1 program. However, the adolescent’s willingness to participate in treatment and to explore his or her level of awareness and readiness to change suggest that treatment at Level 2.5 can be effective.

Results for Criteria Code 0255

DIMENSION 5: Relapse, Continued Use, or Continued Problem Potential

The adolescent’s status in Dimension 5 is characterized by (a) or (b):

a. The adolescent is at high risk of relapse or continued use without almost daily outpatient monitoring and structured therapeutic services (as indicated, for example, by susceptibility to relapse triggers, a pattern of frequent or progressive lapses, inability to overcome the momentum of a pattern of habitual use, difficulty in overcoming a pattern of impulsive behaviors, or ambivalence about or disinterest in treatment). Also, treatment at a less intensive level of care has been attempted or given serious consideration and been judged insufficient to stabilize the adolescent’s condition;
or

b. The adolescent demonstrates impaired recognition and understanding of relapse or continued use issues. He or she has such poor skills in coping with and interrupting substance use problems, and avoiding or limiting relapse, that the near-daily structure afforded by a Level 2.5 program is needed to prevent or arrest significant deterioration in function.

Results for Criteria Code 0256

DIMENSION 6: Recovery Environment

The adolescent’s status in Dimension 6 is characterized by (a) or (b) or (c):

a. Continued exposure to the adolescent’s current school, work, or living environment will render recovery unlikely. The adolescent lacks the resources or skills necessary to maintain an adequate level of functioning without the services of a Level 2.5 program;
or

b. Family members and/or significant other(s) who live with the adolescent are not supportive of his or her recovery goals, or are passively opposed to his or her treatment. The adolescent requires the intermittent structure of Level 2.5 treatment services and relief from the home environment in order to remain focused on recovery, but may live at home because there is no active opposition to, or sabotaging of, his or her recovery efforts;
or

c. The adolescent lacks social contacts, or has high-risk social contacts that jeopardize recovery, or has few friends or peers who do not use alcohol or other drugs. He or she also has insufficient (or severely limited) resources or skills necessary to maintain an adequate level of functioning without the services of a Level 2.5 program, but is capable of maintaining an adequate level of functioning between sessions.

The adolescent may require Level 2.5 services in addition to an out-of-home placement (for example, at Level 3.1 or the equivalent, such as a group home or a non-treatment residential setting such as a detention program). If his or her present environment is supportive of recovery but does not provide sufficient addiction-specific services to foster and sustain recovery goals, the adolescent’s needs in Dimension 6 may be met through an out-of-home placement, while other dimensional criteria would indicate the need for care in a Level 2.5 program.

Results for Criteria Code 0351

DIMENSION 1: Acute Intoxication and/or Withdrawal Potential

The adolescent’s status in Dimension 1 is characterized by the following:

The adolescent is at risk of or experiencing acute or subacute intoxication or withdrawal, with mild to moderate symptoms. He or she needs secure placement and increased treatment intensity (without frequent access to medical or nursing services) to support engagement in treatment, ability to tolerate withdrawal, and prevention of immediate continued use. Alternatively, the adolescent has a history of failure in treatment at the same or a less intensive level of care.

Problems with intoxication or withdrawal are manageable at this level of care.

Withdrawal rating scale tables and flow sheets (which may include tabulation of vital signs) are used as needed.

Drug-specific examples follow:

a. Alcohol: Mild acute withdrawal or moderate subacute withdrawal, with symptoms that require 24-hour support, extended monitoring, and non-pharmacological management; no abnormal vital signs; no need for sedative/hypnotic substitution withdrawal management; a CIWA -Ar score of <8; no significant history of regular morning drinking.

b. Sedative/hypnotics: Mild to moderate withdrawal, with symptoms that require 24-hour support and extended monitoring; may have a recent history of low-level daily sedative/hypnotic use, but no cross-dependence on other substances; may have a need for extended agonist substitution therapy, but only with a stable taper regimen in the context of a step down from a more intensive level of care, where the regimen has been titrated and established; no abnormal vital signs; no unstable complicating exacerbation of affective disorder.

c. Opiates: Mild to moderate withdrawal, with symptoms requiring 24-hour support and extended monitoring and non-pharmacological or over-the-counter medication for symptomatic relief; no need for prescription pharmacological treatments or agonist substitution therapy.

With the high craving states typical of opioid withdrawal, the adolescent may require 24-hour secure placement and increased intensity of treatment because of lack of sufficient impulse control, coping skills, or supports to prevent immediate continued use.

d. Stimulants: Mild to moderate to severe withdrawal (involving lethargy, apathy, agitation, depression, suspiciousness, fearfulness, or hypervigilance) of sufficient intensity that the patient needs 24-hour secure placement and increased intensity of treatment to support the ability to tolerate symptoms, support treatment engagement, and bolster external supports.

With the high craving states typical of stimulant withdrawal, the adolescent may require 24-hour secure placement and increased intensity of treatment because of lack of sufficient impulse control, coping skills, or supports to prevent immediate continued use.

e. Inhalants: Moderate subacute intoxication (involving cognitive impairment, lethargy, agitation, and depression) of sufficient intensity that the patient needs 24-hour secure placement and increased treatment intensity to support the ability to tolerate symptoms, support engagement in treatment, and bolster external supports.

f. Marijuana: Moderate to severe withdrawal symptoms (involving irritability, general malaise, inner agitation, severe sleep disturbance, and severe craving) or sustained susceptibility, subacute intoxication states (involving cognitive disorganization, memory impairment, executive dysfunction, and the like), such that the patient needs 24-hour secure placement and increased treatment intensity to support the adolescent’s ability to tolerate symptoms, support engagement in treatment, and bolster external supports. The patient may be using or likely to use marijuana in order to relieve withdrawal from other substances, and may need secure placement to prevent immediate continued use.

g. Hallucinogens: Moderate to severe chronic intoxication (involving perceptual distortion, moderate non-delusional suspiciousness, moderate affective instability, and the like), which requires 24-hour secure placement and increased intensity of treatment to support the adolescent’s ability to tolerate symptoms, support engagement in treatment, and bolster external supports.

Results for Criteria Code 0353

DIMENSION 3: Emotional, Behavioral, or Cognitive Conditions and Complications

The adolescent’s status in Dimension 3 is characterized by at least one of the following (requiring 24-hour supervision and a medium-intensity therapeutic milieu):

a. Dangerousness/Lethality: The adolescent is at moderate but stable risk of imminent harm to self or others, and needs medium-intensity 24-hour monitoring and/or treatment for protection and safety. However, he or she does not require access to medical or nursing services.

b. Interference with Addiction Recovery Efforts: The adolescent’s recovery efforts are negatively affected by his or her emotional, behavioral, or cognitive problems in significant and distracting ways. He or she requires 24-hour structured therapy and/or a programmatic milieu to promote sustained focus on recovery tasks because of active symptoms.

c. Social Functioning: The adolescent has significant impairments, with moderate to severe symptoms (such as poor impulse control, disorganization, and the like). These seriously impair his or her ability to function in family, social, school, or work settings, and cannot be managed at a less intensive level of care. This might involve, for example, a recent history of high-risk runaway behavior, inability to resist antisocial peer influences, a need for consistent boundaries unavailable in the home environment, or inability to sustain school attendance, and the like.

d. Ability for Self-Care: The adolescent has moderate impairment in his or her ability to manage the activities of daily living and thus requires 24-hour supervision and staff assistance, which can be provided by the program. The adolescent’s impairments may involve a need for intensive modeling and reinforcement of personal grooming and hygiene, a pattern of continuing indiscriminate or unprotected sexual contacts in an adolescent with a history of sexually transmitted diseases, moderate dilapidation and self-neglect in the context of advanced alcohol or drug dependence, a need for intensive teaching of personal safety techniques in an adolescent who has suffered physical or sexual assault, and the like.

e. Course of Illness: The adolescent’s history and present situation suggest that an emotional, behavioral, or cognitive condition would become unstable without 24-hour supervision and a medium-intensity structured programmatic milieu. These may involve, for example, an adolescent whose substance use has been associated with a dangerous pattern of criminal or delinquent behaviors and who needs monitoring to assess safety and the likelihood of successful treatment on an outpatient basis before being returned to the community following release from a juvenile justice setting, or an adolescent with a recent lapse or relapse, whose history suggests that this is likely to result in disruptive behavior that will impede participation in treatment at a less intensive level of care, and the like.

