2331 SERVICES AND SUPPORTS -- LEVELS OF PATIENT CARE STANDARDS

2331.1 A substance abuse treatment facility or program shall develop and implement generally accepted assessment, placement, continuing care, and discharge criteria, such as those provided by the American Society of Addiction Medicine (ASAM) and the Level of Care Utilization System for psychiatric and addiction services (LOCUS).2331.2 A substance abuse treatment facility or program shall develop and implement a service delivery model that includes one or any combination of three (3) levels of treatment and rehabilitation and which outlines in descriptive terms admission criteria established for each level.2331.3 A facility or program shall develop and implement a written plan for referring admitted patient, whose status changes while in treatment, to other programs providing different levels of care based on the patients needs. The plan shall include but be limited to affiliation or other agreements, transportation arrangements, and communications to facilitate referrals and share information as necessary, in accordance with District and federal laws and regulations governing confidentiality. This plan shall be in addition to the referral requirements specified in §2335.9.2331.4 A facility or program seeking reimbursement shall comply with Medicaid regulations or other funding sources criteria for reimbursement.2331.5 A facility's or program's intake and assessment unit may authorize a patient to enter treatment provided the facility or program offers the level of care indicated by the assessment, based on the patient's severity of illness, previous treatment history, and other critical indicators.2331.6 A facility or program shall be categorized by modality in one of the following levels of care based on the described intensity of service:- (a) Level III (Sub-Acute Non-Hospital Medically Monitored Detoxification, Non-Hospital Residential Treatment Programs, Day Treatment/Partial Hospitalization Programs) - This is the most structured and intensive service delivery option in the Rehabilitation Program. Programs falling into three major groups are included here:

- (1) medically monitored non-hospital in-patient programs with ready access to medical, psychiatric and laboratory services,

- (2) clinically monitored residential treatment programs with accessibility to medical, psychiatric and laboratory services, but through a more distant relationship, and

- (3) medically monitored outpatient day treatment programs providing 20 or more hours of structured programming per week, with ready access to psychiatric, medical and laboratory services. Patients admitted to group 3 reside in an overnight environment where access to alcohol and other drugs is controlled, such as a supervised home environment, jail, nursing home or other licensed health care facility. Special attention will be given to assessment of an individual's need for housing and supervision;

- (b) Level II (Intensive Outpatient) - This less restrictive level offers a therapeutic milieu consisting of regularly scheduled sessions for a minimum of nine (9) hours a week in a structured program, which provides patients with the opportunity to remain in their own living environment. It addresses functional impairments as they relate to substance abuse in individuals not in crisis; and

(c) Level I (Basic Outpatient) - This is the least intensive, least restrictive level of care. It offers non-residential services totaling fewer than 9 hours a week. It offers directed treatment and recovery services that address major lifestyle, attitudinal, and behavioral issues that can undermine treatment goals and inhibit a patient's ability to cope with major life tasks, without abusing psychoactive substances. This level of care assists the patient in sustaining treatment gains, and emphasizes personal growth issues such as vocational rehabilitation and relapse prevention methods. Most outpatient abstinence and narcotic treatment programs fall into this level of care.

2331.7 Admission to Level III treatment shall be based on an assessment of the individual's condition, which indicates that the individual's condition meets at least three (3) of the following criteria within six (6) dimensions:

1. (a) Dimension 1. - Acute Intoxication, and/or Withdrawal Potential/Acute Mental Decompensation: Individual displays severe intoxication and/or withdrawal risk (non-life threatening), or a strong potential for risk to self or others if condition deteriorates.
2. (b) Dimension 2. - Biomedical Condition, Co-Morbidity and Complications: Individual's medical condition may be seriously exacerbated by substance abuse and/or mental illness; requires medical monitoring but not intensive treatment.
3. (c) Dimension 3. - Emotional/Behavioral Condition and Functional Status: Individual displays moderate to severe symptomatic distress, or impairment in functioning or behavior, with potential to distract from treatment or recovery, requiring monitoring in a structured setting which may or may not be twenty-four (24) hours.
4. (d) Dimension 4. - Treatment Acceptance/Resistance: Individual needs intensive motivating strategies and highly structured programs. May display destructive and inaccessible attitude.
5. (e) Dimension 5. - Relapse/Regression Potential: Individual is unable to maintain control of symptoms despite active participation in less intensive care or situational crisis.
6. (f) Dimension 6. - Recovery Environment: Necessitates removal of individual from dangerous recovery environment that may also be highly to extremely stressful with minimal to no supportive network.

2331.8 Admission to Level II rehabilitation level of service shall be based on an assessment of the individual's condition, which indicates that the individual's condition is no more severe than the following criteria for Dimensions 1, 2, and 3 and matches at least two (2) of the following criteria for Dimensions 4, 5 or 6:

1. (a) Dimension 1. - Acute Intoxication, and/or Withdrawal Potential/Acute Mental Decompensation: Individual displays minimal withdrawal risk and/or moderate to serious potential for dangerousness.
2. (b) Dimension 2. - Biomedical Condition, Co-Morbidity and Complications: Individual's condition indicates that no biomedical condition exists or individual's condition is significant enough to require management in a Level II setting but is not distracting from addictions and/or mental health treatment.
3. (c) Dimension 3. - Emotional/Behavioral Condition and Functional Status: Individual displays mild to moderate symptomatic distress or impairment in functioning or behavior, which threatens the ability to live in the community and/or has the potential to distract from treatment or recovery.

(d) Dimension 4. - Treatment Acceptance/Resistance: Individual displays obstructive attitude and engagement resistance high enough to require structured program.

(e) Dimension 5. - Relapse/Regression Potential: Individual's past history or current symptomatology indicates likely deterioration/relapse without structured program with close monitoring and support.

(f) Dimension 6. - Recovery Environment: Individual lives in a moderately stressful environment with a limited support network, but with structure or support, the individual can cope.

2331.9 Admission to the Level I treatment shall be based on an assessment of the individual's condition, which indicates that the individual's condition meets at least five (5) of the following criteria within six (6) dimensions:

(a) Dimension 1. - Acute Intoxication, and/or Withdrawal Potential/Acute Mental Decompensation: Individual displays no withdrawal risk and/or minimal to low potential for dangerousness.

(b) Dimension 2. - Biomedical Condition, Co-Morbidity and Complications: Individual's condition indicates that no biomedical condition exist, stable or manageable with minimal indication of adverse affects on substance abuse or mental health treatment.

(c) Dimension 3. - Emotional/Behavioral Condition and Functional Status: Individual does not displays any emotional/behavior condition, minimal or mild symptomatic distress or impairment in functioning or behavior.

(d) Dimension 4. - Treatment Acceptance/Resistance: Individual displays optimal/constructive attitude and engagement but needs motivating and monitoring strategies.

(e) Dimension 5. - Relapse/Regression Potential: Individual is able to maintain community functioning with minimal support; has a history of positive treatment outcomes; and is able to maintain abstinence and/or medication regimen.

(f) Dimension 6. - Recovery Environment: Individual lives in a low to mildly stressful/supportive environment and has coping skills.

SOURCE: Final Rulemaking published at 47 DCR 9341 (November 24, 2000), adopting Emergency and Proposed Rulemaking published at 47 DCR 7708, 7748 (September 22, 2000).

EDITOR'S NOTE: This section as adopted included two subsections numbered "2331.6" In this edition, the second §2331.6 has been renumbered §2331.7. Concurrently, original §§2331.7 and 2331.8 have been renumbered §§2331.8 and 2331.9, respectively.