Overview of a Continuum of Care
“Continuum of care” refers to a treatment system in which clients enter treatment ata level appropriate to their needs and then step up to more intense treatment or downto less intense treatment as needed. As outlined by Mee-Lee and Shulman (2003), an effective continuum of carefeatures successful transfer of the client between levels of care, similar treatmentphilosophy across levels of care, and efficient transfer of client records. TheAmerican Society of Addiction Medicine (ASAM) has established five main levels in acontinuum of care for substance abuse treatment:
Level 0.5: Early intervention services
Level I: Outpatient services
Level II: Intensive outpatient/Partial hospitalization services (Level II issubdivided into levels II.1 and II.5)
Level III: Residential/Inpatient services (Level III is subdivided into levelsIII.1, III.3, III.5, and III.7)
Level IV: Medically managed intensive inpatient services
These levels should be thought of not as discrete levels of care but rather as pointsin a continuum of treatment services (Mee-Lee andShulman 2003).
From program to program, the treatment philosophy, services, settings, and clientcharacteristics may vary for any given level of care because some aspects oftreatment may be tailored to a specific population. For instance, a rural residentialprogram primarily treating women who are alcohol dependent would be quite differentfrom an urban residential program treating mostly men dependent on stimulants.Despite variability in the specific features of intensive outpatient treatment (IOT)or Level II care in programs across the country, the continuum of care model tries toensure consistency throughout treatment and to ease the process of moving clientsthrough treatment.
In addition to the levels of care described by ASAM, outpatient treatment can bebroken down into four sequential stages that clients work through, regardless of thelevel of care at which they enter treatment:
Stage 1—Treatment engagement
Stage 2—Early recovery
Stage 3—Maintenance
Stage 4—Community support
These stages are discussed later in the chapter in the context of IOT and outpatienttreatment.
Conceiving of a Continuum of Care
To reinforce the idea of a continuum of care, Mee-Lee and Shulman (2003) suggest that clinicians and administrators“envision admitting the client into the continuum through theirprogram rather than admitting the client to their program” (p. 456).This early focus on moving the client along the continuum also prompts clinicians tolook ahead to the next step in a client's treatment. This, in turn, helps cliniciansengage in the treatment planning that is integral not only to the client's ongoingcare but also to the transition from one level of treatment to the next.
IOT Programs and the Continuum of Care
IOT programs are diverse and flexible with respect to the spectrum, intensity, andduration of services and the settings in which services are delivered. They are,therefore, well suited to meet the varied needs of persons with substance usedisorders. Conceptually, IOT is an intermediate level of ambulatory care thatserves the following functions:
An entry point into substance abuse treatment. The client comesto the IOT program, an assessment reveals that the client would benefit fromIOT (see chapter 5 of thisTIP for placement criteria), a treatment plan is developed, and services arebegun.
A stepdown level of care. The client is transitioned to the IOTprogram from an inpatient or residential facility. In this case, the clientmay have been stabilized in a hospital facility or residential treatmentprogram and now needs intensive treatment services to achieve or maintainabstinence as well as address other problems.
A step-up level of care. The client is referred to the IOTprogram if he or she has been unsuccessful in outpatient treatment orcontinuing community care and is assessed as needing an intensive andstructured level of care to regain abstinence, work on relapse preventionskills, and address other issues.
Assisting the Client Along the Continuum
IOT is part of a seamless continuum of levels of care. Moving the client along thecontinuum may require the IOT provider to refer the client to another treatmentorganization or may be the result of an internal transfer to another component ofa comprehensive IOT program.
Any change of setting, staff, or peers interjects a risk of the client's droppingout of treatment. Experience suggests that the administrative paperwork andapprovals needed to transfer a client between levels of care within the sameorganization can be accomplished with less disruption for the client than areferral to a new provider organization. Consequently, when referrals are made toa nonaffiliated provider organization, coordination and case management needsincrease.
Key Aspects of IOT (Level II)
After considering IOT from the broad perspective of the continuum of care, it isnecessary to look within Level II to understand IOT's particular goals, intensity,duration, settings, and stages.