Results for Criteria Code 0354

DIMENSION 4: Readiness to Change

The adolescent’s status in Dimension 4 is characterized by at least one of the following:

a. Because of the intensity and chronicity of the addictive disorder or the adolescent’s mental health problems, he or she has limited insight into and little awareness of the need for continuing care or the existence of his or her substance use or mental health problem and need for treatment, and thus has limited readiness to change;

or

b. Despite experiencing serious consequences or effects of the addictive disorder or mental health problem, the adolescent has marked difficulty in understanding the relationship between his or her substance use, addiction, mental health, or life problems and his or her impaired coping skills and level of functioning, often blaming others for his or her addiction problems;

or

c. The adolescent demonstrates passive or active opposition to addressing the severity of his or her mental health problem or addiction, or does not recognize the need for treatment. Such continued substance use or inability to follow through with mental health treatment poses a danger of harm to self or others. However, assessment indicates that treatment interventions available at Level 3.5 may increase the patient’s degree of readiness to change;

or

d. The adolescent requires structured therapy and a 24-hour programmatic milieu to promote treatment progress and recovery, because motivational interventions have not succeeded at less intensive levels of care and such interventions are assessed as not likely to succeed at a less intensive level of care;

or

e. The adolescent’s perspective impairs his or her ability to make behavior changes without repeated, structured, clinically directed motivational interventions, which will enable him/her to develop insight into the role he or she plays in his or her substance use and/or mental condition, and empower him/her to make behavioral changes, which can only be delivered in a 24-hour milieu;

or

f. Despite recognition of a substance use or addictive behavior problem and understanding of the relationship between his or her substance use, addiction, and life problems, the patient expresses little to no interest in changing. Because of the intensity or chronicity of the adolescent’s addictive disorder and high-risk criminogenic needs, he or she is in imminent danger of continued substance use or addictive behavior. This poses imminent serious life consequences (ie, imminent risk to public safety or imminent abuse or neglect of children) and/or a continued pattern of risk of harm to others (ie, extensive pattern of assaults, burglaries) while under the influence of substances;

or

g. The adolescent attributes his or her alcohol, drug, addictive, or mental health problem to other persons or external events, rather than to a substance use or addictive or mental disorder. The adolescent requires clinical, directed motivation interventions that will enable him or her to develop insight into the role he/she plays in his or her health condition, and empower him or her to make behavioral changes. Interventions are adjudged as not feasible or unlikely succeed at a less intensive level of care.

Results for Criteria Code 0355

DIMENSION 5: Relapse, Continued Use, or Continued Problem Potential

The adolescent’s status in Dimension 5 is characterized by at least one of the following:

a. The adolescent does not recognize relapse triggers and lacks insight into the benefits of continuing care, and is therefore not committed to treatment. His or her continued substance use poses an imminent danger of harm to self or others in the absence of 24-hour monitoring and structured support;

or

b. The adolescent’s psychiatric condition is stabilizing. However, despite his or her best efforts, the adolescent is unable to control his or her use of alcohol, other drugs, and/or antisocial behaviors, with attendant probability of harm to self or others. The adolescent has limited ability to interrupt the relapse process or continued use, or to use peer supports when at risk for relapse to his or her addiction or mental disorder. His or her continued substance use poses an imminent danger of harm to self or others in the absence of 24-hour monitoring and structured support;

or

c. The adolescent is experiencing psychiatric or addiction symptoms such as drug craving, insufficient ability to postpone immediate gratification, and other drug-seeking behaviors. This situation poses an imminent danger of harm to self or others in the absence of close 24-hour monitoring and structured support. The introduction of psychopharmacologic support is indicated to decrease psychiatric or addictive symptoms, such as cravings, that will enable the patient to delay immediate gratification and reinforce positive recovery behaviors;

or

d. The adolescent is in imminent danger of relapse or continued use, with dangerous emotional, behavioral, or cognitive consequences, as a result of a crisis situation;

or

e. Despite recent, active participation in treatment at a less intensive level of care, the adolescent continues to use alcohol or other drugs, or to deteriorate psychiatrically, with imminent serious consequences, and is at high risk of continued substance use or mental deterioration in the absence of close 24-hour monitoring and structured treatment;

or

f. The adolescent demonstrates a lifetime history of repeated incarceration with a pattern of relapse to substances and uninterrupted use outside of incarceration, with imminent risk of relapse to addiction or mental health problems and recidivism to criminal behavior (for example, extensive and recurrent pattern of crimes such as burglary, assault, robbery). This poses imminent risk of harm to self or others. The adolescent’s imminent danger of relapse is accompanied by an uninterrupted cycle of relapse-reoffending-incarceration-release-relapse without the opportunity for treatment. The adolescent requires 24-hour monitoring and structure to assist in the initiation and application of recovery and coping skills.

Results for Criteria Code 0356

DIMENSION 6: Recovery Environment

The adolescent’s status in Dimension 6 is characterized by at least one of the following:

a. The adolescent has been living in an environment in which there is a high risk of neglect, or initiation or repetition of physical, sexual, or severe, emotional abuse, such that the patient is assessed as being unable to achieve or maintain recovery without residential treatment.

or

b. The adolescent has a family or other household member who has an active substance use disorder, or substance use is endemic in his or her home environment or broader social network, so that recovery goals are assessed as unachievable without residential treatment.

or

c. The adolescent’s home environment or social network is too chaotic or ineffective to support or sustain treatment goals, so that recovery is assessed as unachievable without residential treatment. For example, the adolescent’s family reinforces antisocial norms and values, or the family cannot sustain treatment engagement or school attendance, or the family is experiencing significant social isolation or withdrawal.

or

d. Logistical impediments (such as distance from a treatment facility, mobility limitations, lack of transportation, and the like) preclude participation in treatment at a less intensive level of care.

Results for Criteria Code 0371

DIMENSION 1: Acute Intoxication and/or Withdrawal Potential

The adolescent’s status in Dimension 1 is characterized by the following:

The adolescent is experiencing or at risk of acute or subacute intoxication or withdrawal, with moderate to severe signs and symptoms. He or she needs 24-hour treatment services, including the availability of active medical and nursing monitoring to manage withdrawal, support engagement in treatment, and prevent immediate continued use. Alternatively, the adolescent has a history of failure in treatment at the same or a less intensive level of care.

Problems with intoxication or withdrawal are manageable at this level of care.

Withdrawal rating scale tables and flow sheets (which may include tabulation of vital signs) are used as needed.

Drug-specific examples follow:

a. Alcohol: Moderate withdrawal, with significant symptoms that require access to nursing and medical monitoring. The patient may have a history of daily drinking or drinking to self-medicate withdrawal, or regular morning drinking. He or she may require sedative/hypnotic substitution therapy, but typically this can be managed with a standing taper without the need for extensive titration.

b. Sedative/hypnotics: Moderate withdrawal, with significant symptoms that require access to nursing and medical monitoring. The adolescent may be cross-dependent on other substances and may require withdrawal management with tapering substitute agonist therapy and/or pharmacological management of symptoms.

c. Opiates: Moderate to severe withdrawal, usually in the context of daily opiate use. The patient requires access to nursing and medical monitoring, may require use of prescription medications or agonist substitution therapy, and may need monitoring for induction of antagonist therapy (as with naltrexone). Severe craving states or affective instability typical of withdrawal may require high-intensity 24-hour treatment to support engagement.

d. Stimulants: Severe withdrawal (involving sustained affective or behavioral disturbances or mild psychotic symptoms), which requires access to nursing and medical monitoring. Severe craving states or affective instability typical of withdrawal may require high-intensity 24-hour treatment to support engagement.

e. Inhalants: Severe subacute intoxication (involving mild delirium or other serious cognitive impairment, lethargy, agitation, and depression) of sufficient intensity that the patient requires access to nursing and medical monitoring.

f. Marijuana: Severe sustained intoxication (involving mild psychosis, coarse cognitive disorganization, agitation, and the like), which requires access to nursing and medical monitoring.

g. Hallucinogens: Severe chronic intoxication (involving mild delirium, mild psychosis, agitation, moderate to severe affective instability, cognitive disorganization, and the like), which requires access to nursing and medical monitoring.

Results for Criteria Code 0372

DIMENSION 2: Biomedical Conditions and Complications

The adolescent’s status in Dimension 2 is characterized by one of the following:

a. The interaction of the adolescent’s biomedical condition and continued alcohol and/or other drug use places the adolescent at significant risk of serious damage to physical health or concomitant biomedical conditions (such as pregnancy with vaginal bleeding or ruptured membranes, unstable diabetes or asthma, etc.);

or

b. A current biomedical condition requires 24-hour nursing and medical monitoring or active treatment, but not the full resources of an acute care hospital.

Biomedical Enhanced Services

The adolescent who has a biomedical problem that requires a degree of staff attention (such as monitoring of medications or assistance with mobility) or staff intervention (such as changes in medication) that is not available in other Level 3.7 programs is in need of biomedical enhanced services.

Results for Criteria Code 0373

DIMENSION 3: Emotional, Behavioral, or Cognitive Conditions and Complications

The adolescent’s status in Dimension 3 is characterized by at least one of the following (requiring 24-hour supervision and a high-intensity therapeutic milieu, with access to nursing and medical monitoring and treatment):

a. Dangerousness/Lethality: The adolescent is at moderate (and possibly unpredictable) risk of imminent harm to self or others and needs 24-hour monitoring and/or treatment in a high-intensity programmatic milieu and/or enforced secure placement for safety.

b. Interference with Addiction Recovery Efforts: The adolescent’s recovery efforts are negatively affected by his or her emotional, behavioral, or cognitive problems in significant and distracting ways. He or she requires 24-hour structured therapy and/or a high-intensity programmatic milieu to stabilize unstable emotional or behavioral problems (as through ongoing medical or nursing evaluation, behavior modification, titration of medications, and the like).

c. Social Functioning: The adolescent has significant impairments, with severe symptoms (such as poor impulse control, disorganization, and the like), which seriously impair his or her ability to function in family, social, school, or work settings and which cannot be managed at a less intensive level of care. These might involve a recent history of aggressive or severely disruptive behavior, severe inability to manage peer conflict, a recurrent or chronic pattern of runaway behavior requiring enforced confinement, and the like.

d. Ability for Self-Care: The adolescent has a significant lack of personal resources and moderate to severe impairment in ability to manage the activities of daily living. He or she thus needs 24-hour supervision and significant staff assistance, including access to nursing or medical services. The adolescent’s impairments may involve progressive and severe dilapidation and self-neglect in the context of advanced substance use disorder, the need for observation after eating to prevent self-induced vomiting, the need for intensive reinforcement of medication adherence, the need for intensive modeling of adequate self-care during pregnancy, the need for intensive training for self-care in a cognitively impaired patient, and the like.

e. Course of Illness: The adolescent’s history and present situation suggest that an emotional, behavioral, or cognitive condition would become unstable without 24-hour supervision and a high-intensity structured programmatic milieu, with access to nursing or medical monitoring or treatment. These may be required to treat an adolescent who, for example, requires secure placement or enforced abstinence for reinstatement or titration of a pharmacological treatment regimen; or an adolescent whose substance use has been associated with a dangerous pattern of aggressive/violent behaviors and who needs monitoring to assess safety and likelihood of outpatient treatment success before returning to the community following release from a juvenile justice setting; or an adolescent who requires intensive monitoring or treatment because ongoing substance use prevents adequate or safe treatment or diagnostic clarification for an emotional, behavioral, or cognitive condition that may or may not be substance-induced; or an adolescent whose history suggests rapid escalation of dangerousness/lethality when using alcohol or drugs and who is in relapse or at imminent risk of relapse.

Results for Criteria Code 1211

DIMENSION 1:  Acute Intoxication and/or Withdrawal Potential.

All Programs

The patient has no signs or symptoms of withdrawal, or his or her withdrawal needs can be safely managed in a Level 2.1 setting. See separate withdrawal management chapter for how to approach “unbundled” withdrawal management for adults.   

Results for Criteria Code 1212

DIMENSION 2:   Biomedical Conditions and Complications.

All Programs

In Dimension 2, the patient’s biomedical conditions and problems, if any, are stable or are being addressed concurrently and thus will not interfere with treatment. Examples include mild pregnancy-related hypertension, asthma, hypertension, or diabetes.  

Results for Criteria Code 1213

DIMENSION 3: Emotional, Behavioral, or Cognitive Conditions and Complications .

All Programs

Problems in Dimension 3 are not necessary for admission to a Level 2.1 program. However, if any of the Dimension 3 conditions are present, the patient must be admitted to either a co-occurring capable or co-occurring enhanced program, depending on the patient’s level of function, stability, and degree of impairment in this dimension.

Co-Occurring Capable Programs

The patient’s status in Dimension 3 is characterized by (a) or (b):

a. The patient engages in abuse of family members or significant others, and requires intensive outpatient treatment to reduce the risk of further deterioration; or

b. The patient has a diagnosed emotional, behavioral, or cognitive disorder that requires intensive outpatient monitoring to minimize distractions from his or her treatment or recovery.

Co-Occurring Enhanced Programs

The patient’s status in Dimension 3 is characterized by (a) or (b) or (c):

a. The patient has a diagnosed emotional, behavioral, or cognitive disorder that requires management because the patient’s history suggests a high potential for distraction from treatment; such a disorder requires stabilization concurrent with addiction treatment (for example, an unstable borderline personality disorder, compulsive personality disorder, unstable anxiety, or mood disorder);

or

b. The patient is assessed as at mild risk of behaviors endangering self, others, or property (for example, he or she has suicidal or homicidal thoughts but no active plan);

or

c. The patient is at significant risk of victimization by another. However, the risk is not severe enough to require 24-hour supervision (for example, the patient has sufficient coping skills to maintain safety through attendance at treatment sessions at least 9 or more hours per week).