IOT Goals
Goals of IOT programs vary based on such factors as the treatment population,program comprehensiveness, and the program's philosophy. Although programs differ,all IOT programs attempt to address the following general goals:
To achieve abstinence
To foster behavioral changes that support abstinence and a new lifestyle
To facilitate active participation in community-based support systems (e.g.,12-Step fellowship)
To assist clients in identifying and addressing a wide range of psychosocialproblems (e.g., housing, employment, adherence to probationrequirements)
To assist clients in developing a positive support network
To improve clients' problemsolving skills and coping strategies
Intensity of Treatment
Relative to traditional outpatient treatment, IOT provides an increased frequencyof contact and services that respond to the chronicity and severity of substanceuse disorders and other problems experienced by clients. The actual number ofhours and days per week that clients participate in IOT varies depending onindividual client needs. State licensure bodies may require 9 treatment hours;ASAM defines IOT as 9 hours of treatment per week for adults (Mee-Lee et al. 2001). Although IOT programsgenerally provide structured programming for 9 hours or more per week spread over3 to 5 days, some IOT programs provide fewer hours. The consensus panel recommendsthat the number of programming hours be 6 to 30 hours, based on client needs. Someclinicians find that more frequent, shorter visits are of greater benefit to theclient than less frequent but longer sessions. However, some clients requirelonger treatment sessions, similar in intensity to partial hospitalization. Moreresearch is needed on optimal treatment intensity and factors to be considered inincreasing or decreasing treatment intensity.
Duration of Treatment
The recommended minimum duration of the IOT phase often is cited as 90 days.Low-intensity outpatient treatment over a longer period may be a cost-effectivemeans to enhance treatment outcomes because this approach is associated with lesssubstance use and better social functioning in clients (Moos et al. 2001). Duration of treatment should beincreased or decreased based on the client's clinical needs, support system, andpsychiatric status, among other factors. Longer duration of care is related tobetter treatment outcomes (Moos and Moos2003).
Treatment Settings
IOT can be provided in any setting that meets State licensure or certificationcriteria (Mee-Lee et al. 2001). Programsoffering IOT only and comprehensive programs offering several levels of care maydiffer in structures and services provided. IOT programs that are part of a largehospital setting can provide medical detoxification services, pharmacotherapy, andtreatment for other medical and psychiatric conditions. IOT programs located inprison facilities treat offenders with alcohol and drug problems and successfullylink offenders with stepdown services in the community on release. Other IOTprograms may be located near vocational training sites so that welfare recipientsand others easily can attend both treatment and training sessions in homelessshelters and in modified therapeutic community programs.
Stages of Treatment
Within IOT or Level II care, treatment often is delivered in sequential stages,with service intensity and structure lessening as clients progress. As IOTservices taper in intensity, the client assumes increasing responsibility and isprovided less structure and supervision from treatment staff. IOT programs shouldhave the flexibility to increase the intensity of services if the client's lack ofprogress indicates such a need.
Sequenced IOT can motivate clients, help them succeed in reaching recoverymilestones and in meeting the criteria for completing a treatment stage, andprovide an incentive for clients to grow and progress. Marking the passage fromone IOT stage to the next with a celebration or ceremony also motivates clients.Sequenced stages allow complex information to be broken into small units that canbe modified and made appropriate for each client's cognitive and psychologicalfunctioning and stage of readiness.
IOT may be conceptualized as having two core stages, which correspond with theclient's progress in treatment: stage 1—treatment engagement and stage 2—earlyrecovery. Definitions of IOT, such as those adopted by some States or healthinsurers, may include additional or fewer stages or may blend similar goals andservices within different stages.
Stage 1—Treatment engagement
Goals and durationOne of the most critical tasks for the counselorand clinic is encouraging the client to remain in treatment. Many clients dropout of treatment after attending only a few sessions. During this initialstage, the counselor determines the client's presenting problems with respectto substance abuse; physical, psychological, and social functioning; and socialsupport network. Also, the counselor explains program rules and expectationsand works to stabilize any crises. Exhibit 3-1 presents the goals, duration, counselor activities, andcompletion criteria of this stage of IOT.