Results for Criteria Code 1214

DIMENSION 4: Readiness to Change

All Programs

The patient’s status in Dimension 4 is characterized by (a) or (b):

a. The patient requires structured therapy and a programmatic milieu to promote treatment progress and recovery because motivational interventions at another level of care have failed. Such interventions are not feasible or are not likely to succeed in a Level 1 program;

or

b. The patient’s perspective inhibits his or her ability to make behavioral changes without repeated, structured, clinically directed motivational interventions. (For example, the patient attributes his or her alcohol or other drug and mental health problems to other persons or external events rather than to an addictive or mental disorder.) Such interventions are not feasible or are not likely to succeed in a Level 1 program. However, the patient’s willingness to participate in treatment and to explore his or her level of awareness and readiness to change suggest that treatment at Level 2.1 can be effective.

Co-Occurring Enhanced Programs

The patient’s status in Dimension 4 is characterized by meeting criteria for all programs and (a); and one of (b) or (c):

a. The patient is reluctant to agree to treatment and is ambivalent about his or her commitment to change a co-occurring mental health problem;

and

b. The patient is assessed as requiring intensive services to improve his or her awareness of the need to change. The patient has such limited awareness of or commitment to change that he or she cannot maintain an adequate level of functioning without Level 2.1 services. For example, the patient continues to experience mild to moderate depression, anxiety, or mood swings, and is inconsistent in taking medication, keeping appointments, and completing mental health assignments;

or

c. The patient’s follow through in treatment is so poor or inconsistent that Level 1 services are not succeeding or are not feasible.

Results for Criteria Code 1215

DIMENSION 5: Relapse, Continued Use, or Continued Problem Potential.

All Programs

The patient’s status in Dimension 5 is characterized by (a) or (b):

a. Although the patient has been an active participant at a less intensive level of care, he or she is experiencing an intensification of symptoms of the substance-related disorder (such as difficulty postponing immediate gratification and related drug-seeking behavior) and his or her level of functioning is deteriorating despite modification of the treatment plan;

or

b. There is a high likelihood that the patient will continue to use or relapse to use of alcohol and/or other drugs or gambling without close outpatient monitoring and structured therapeutic services, as indicated by his or her lack of awareness of relapse triggers, difficulty in coping, or in postponing immediate gratification or ambivalence toward treatment. The patient has unsuccessfully attempted treatment at a less intensive level of care, or such treatment is adjudged insufficient to stabilize the patient’s condition so that direct admission to Level 2.1 is indicated.

Co-Occurring Enhanced Programs

The patient’s status in Dimension 5 is characterized by psychiatric symptoms that pose a moderate risk of relapse to the alcohol, other drug, or other addictive or psychiatric disorder.

Such a patient has impaired recognition or understanding of—and difficulty in managing—relapse issues, and requires Level 2.1 co-occurring enhanced program services to maintain an adequate level of functioning. For example, the patient may have chronic difficulty in controlling his or her anger, with impulses to damage property, or the patient continues to increase his or her medication dose beyond the prescribed level in an attempt to control continued symptoms of anxiety or panic.

Results for Criteria Code 1216

DIMENSION 6: Recovery Environment

All Programs

The patient’s status in Dimension 6 is characterized by (a) or (b):

a. Continued exposure to the patient’s current school, work, or living environment will render recovery unlikely. The patient lacks the resources or skills necessary to maintain an adequate level of functioning without the services of a Level 2.1 program;

or

b. The patient lacks social contacts, has unsupportive social contacts that jeopardize recovery, or has few friends or peers who do not use alcohol or other drugs. He or she also lacks the resources or skills necessary to maintain an adequate level of functioning without Level 2.1 services.

Co-Occurring Enhanced Programs

The patient’s status in Dimension 6 is characterized by a living, working, social, and/or community environment that is not supportive of good mental functioning. The patient has insufficient resources and skills to deal with this situation.

For example, the patient is unable to cope with continuing stresses caused by hostile family members with addiction, and he or she evidences increasing depression and anxiety. The support and structure of a Level 2.1 co-occurring enhanced program provide sufficient stability to prevent further deterioration.

Results for Criteria Code 1251

DIMENSION 1: Acute Intoxication and/or Withdrawal Potential. 

All Programs.

The patient has no signs or symptoms of withdrawal, or his or her withdrawal needs can be safely managed in a Level 2.5 setting. See separate withdrawal management chapter for how to approach “unbundled” withdrawal management for adults.

Results for Criteria Code 1252

DIMENSION 2: Biomedical Conditions and Complications. 

All Programs

In Dimension 2, the patient’s biomedical conditions and problems, if any, are not sufficient to interfere with treatment, but are severe enough to distract from recovery efforts. Examples include unstable hypertension or asthma requiring medication adjustment or chronic back pain that distracts from recovery efforts.

Such problems require medical monitoring and/or medical management, which can be provided by a Level 2.5 program either directly or through an arrangement with another treatment provider.

Results for Criteria Code 1253

DIMENSION 3: Emotional, Behavioral, or Cognitive Conditions and Complications

All Programs

Problems in Dimension 3 are not necessary for admission to a Level 2.5 program. However, if any of the Dimension 3 conditions are present, the patient must be admitted to either a co-occurring capable or co-occurring enhanced program, depending on the patient’s level of function, stability, and degree of impairment in this dimension.

The severity of the patient’s problems in Dimension 3 may require partial hospitalization or a similar supportive living environment in conjunction with a Level 3.1 program. On the other hand, if the patient receives adequate support from his or her family or significant other(s), a Level 2.5 program may suffice.

Co-Occurring Capable Programs
The patient’s status in Dimension 3 is characterized by a history of mild to moderate psychiatric decompensation (marked by paranoia or mild psychotic symptoms) on discontinuation of the drug use. Such decompensation may occur and requires monitoring to permit early intervention.

Co-Occurring Enhanced Programs
The patient’s status in Dimension 3 is characterized by (a) or (b) or (c):

a. The patient evidences current inability to maintain behavioral stability over a 48-hour period (as evidenced by distractibility, negative emotions, or generalized anxiety that significantly affects his or her daily functioning);

or

b. The patient has a history of moderate psychiatric decompensation (marked by severe, non-suicidal depression) on discontinuation of the drug of abuse. Such decompensation is currently observable;

or

c. The patient is at mild to moderate risk of behaviors endangering self, others, or property, and is at imminent risk of relapse, with dangerous emotional, behavioral, or cognitive consequences, in the absence of Level 2.5 structured services. For example, the patient does not have sufficient internal coping skills to maintain safety to self, others, or property without the consistent structure achieved through attendance at treatment sessions daily, or at least 20 hours per week.

Results for Criteria Code 1254

DIMENSION 4: Readiness to Change

All Programs

The patient’s status in Dimension 4 is characterized by (a) or (b):

a. The patient requires structured therapy and a programmatic milieu to promote treatment progress and recovery because motivational interventions at another level of care have failed. Such interventions are not feasible or are not likely to succeed in a Level 2.1 program;
or

b. The patient’s perspective and lack of impulse control inhibit his or her ability to make behavioral changes without repeated, structured, clinically directed motivational interventions. (For example, the patient has unrealistic expectations that his or her alcohol, other drug, or mental health problem will resolve quickly, with little or no effort, or the patient experiences frequent impulses to harm himself or herself. He or she is willing to reach out but lacks ability to ask for help.) Such interventions are not feasible or are not likely to succeed in a Level 1 or Level 2.1 program. However, the patient’s willingness to participate in treatment and to explore his or her level of awareness and readiness to change suggest that treatment at Level 2.5 can be effective.

Co-Occurring Enhanced Programs
The patient’s status in Dimension 4 is characterized by (a); and one of (b) or (c):

a. The patient has little awareness of his or her co-occurring mental disorder;
and

b. The patient is assessed as requiring more intensive engagement, community, or case management services than are available at Level 2.1 in order to maintain an adequate level of functioning (for example, the patient experiences frequent impulses to harm himself or herself, with poor commitment to reach out for help); 
or

c. The patient’s follow through in treatment is so poor or inconsistent that Level 2.1 services are not succeeding or are not feasible.

Results for Criteria Code 1255

DIMENSION 5: Relapse, Continued Use, or Continued Problem Potential

 All Programs
The patient’s status in Dimension 5 is characterized by (a) or (b):

a. Although the patient has been an active participant at a less intensive level of care, he or she is experiencing an intensification of symptoms of the substance-related disorder (such as difficulty postponing immediate gratification and related drug-seeking behavior) and his or her level of functioning is deteriorating despite modification of the treatment plan;
or

b. There is a high likelihood that the patient will continue to use or relapse to use of substances or gambling without close outpatient monitoring and structured therapeutic services, as indicated by his or her lack of awareness of relapse triggers, difficulty in coping or postponing immediate gratification, or ambivalence toward treatment. The patient has unsuccessfully attempted treatment at a less intensive level of care, or such treatment is adjudged insufficient to stabilize the patient’s condition so that direct admission to Level 2.5 is indicated.

Co-Occurring Enhanced Programs
The patient’s status in Dimension 5 is characterized by psychiatric symptoms that pose a high risk of relapse to the substance or psychiatric disorder.

Such a patient has impaired recognition or understanding of relapse issues, and inadequate skills in coping with and interrupting mental disorders and/or avoiding or limiting relapse. Such a patient’s follow through in treatment is so inadequate or inconsistent, and his or her relapse problems are escalating to such a degree, that treatment at Level 2.1 is not succeeding or not feasible.

For example, the patient may continue to inflict superficial wounds on himself or herself and have continuing suicidal ideation and impulses. However, he or she has no specific suicide plan and agrees to reach out for help if seriously suicidal. Or the patient’s continuing substance-induced psychotic symptoms are resolving, but difficulties in controlling his or her substance use exacerbate the psychotic symptoms.

Results for Criteria Code 1256

DIMENSION 6: Recovery Environment.

All Programs
The patient’s status in Dimension 6 is characterized by (a) or (b):

a. Continued exposure to the patient’s current school, work, or living environment will render recovery unlikely. The patient lacks the resources or skills necessary to maintain an adequate level of functioning without the services of a Level 2.5 program;
or

b. Family members and/or significant other(s) who live with the patient are not supportive of his or her recovery goals, or are passively opposed to his or her treatment. The patient requires the intermittent structure of Level 2.5 treatment services and relief from the home environment in order to remain focused on recovery, but may live at home because there is no active opposition to, or sabotaging of, his or her recovery efforts.

Co-Occurring Enhanced Programs
The patient’s status in Dimension 6 is characterized by a living, working, social, and/or community environment that is not supportive of good mental functioning. The patient has such limited resources and skills to deal with this situation that treatment is not succeeding or not feasible.

For example, the patient is unable to cope with continuing stresses caused by homelessness, unemployment, and isolation, and evidences increasing depression and hopelessness. The support and intermittent structure of a Level 2.5 co-occurring enhanced program provide sufficient stability to prevent further deterioration.

Results for Criteria Code 1351

DIMENSION 1: Acute Intoxication and/or Withdrawal Potential

All Programs
The patient has no signs or symptoms of withdrawal, or his or her withdrawal needs can be safely managed in a Level 3.5 setting. See separate withdrawal management chapter for how to approach “unbundled” withdrawal management for adults.

NOTE: A patient who is being transferred from a Level 3.7 program should not require medically managed or monitored withdrawal management services.

Results for Criteria Code 1352

DIMENSION 2: Biomedical Conditions and Complications

All Programs
The patient’s status in Dimension 2 is characterized by one of the following:

a. Biomedical problems, if any, are stable and do not require 24-hour medical or nurse monitoring, and the patient is capable of self-administering any prescribed medications;
or

b. A current biomedical condition is not severe enough to warrant inpatient treatment but is sufficient to distract from treatment or recovery efforts. The problem requires medical monitoring, which can be provided by the program or through an established arrangement with another provider.

Biomedical Enhanced Services
The patient is in need of biomedical enhanced services if he or she has a biomedical problem that requires a degree of staff attention (such as monitoring of adherence to medications or assistance with mobility) that is not available in other Level 3.5 programs.

Results for Criteria Code 1353

DIMENSION 3: Emotional, Behavioral, or Cognitive Conditions and Complications

If any of the Dimension 3 conditions are present, the patient must be admitted to a co-occurring capable or co-occurring enhanced program (depending on his or her level of function, stability, and degree of impairment).

Co-Occurring Capable Programs
The patient’s status in Dimension 3 is characterized by (a); and one of (b) or (c) or (d) or (e) or (f):

a. The patient’s mental status (including emotional stability and cognitive functioning) is assessed as sufficiently stable to permit the patient to participate in the therapeutic interventions provided at this level of care and to benefit from treatment.
and

b. The patient’s psychiatric condition is stabilizing. However, despite his or her best efforts, the patient is unable to control his or her use of alcohol, tobacco, and/or other drugs and/or antisocial behaviors, with attendant probability of imminent danger. The resulting level of dysfunction is so severe that it precludes the patient’s participation in a less structured and intensive level of care;
or

c. The patient demonstrates repeated inability to control his or her impulses to use alcohol and/or other drugs and/or to engage in antisocial behavior, and is in imminent danger of relapse, with attendant likelihood of harm to self, others, or property. The resulting level of dysfunction is of such severity that it precludes participation in treatment in the absence of the 24-hour support and structure of a Level 3.5 program;
or

d. The patient demonstrates antisocial behavior patterns (as evidenced by criminal activity) that have led or could lead to significant criminal justice problems, lack of concern for others, and extreme lack of regard for authority (expressed through distrust, conflict, or opposition), and which prevents movement toward positive change and precludes participation in a less structured and intensive level of care;
or

e. The patient has significant functional deficits, which are likely to respond to staff interventions. These symptoms and deficits, when considered in the context of his or her home environment, are sufficiently severe that the patient is not likely to maintain mental stability and/or abstinence if treatment is provided in a non-residential setting. The functional deficits are of a pervasive nature, requiring treatment that is primarily habilitative in focus; they do not require medical monitoring or management. They may include—but are not limited to—residual psychiatric symptoms, chronic addictive disorder, history of criminality, marginal intellectual ability, limited educational achievement, poor vocational skills, inadequate anger management skills, poor impulse control, and the sequelae of physical, sexual, or emotional trauma. These deficits may be complicated by problems in Dimensions 2 through 6;
or

f. The patient’s concomitant personality disorders (eg, antisocial personality disorder with verbal aggressive behavior requiring consistent limit-setting) are of such severity that the accompanying dysfunctional behaviors provide opportunities to promote continuous boundary setting interventions.

Co-Occurring Enhanced Programs
The patient’s status in Dimension 3 is characterized by a range of psychiatric symptoms that require active monitoring, such as low anger management skills. These are assessed as posing a risk of harm to self or others if the patient is not contained in a 24-hour structured environment.

Although such patients do not require specialized psychiatric nursing and close observation, they do need monitoring and interventions by mental health staff to limit and de-escalate their behaviors, develop a therapeutic alliance, and process events that trigger symptomatology and identify and utilize appropriate coping techniques and medical interventions or relaxation. A 24-hour milieu is sufficient to contain such impulses in most cases, but enhanced staff and therapeutic interventions are required to manage unpredictable losses of impulse control.