Box
Exhibit 3-1. Goals, Duration, Activities, and Completion Criteria ofStage 1. Goals of the treatment engagement stage: Establish a treatment contract with the counselor that specifiestreatment goals, client responsibilities (e.g., attend group sessions,remain (more...)
Stage 2—Early recovery
Goals and durationThis stage is highly structured with educationalactivities, group involvement, and new behaviors to help the client developrecovery skills, address lapses, and build a substance-free lifestyle. Exhibit 3-2 presents the goals,duration, counselor activities, and completion criteria of this stage oftreatment.
Exhibit 3-2. Goals, Duration, Activities, and Completion Criteriaof Stage 2
Goals of the early recovery stage: • Maintain abstinence. • Demonstrate ability to sustainbehavioral changes. • Eliminate drug-using lifestyle andreplace it with treatment-related routines and drug-freeactivities. • Identify relapse triggers anddevelop relapse prevention strategies. • Identify personal problems andbegin to resolve them. • Begin active involvement in a12-Step or other mutual-help program. Duration of the early recovery stage: 6 weeks toabout 3 months Counselor activities of the early recovery stage: • Assist clients in following theirindividual plans to achieve and sustain abstinence. • Assist clients in identifyingrelapse triggers and developing strategies to avoid or cope withtriggers. • Support evidence of positivechange. • Initiate random drug tests andprovide rapid feedback of results. • Assist clients in successfullyintegrating into a 12-Step fellowship or other mutual-helpprogram. • Help clients develop and strengthena positive social support network. • Encourage participation inhealthful recreation and social activities. • Continue pharmacotherapy, ifappropriate, and other medical and psychiatric treatments. • Offer education on topics such ashepatitis C and HIV infection, anger management, andparenting. • Continue assessments for otherissues requiring intervention. • Educate clients and family memberson addiction, the recovery process, and relapse. • Provide family and multifamilycounseling. • Introduce families to 12-Step andother mutual-help programs appropriate for them; help familiesintegrate into support groups. Completion criteria: Clinical indications thatsupport the client's transition from the early recovery stage ofIOT to the next level of care include the client's having • Sustained abstinence for 30 days orlonger • Completed goals as indicated in thetreatment plan • Created and implemented a relapseprevention and continuing care plan • Participated regularly in a supportgroup • Maintained a sober social supportnetwork • Obtained stable, drug-freehousing • Resolved medical, psychiatric,housing, and peer situations that may trigger relapse
Transition to Outpatient Treatment
Effective treatment in a continuum of care includes ongoing, less intensive, andtapered contact with treatment systems, much as with other chronic healthconditions (McLellan et al. 2000). Theclient and counselor must prepare for the transition to less intensive treatment,a juncture that presents a high dropout risk. This stepdown level of caresometimes is provided as part of a comprehensive IOT program by the same staff andin the same facility. In other cases, clients are transferred through formallinkages to outpatient treatment delivered by a separate community-based program,often referred to as standard, traditional, or—in this TIP—simply outpatienttreatment.
Compatible models of care
The consensus panel believes that, whenever possible, the client should bereferred to an outpatient treatment program with a treatment model (e.g.,12-Step, cognitive-behavioral, combined) that is compatible with that offeredby the IOT program to ensure that the client is not confronted withsignificantly different treatment goals, approaches, and philosophies. If aclient is to be transferred to a program with a different philosophy, theclient should be oriented to the differences so that the transition is notconfusing and the client can benefit from the new program.
Transition planning
An individual transition plan helps the client transition from one level ofcare to another and provides an important link between his or her currenttreatment provider and the next. To prepare an effective transition plan, theIOT counselor can
Engage the client as an active participant in developing the plan earlyin IOT, including setting goals, establishing criteria for measuringprogress, and identifying activities that will be part of ongoingtreatment.
Maintain a working knowledge of the services and resources that areavailable in the community.
Develop strong working relationships with staff of key agencies (e.g.,justice organizations, employers) to facilitate the transition, makespecial arrangements as needed, and eliminate unnecessary barriers forthe client during transition.