The treatment regimen should be strengths-based and focused on rapid formal feedback regarding change of treatment plan, process, and outcomes in treatment, while avoiding highly confrontational strategies or strong affect that are intended to induce submissive behavior.

Results for Criteria Code 1354

DIMENSION 4: Readiness to Change

All Programs
The patient’s status in Dimension 4 is characterized by at least one of the following:

a. Because of the intensity and chronicity of the addictive disorder or the patient’s mental health problems, he or she has limited insight and little awareness of the need for continuing care or the existence of his or her substance use or mental health problem and need for treatment, and thus has limited readiness to change;
or

b. Despite experiencing serious consequences or effects of the addictive disorder or mental health problem, the patient has marked difficulty in understanding the relationship between his or her substance use, addiction, mental health, or life problems and his or her impaired coping skills and level of functioning, often blaming others for his or her addiction problems;
or

c. The patient demonstrates passive or active opposition to addressing the severity of his or her mental or addiction problem, or does not recognize the need for treatment. Such continued substance use or inability to follow through with mental health treatment poses a danger of harm to self or others. However, assessment indicates that treatment interventions available at Level 3.5 may increase the patient’s degree of readiness to change;
or

d. The patient requires structured therapy and a 24-hour programmatic milieu to promote treatment progress and recovery, because motivational interventions have not succeeded at less intensive levels of care and such interventions are assessed as not likely to succeed at a less intensive level of care;
or

e. The patient’s perspective impairs his or her ability to make behavior changes without repeated, structured, clinically directed motivational interventions, which will enable him/her to develop insight into the role he or she plays in his or her substance use and/or mental condition, and empower him/her to make behavioral changes which can only be delivered in a 24-hour milieu;
or

f. Despite recognition of a substance use or addictive behavior problem and understanding of the relationship between his or her substance use, addiction, and life problems, the patient expresses little to no interest in changing. Because of the intensity or chronicity of the patient’s addictive disorder and high-risk criminogenic needs, he or she is in imminent danger of continued substance use or addictive behavior. This poses imminent serious life consequences (ie, imminent risk to public safety or imminent abuse or neglect of children) and/or a continued pattern of risk of harm to others (ie, extensive pattern of assaults, burglaries, DUI) while under the influence of substances;
or

g. The patient attributes his or her alcohol, drug, addictive, or mental health problem to other persons or external events, rather than to a substance use or addictive or mental disorder. The patient requires clinical directed motivation interventions that will enable him or her to develop insight into the role he/she plays in his or her health condition, and empower him or her to make behavioral changes. Interventions are adjudged as not feasible or unlikely succeed at a less intensive level of care.

Co-Occurring Enhanced Programs
The patient’s status in Dimension 4 is characterized by a lack of commitment to change and reluctance to engage in activities necessary to address a co-occurring mental health problem. For example, the patient does not understand the need for antidepressant or antimania medications, and so does not adhere to a medication regimen.

Similarly, the patient is appropriately placed in a Level 3.5 co-occurring enhanced program if he or she is not consistently able to follow through with treatment, or demonstrates minimal awareness of a problem, or is unaware of the need to change. Such a patient requires active interventions with family, significant others, and other external systems to create leverage and align incentives so as to promote engagement in treatment.

Results for Criteria Code 1355

DIMENSION 5: Relapse, Continued Use, or Continued Problem Potential

All Programs
The patient’s status in Dimension 5 is characterized by at least one of the following:

a. The patient does not recognize relapse triggers and lacks insight into the benefits of continuing care, and is therefore not committed to treatment. His or her continued substance use poses an imminent danger of harm to self or others in the absence of 24-hour monitoring and structured support;
or

b. The patient’s psychiatric condition is stabilizing. However, despite his or her best efforts, the patient is unable to control his or her use of alcohol, other drugs, and/or antisocial behaviors, with attendant probability of harm to self or others. The patient has limited ability to interrupt the relapse process or continued use, or to use peer supports when at risk for relapse to his or her addiction or mental disorder. His or her continued substance use poses an imminent danger of harm to self or others in the absence of 24-hour monitoring and structured support;
or

c. The patient is experiencing psychiatric or addiction symptoms such as drug craving, insufficient ability to postpone immediate gratification, and other drug-seeking behaviors. This situation poses an imminent danger of harm to self or others in the absence of close 24-hour monitoring and structured support. The introduction of psychopharmacologic support is indicated to decrease psychiatric or addictive symptoms, such as cravings, that will enable the patient to delay immediate gratification and reinforce positive recovery behaviors;
or

d. The patient is in imminent danger of relapse or continued use, with dangerous emotional, behavioral, or cognitive consequences, as a result of a crisis situation;
or

e. Despite recent, active participation in treatment at a less intensive level of care, the patient continues to use alcohol or other drugs, or to deteriorate psychiatrically, with imminent serious consequences, and is at high risk of continued substance use or mental deterioration in the absence of close 24-hour monitoring and structured treatment;
or

f. The patient demonstrates a lifetime history of repeated incarceration with a pattern of relapse to substances and uninterrupted use outside of incarceration, with imminent risk of relapse to addiction or mental health problems and recidivism to criminal behavior (for example, extensive and recurrent pattern of crimes such as burglary, assault, robbery, DUI). This poses imminent risk of harm to self or others. The patient’s imminent danger of relapse is accompanied by an uninterrupted cycle of relapse-reoffending-incarceration-release-relapse without the opportunity for treatment. The patient requires 24-hour monitoring and structure to assist in the initiation and application of recovery and coping skills.

Co-Occurring Enhanced Programs
The patient’s status in Dimension 5 is characterized by psychiatric symptoms that pose a moderate to high risk of relapse to a substance use or mental disorder. Such a patient demonstrates limited ability to apply relapse prevention skills, as well as inadequate skills in coping with mental disorders and/or avoiding or limiting relapse, with imminent serious consequences.

For example, the patient continues to engage repetitively and compulsively in behaviors that pose a risk of relapse (such as antisocial behavior or criminal activity, or spending time in places where antisocial behavior is the attraction) because of an inability to understand the relationship between those behaviors and relapse to substance use or mental disorders or criminal activity. The presence of these relapse issues requires the intensity and types of services and 24-hour structure of a Level 3.5 co-occurring enhanced program.

Case management and collaboration across levels of care may be needed to manage anticraving, psychotropic, or opioid agonist medications. For example, because of an external locus of control, the patient may have difficulty resisting pressures to use psychoactive substances. He or she may continue involvement or become reinvolved with peers who are engaged in antisocial and/or criminal behaviors, and thus requires some type of group living situation that provides ongoing structure and support. (Such a group home may be a supervised living arrangement for ex-offenders.)

Discharge planning includes preparation for transfer of the patient to a less intensive level of care, a different type of service in the community, and/or reentry into the community. This requires case management and staff exploration of supportive living environments, separate from their therapeutic work with the patient.

Results for Criteria Code 1356

DIMENSION 6: Recovery Environment

All Programs

The patient’s status in Dimension 6 is characterized by at least one of the following:

a. The patient has been living in an environment that is characterized by a moderately high risk of neglect; initiation or repetition of physical, sexual, or emotional abuse; or substance use so endemic that the patient is assessed as being unable to achieve or maintain recovery at a less intensive level of care;
or

b. The patient’s social network includes regular users of alcohol, tobacco, and/or other drugs, such that recovery goals are assessed as unachievable at a less intensive level of care;
or

c. The patient’s social network is characterized by significant social isolation or withdrawal, such that recovery goals are assessed as inconsistently unachievable at a less intensive level of care;
or

d. The patient’s social network involves living with an individual who is a regular user, addicted user or dealer of alcohol or other drugs, or the patient’s living environment is so highly invested in alcohol and/or other drug use that his or her recovery goals are assessed as unachievable;
or

e. The patient is unable to cope, for even limited periods of time, outside of 24-hour care. He or she needs staff monitoring to learn to cope with Dimension 6 problems before being transferred safely to a less intensive setting.

Co-Occurring Enhanced Programs

The patient’s status in Dimension 6 is characterized by severe and chronic mental illness. He or she may be too ill to benefit from skills training to learn to cope with problems in the recovery environment. Such a patient requires planning for assertive community treatment, intensive case management, or other community outreach and support services.

Such a patient’s living, working, social, and/or community environment is not supportive of good mental health functioning. He or she has insufficient resources and skills to deal with this situation. For example, the patient may be unable to cope with the continuing stress of peer pressure to be involved in criminal behavior, or threats by former criminal associates, or hostile family members with alcohol use disorder, and thus exhibits increasing anxiety and depression. Such a patient needs the support and structure of a Level 3.5 co-occurring enhanced program to achieve stabilization and prevent further deterioration.

Results for Criteria Code 1371

DIMENSION 1: Acute Intoxication and/or Withdrawal Potential

All Programs

See separate withdrawal management chapter for how to approach “unbundled” withdrawal management for adults.

Results for Criteria Code 1372

DIMENSION 2: Biomedical Conditions and Complications

All Programs

The patient’s status in Dimension 2 is characterized by one of the following:

a. The interaction of the patient’s biomedical condition and continued alcohol and/or other drug use places the patient at significant risk of serious damage to physical health or concomitant biomedical conditions (such as pregnancy with vaginal bleeding or ruptured membranes, unstable diabetes, etc.);

or

b. A current biomedical condition requires 24-hour nursing and medical monitoring or active treatment, but not the full resources of an acute care hospital.

Biomedical Enhanced Services

The patient who has a biomedical problem that requires a degree of staff attention (such as monitoring of medications or assistance with mobility) or staff intervention (such as changes in medication) that is not available in other Level 3.7 programs is in need of biomedical enhanced services.

Results for Criteria Code 1373

DIMENSION 3: Emotional, Behavioral, or Cognitive Conditions and Complications

All Programs

Problems in Dimension 3 are not necessary for admission to a Level 3.7 program. However, if any of the Dimension 3 conditions are present, the patient must be admitted to a co-occurring capable or co-occurring enhanced program (depending on his or her level of function, stability, and degree of impairment).

Co-Occurring Capable Programs

The patient’s status in Dimension 3 is characterized by at least one of the following:

a. The patient’s psychiatric condition is unstable and presents with symptoms (which may include compulsive behaviors, suicidal or homicidal ideation with a recent history of attempts but no specific plan, or hallucinations and delusions without acute risk to self or others) that are interfering with abstinence, recovery, and stability to such a degree that the patient needs a structured 24-hour, medically monitored (but not medically managed) environment to address recovery efforts;

or

b. The patient exhibits stress behaviors associated with recent or threatened losses in work, family, or social domains; or there is a reemergence of feelings and memories of trauma and loss once the patient achieves abstinence, to a degree that his or her ability to manage the activities of daily living is significantly impaired. The patient thus requires a secure, medically monitored environment in which to address self-care problems (such as those associated with eating, sleeplessness, or personal hygiene) and to focus on his or her substance use or behavioral health problems;

or

c. The patient has significant functional limitations that require active psychiatric monitoring. They may include—but are not limited to—problems with activities of daily living; problems with self-care, lethality, or dangerousness; and problems with social functioning. These limitations may be complicated by problems in Dimensions 2 through 6;

or

d. The patient is at moderate risk of behaviors endangering self, others, or property, likely to result in imminent incarceration or loss of custody of children, and/or is in imminent danger of relapse (with dangerous emotional, behavioral, or cognitive consequences) without the 24-hour support and structure of a Level 3.7 program;

or

e. The patient is actively intoxicated, with resulting violent or disruptive behavior that poses imminent danger to self or others. Such a patient may, on further evaluation, belong in Level 4-WM withdrawal management or an acute observational setting if assessed as not safe in a Level 3.7 service;

or

f. The patient is psychiatrically unstable or has cognitive limitations that require stabilization but not medical management.

Co-Occurring Enhanced Programs

The patient’s status in Dimension 3 is characterized by at least one of the following:

a. The patient has a history of moderate psychiatric decompensation (which may involve paranoia; moderate psychotic symptoms; or severe, depressed mood, but not actively suicidal); or such symptoms occur during discontinuation of addictive drugs or when experiencing post-acute withdrawal symptoms, and such decompensation is present;

or

b. The patient is assessed as at moderate to high risk of behaviors endangering self, others or property, or is in imminent danger of relapse (with dangerous emotional, behavioral, or cognitive consequences) without 24-hour structure and support and medically monitored treatment. For example, without medically monitored inpatient treatment, the patient does not have sufficient coping skills to avoid harm to self, others, or property because of co-occurring mania;

or

c. The patient is severely depressed, with suicidal urges and a plan. However, he or she is able to reach out for help as needed and does not require a one-on-one suicide watch;

or

d. The patient has a co-occurring psychiatric disorder (such as anxiety, distractibility, or depression) that is interfering with his or her addiction treatment or ability to participate in a less intensive level of care, and thus requires stabilization with psychotropic medications;

or

e. The patient has a co-occurring psychiatric disorder of moderate to high severity that is marginally and tenuously stable and requires care to prevent further decompensation. The patient thus requires co-occurring enhanced services and is best served in an addiction treatment program with integrated mental health services, or in a mental health program with integrated addiction treatment services.

Results for Criteria Code 1374

DIMENSION 4: Readiness to Change

All Programs

The patient’s status in Dimension 4 is characterized by at least one of the following:

a. Despite experiencing serious consequences or effects of the addictive disorder and/or behavioral health problem, the patient does not accept or relate the addictive disorder to the severity of the presenting problem;

or

b. The patient is in need of intensive motivating strategies, activities, and processes available only in a 24-hour structured, medically monitored setting;

or

c. The patient needs ongoing 24-hour psychiatric monitoring to assure follow through with the treatment regimen, and to deal with issues such as ambivalence about adherence to psychiatric medications and a recovery program.

Co-Occurring Enhanced Programs

The patient’s status in Dimension 4 is characterized by no commitment to change and no interest in engaging in activities necessary to address a co-occurring psychiatric disorder. For example, the patient with bipolar disorder prefers his or her manic state over what feels like depression when stabilized, and thus does not adhere to a regimen of mood-stabilizing medications.

Similarly, the patient is not consistently able to follow through with treatment, or demonstrates minimal awareness of a problem, or is unaware of the need to change behaviors related to behavioral or health problems. Such an individual requires active interventions with family, significant others, and/or other external systems to create leverage and align incentives so as to promote engagement in treatment, and is appropriately placed in a Level 3.7 co-occurring enhanced program.