Obtain the client's written consent and arrange for the smooth and timelytransfer of clinical information or documents to the new treatmentprogram.
The panel recommends that the responsibility for client care be transferredclearly before a provider relinquishes clinical responsibility.
Key Aspects of Outpatient Treatment (Level I)
For clients who are stepped down from IOT, outpatient treatment offers the supportthey need to continue developing relapse prevention skills and resolving thepersonal, relationship, employment, legal, and other problems often associated withearly recovery.
Outpatient Treatment Goals
The goals, strategies for treatment engagement, and recovery services ofoutpatient treatment are similar to those of IOT. However, the intensity andduration of the services differ from those provided in IOT.
Comparison of IOT and Outpatient Treatment
A study by McLellan and colleagues(1997) compared several components of 6 IOT programs and 10 outpatienttreatment programs. Both types of programs provided group and individualabstinence counseling, relapse prevention programming, and drug and alcoholeducation. The IOT programs' treatment duration ranged from 30 to 90 days, andthey provided 3 to 5 sessions per week. Hours per session ranged from 3 to 6. Theoutpatient programs' treatment duration ranged from 45 to 60 days, and theyprovided 1 to 2 sessions per week. Hours per session ranged from 1 to 2. Whereasthe IOT programs provided more substance abuse counseling than the outpatienttreatment programs, the outpatient treatment programs were more likely than IOTprograms to offer medical appointments, family therapy sessions, psychotherapy,and employment counseling (McLellan et al.1997).
Although outpatient treatment duration is typically 60 days, it is suggestedstrongly that clients be scheduled for periodic followup sessions on a long-termbasis. The best outcomes from treatment of substance use disorders have been seenin clients who participate in continuing care, such as methadone maintenance orAlcoholics Anonymous-style support programs (McLellan et al. 2000). Because the availability of funding for followupappointments varies, outpatient treatment programs might consider strategies forestablishing a service model that supports the delivery of followup sessions.
Stepdown Treatment
Clients who have completed stages 1 and 2 of their treatment at the IOT level ofcare can step down to outpatient treatment programs and enter stage 3—maintenance,having demonstrated a commitment to change, been stabilized, become abstinent, anddeveloped relapse prevention skills.
Stage 3—Maintenance
Goals and durationStage 3—maintenance helps the client build ongains made during stages 1 and 2. The goals, duration, counselor activities,and completion criteria of this stage of treatment are presented in Exhibit 3-3.
Exhibit 3-3. Goals, Duration, Activities, and Completion Criteriaof Stage 3
Goals of the maintenance stage: • Solidify abstinence. • Practice relapse preventionskills. • Improve emotional functioning. • Broaden sober social networks. • Address other problem areas. Duration of the maintenance stage: About 2 monthsto 1 year Counselor activities of the maintenance stage: • Continue teaching and helpingclients practice relapse prevention skills and refine plans toaddress relapse triggers. • Help clients acknowledge andquickly contain “slips” to keep them from becoming full-blownrelapses. • Support clients as they workthrough painful feelings (e.g., sadness, anxiety, loneliness,shyness, shame, guilt). • Teach clients new coping andproblemsolving skills that increase self-esteem and improveinterpersonal relationships, including better communicationskills, anger management skills, and making amends. • Help clients identify vocational oreducational needs, improve work-related functioning, resolvefamily conflicts, and initiate new recreational activities. • Facilitate client linkages withcommunity resources that foster clients' interests and offerneeded services for accomplishing life goals. • Assist clients in making andsustaining positive lifestyle changes. • Encourage continuing participationin support groups and ongoing work with a sponsor. • Emphasize the importance ofspirituality or altruistic values that help clients see beyondthemselves and work for community goals. • Continue monitoring random drugtest results and providing feedback on results. • Continue pharmacotherapy, asneeded, and other medical or psychiatric assistance. • Avoid complacency. Completion criteria: Clinical indications thatsupport the client's transition from the maintenance stage tocontinuing care include the client's having • Sustained abstinence (30 days orlonger) • Improved relationships with family,friends, and significant others • Improved coping and problemsolvingskills • Obtained drug-free, stablehousing • Continued participation in asupport group • Obtained ongoing assistance withother problems, if necessary
Transfer to Continuing Community Care
Having completed stage 3 of their treatment, clients are discharged from formaltreatment to continuing community care. Clients who remain within a system ofongoing care relevant to their needs are more likely to maintain their gains inabstinence and overall lifestyle changes. Participation in continuing communitycare is related to an increase in positive outcomes (Miller et al. 1997; Ritsher et al. 2002). Continuing care planning is therefore a centraltask for IOT program staff whose clients remain in stepdown care within theprogram. IOT programs that refer clients to separate programs for a stepdown levelof care must ensure, through their referral agreements and procedures, that theoutpatient treatment program agrees to engage in continuing care planning.