Results for Criteria Code 1375

DIMENSION 5: Relapse, Continued Use, or Continued Problem Potential

All Programs

The patient’s status in Dimension 5 is characterized by at least one of the following:

a. The patient is experiencing an acute psychiatric or substance use crisis, marked by intensification of symptoms of his or her addictive or mental disorder (such as poor impulse control, drug seeking behavior, or increasing severity of anxiety or depressive symptoms). This situation poses a serious risk of harm to self or others in the absence of 24-hour monitoring and structured support;

or

b. The patient is experiencing an escalation of relapse behaviors and/or reemergence of acute symptoms, which places the patient at serious risk to self or others in the absence of the type of 24-hour monitoring and structured support found in a medically monitored setting (for example, Driving Under the Influence (DUI), or not taking life-sustaining medications);

or

c. The modality or intensity of treatment protocols to address relapse require that the patient receive care in a Level 3.7 program (such as initiating or restarting medications for medical or psychiatric conditions, an acute stress disorder, or the processing of a traumatic event) to safely and effectively initiate antagonist therapy (such as naltrexone for severe opioid use disorder), or agonist therapy (such as methadone or buprenorphine for severe opioid use disorder).

Co-Occurring Enhanced Programs

The patient’s status in Dimension 5 is characterized by psychiatric symptoms that pose a moderate to high risk of relapse to a substance use or mental disorder. Such a patient demonstrates limited ability to apply relapse prevention skills, as well as demonstrating poor skills in coping with psychiatric disorders and/or avoiding or limiting relapse, with imminent serious consequences.

The patient’s follow through in treatment is limited or inconsistent, and his or her relapse problems are escalating to such a degree that treatment at a less intensive level of care is not succeeding or not feasible.

For example, the patient continues to evidence self-harm behaviors or suicidal ideation or impulses with a plan to commit suicide, but agrees to reach out if seriously suicidal, and is assessed as capable of enough internal control to do so. Or the patient’s continuing substance-induced mood states or psychotic symptoms are resolving, but his or her difficulties in remaining abstinent and craving for use are exacerbating his or her psychiatric symptoms.

Results for Criteria Code 1376

DIMENSION 6: Recovery Environment

All Programs

The patient’s status in Dimension 6 is characterized by at least one of the following:

a. The patient requires continuous medical monitoring while addressing his or her substance use and/or psychiatric symptoms because his or her current living situation is characterized by a high risk of initiation or repetition of physical, sexual, or emotional abuse, or active substance use, such that the patient is assessed as being unable to achieve or maintain recovery at a less intensive level of care. For example, the patient is involved in an abusive relationship with an actively using significant other;

or

b. Family members or significant others living with the patient are not supportive of his or her recovery goals and are actively sabotaging treatment, or their behavior jeopardizes recovery efforts. This situation requires structured treatment services and relief from the home environment in order for the patient to focus on recovery;

or

c. The patient is unable to cope, for even limited periods of time, outside of 24-hour care. The patient needs staff monitoring to learn to cope with Dimension 6 problems before he or she can be transferred safely to a less intensive setting.

Co-Occurring Enhanced Programs

The patient’s status in Dimension 6 is characterized by severe psychiatric symptoms. He or she may be too compromised to benefit from skills training to learn to cope with problems in the recovery environment. Such a patient requires planning for assertive community treatment, intensive case management, or other community outreach and support services.

Such a patient’s living, working, social, and/or community environment is not supportive of addiction and/or psychiatric recovery. He or she has insufficient resources and skills to deal with this situation. For example, the patient may be unable to cope with a hostile family member with alcohol use disorder, and thus exhibits increasing anxiety and depression. Such a patient needs the support and structure of a Level 3.7 co-occurring enhanced program to achieve stabilization and prevent further decompensation.

Results for Criteria Code 0374

DIMENSION 4: Readiness to Change

The adolescent’s status in Dimension 4 is characterized by at least one of the following:

a. Despite experiencing serious consequences or effects of the addictive disorder and/or behavioral health problem, the adolescent does not accept or relate the addictive disorder to the severity of the presenting problem;

or

b. The adolescent is in need of intensive motivating strategies, activities, and processes available only in a 24-hour structured, medically monitored setting;

or

c. The adolescent needs ongoing 24-hour psychiatric monitoring to assure follow through with the treatment regimen, and to deal with issues such as ambivalence about adherence to psychiatric medications and a recovery program.

Results for Criteria Code 0375

DIMENSION 5: Relapse, Continued Use, or Continued Problem Potential

The adolescent’s status in Dimension 5 is characterized by at least one of the following:

a. The adolescent is experiencing an acute psychiatric or substance use crisis, marked by intensification of symptoms of his or her addictive or mental disorder (such as poor impulse control, drug seeking behavior, or increasing severity of anxiety or depressive symptoms). This situation poses a serious risk of harm to self or others in the absence of 24-hour monitoring and structured support;

or

b. The adolescent is experiencing an escalation of relapse behaviors and/or reemergence of acute symptoms, which places the patient at serious risk to self or others in the absence of the type of 24-hour monitoring and structured support found in a medically monitored setting (for example, not taking life-sustaining medications; or the adolescent has severe and chronic problems with impulse control that require stabilization through high-intensity medical and nursing interventions; or he or she has issues with intoxication or withdrawal that require stabilization in a medically monitored setting; or there is a likelihood of self-medication of recurrent symptoms of a mood disorder, which require stabilization in a medically monitored setting). Treatment at a less intensive level of care has been attempted or given serious consideration.

or

c. The modality or intensity of treatment protocols to address relapse require that the patient receive care in a Level 3.7 program (such as initiating or restarting medications for medical or psychiatric conditions, an acute stress disorder, or the processing of a traumatic event; to safely and effectively initiate antagonist therapy (such as naltrexone for severe opioid use disorder), or agonist therapy (such as methadone or buprenorphine for severe opioid use disorder).

Results for Criteria Code 0376

DIMENSION 6: Recovery Environment

The adolescent’s status in Dimension 6 is characterized by one of the following:

a. The adolescent has been living in an environment in which supports that might otherwise have enabled treatment at a less intensive level of care are unavailable. For example, the family undermines the adolescent’s treatment, or is unable to sustain treatment attendance at a less intensive level of care, or family members have active substance use disorders and/or facilitate access to alcohol or other drugs, or the home environment is dangerously chaotic or abusive, or the family is unable to adequately supervise medications, or the family is unable to adequately implement a needed behavior management plan. Level 3.7 care thus is needed to effect a change in the home environment so as to establish a successful transition to a less intensive level of care.

or

b. Logistical impediments (such as distance from a treatment facility, mobility limitations, lack of transportation, and the like) preclude participation in treatment at a less intensive level of care, and Level 3.7 care is necessary to establish a successful transition to a less intensive level of care.

Results for Criteria Code 0352

DIMENSION 2: Biomedical Conditions and Complications

The adolescent’s status in Dimension 2 is characterized by one of the following:

a. Biomedical conditions distract from recovery efforts and require residential supervision (that is unavailable at a less intensive level of care) to ensure their adequate treatment, or they require medium-intensity residential treatment to provide support to overcome the distraction. Adequate nursing or medical monitoring can be provided through an arrangement with another provider. The adolescent is capable of self-administering any prescribed medications or procedures, with available supervision.

or

b. Continued substance use would place the adolescent at risk of serious damage to his or her physical health because of a biomedical condition (such as pregnancy or HIV) or an imminently dangerous pattern of high-risk use (such as continued use of shared injection apparatus). Adequate nursing or medical monitoring for biomedical conditions can be provided through an arrangement with another provider. The adolescent is capable of self-administering any prescribed medications or procedures, with available supervision.

Biomedical Enhanced Services
The adolescent is in need of biomedical enhanced services if he or she has a biomedical problem that requires a degree of staff attention (such as monitoring of adherence to medications or assistance with mobility) that is not available in other Level 3.5 programs.