Continuing community care in the form of 12-Step support groups, faith fellowship,or other community-based organizations is sometimes neglected by treatmentproviders because of the difficulties of remaining engaged with clients afterformal treatment is completed. Still, the benefits of carefully planning fortransferring clients into community support groups are such that added attentionshould be given to these tasks. To ensure client access to a full continuum ofcare, treatment programs need to be aware of support groups and other communityresources and introduce this information to clients early in the treatmentprocess. Other key responsibilities for providers include ensuring transition ofcase management responsibilities, supporting clients' early engagement incontinuing community care, contributing to the expansion of community services,and encouraging clients who drop out to reengage with treatment.
Continuing Community Care
Continuing community care following IOT and stepdown care is essential for all IOTclients, especially for those who may have other long-term psychiatric, social, ormedical issues. The process of rebuilding a healthy, productive, and stable lifetakes years, and maintaining gains made over time may require continuous support forsome individuals.
Once the client maintains abstinence and has begun to address other serious problemsthat could threaten recovery, the client can be discharged into continuing communitycare. Stage 4—community support consists of the client's participating in 12-Step orother mutual-help groups and meeting with psychologists, case managers, or staff fromcommunity-based agencies, with limited support and involvement from the treatmentprogram.
Services in Continuing Community Care
As part of continuing care services, programs can sponsor alumni meetings andprovide booster or checkup counseling sessions at the IOT or outpatient treatmentfacility. Periodic telephone contact also may be valuable (McKay et al. 2005). Other aspects of continuing careinclude involvement with selected community resources as needed, such asvocational training, recreational therapy, family therapy, or medical care.
Stage 4—Community support
Goals and durationThis stage is based on a detailed andindividualized discharge plan for continuing recovery in the community usingavailable resources. Exhibit 3-4presents the goals, duration, counselor activities, and completion criteria ofthis stage.
Exhibit 3-4. Goals, Duration, Activities, and Completion Criteriaof Stage 4
Goals of the community support stage: • Maintainabstinence. • Maintain a healthylifestyle. • Develop independencefrom the treatment program. • Maintain social networkconnections. • Establish strongconnection with support groups and pursue healthy communityactivities. • Establish recreationalactivities and develop new interests. Duration of the community support stage: Years,ongoing Counselor activities of the community supportstage: • Assist clients indeveloping a realistic, comprehensive, and individualized planfor continuing recovery. • Acquaint clients withlocal resources that allow them to • Sustain abstinence • Continue participating in 12-Stepor other mutual-help groups • Obtain medical or psychotherapeuticassistance as needed • Continue pharmacotherapy asneeded • Start or continue vocational oreducational training or other courses • Seek and obtain employment • Strengthen social supportnetworks • Manage stress • Prevent or respond to relapse • Enjoy abstinence • Provide informationabout and encourage attendance at alumni or booster sessions atthe IOT or outpatient treatment program to review recoverystatus. • Provide a biannualcheckup during which a comprehensive assessment is conducted ofclients' recovery and status. Completion criteria: Clients may need communitysupport for the rest of their lives to remain abstinent orrecover from relapses.
Intensity and Duration of Continuing Community Care
The duration of continuing community care varies for each individual. The chronicrelapsing nature of substance use disorders often means that individuals mayremain in this level of care for many months or years, relapse, return tooutpatient treatment or IOT care, regain abstinence, and return to continuingcommunity care.
