Navigating the Levels of Care in Addiction Treatment: What You Need to Know
Author: Atlanta Addiction Recovery Center Editor
“Great treatment exists…good treatment exists…and horrible treatment exists”, says Daniel Lettenberger-Klein, MS, LMFT and Executive Director of RiverMend Health Center of Atlanta and Atlanta Addiction Recovery Center. In his interview with Prodigal Child Ministries, Daniel explains the differing levels of care within addiction treatment and candidly discusses how to navigate pitfalls when dealing with insurance companies and choosing appropriate treatment options.
Starting with crisis intervention all the way through outpatient care, Daniel sheds light on exactly which experts to turn to, what questions to ask and what resources to utilize when a loved one is struggling with addiction.
The Levels of Care in Addiction Treatment
“Crisis is where we all begin to some degree not knowing what to do. Feeling out of control. That’s the one constant in active addiction…it’s an out of control state. Some people have great resources all around them and they know where to turn. But some people don’t”, says Daniel.
When crisis hits and you’re desperate for help, what do you do? Perhaps you turn to your primary care physician, or maybe it’s the Internet, or maybe you’ve seen a phone number on television to call. For many, you’re just looking to stabilize your loved one and fix the problem. But addiction isn’t a quick fix. There’s no magic pill or easy solution. It’s a lifelong, chronic disease that requires careful management and exceptional care—and from experts who know how. But in a crisis, you may not be thinking of all the moving parts. Crisis intervention is the first level of care that individuals with addiction experience, and without proper guidance, it’s the first place that people usually fail to find what they need. Crisis is a time when people are feeling vulnerable and can fall prey to predatory marketing. If you haven’t done your research and know what to look for in a treatment center, your loved one could end up not getting the care that will see them through to stable early recovery. Understanding the different levels of care and knowing the right questions to ask will start them off on the right path.
Often times, insurance companies will push for patients to begin with ambulatory detox. But for many, this is actually not a great place to start. “Insurance companies push for ambulatory detox because they are looking to keep people from dying.” The purpose for this referral from the insurance company is to hope that a patient can be stabilized for the lowest possible cost. The issue is that these settings allow for those in active addiction and who most likely already struggle with decision making and impulse control to manage their medications with little to no therapeutic intervention Daniel explains.
Ambulatory detox is never appropriate for those experiencing withdrawal symptoms like delirium, tremors, severe hypertension, tachycardia, and seizures. Patients who experience these severe symptoms need inpatient medical detox which provides 24-hour medical monitoring.
A good inpatient detox treatment center should:
- Have the ability to admit patients 24 hours a day.
- Put patients on a “taper”. This means using safe medications to help people who have physical dependency issues get through withdrawal syndrome .
- Safely detox patients within five to ten days on average (unless there is a more serious medical complexity).
- Provide individualized therapy that is case management and continuing care driven and provide group therapy.
- Have patients meet with medical staff on a daily basis.
- Work with patients on discharge planning. A continuing care plan should start taking shape as soon as a patient enters detox.
Residential care is the next level of care after detox and typically consists of a 30-day program but can also range anywhere from 30-60-90 days and even longer in certain instances (Insurance is likely to cover at most 30 days in residential care so be prepared going in that a longer term stay may be a challenge to get insurance coverage). When choosing the right program, it’s important to know the credentials of the clinical team and any specialized clinical care such as experiential work that they are qualified to do. Daniel explains how finding a facility that supports family involvement is key to recovery.
Find out about the medical team, the clinical team and find out about the coordination between the family and the treatment center. The family is the biggest change agent for anyone in recovery. If you do not have a systemic change, the likelihood of relapse is also very high. As an LMFT, you see transformation happen in the system—you don’t just see it happen with one person. If you always go back into the same family system and expect the same thing…eventually the same thing happens…so the family work is exceptionally important when you go into a residential setting or an outpatient setting.
A good residential program should have a firm discharge plan set in place as well. Asking what the recommendation is after residential treatment is critical to the next steps in recovery. “If they say ‘Your loved one wants to go back home so we will support that”…I would hang up. Call the next place. That’s not going to work. They’ll be back in the same place”, Daniel says.
PHP and IOP
After a 30-day residential treatment program has been completed, patients will typically enter a partial hospitalization program (PHP) or an intensive outpatient program (IOP). In some residential facilities when insurance companies will no longer cover residential programming the patient can be covered with their PHP benefit if it allows for care to happen in a residential setting (meaning all under one roof). This is a great opportunity for the patient to receive a higher level of care and containment without moving into an outpatient setting. The main difference in an outpatient PHP and IOP setting is that PHP consists of longer programming with more medical follow-up. PHP is highly structured, and offers therapy, support services and medical treatment from doctors, psychiatrists and nurses. PHP runs about five to six hours a day, every day.
An IOP includes many of these treatments but usually requires less time. An IOP runs three hours a day, three to five days a week, and focuses on group therapy, one-on-one counseling and recovery skills in a supportive environment.
When entering a PHP or IOP, Daniel explains the importance of conducting a comprehensive assessment of the patient. “We never admit someone without knowing as much as possible about them…you need a legitimate drug test (Not just done as a urine specimen collected onsite but sent out to a lab for confirmatory analysis (this will tell us more about amount used and timeframe) …and a biopsychosocial assessment. Every patient needs a history and physical on the first day of treatment. We need to know as much as possible to understand what level of care will provide the patient with the best opportunity to succeed. And we ask the patient what’s important to them at their stage in recovery.”
When finding an effective sober living environment, Daniel gives suggestions on what to look for so you can make the best choice.
What you typically want to see in a sober living setting is:
- A residence manager who lives onsite. Someone who can actively manage a patient population and crisis.
- Regular drug testing.
- Clean and comfortable rooms. Take a tour. Ask yourself, “Is this a place I want my loved one?”
- There should be community rules. Ask the right questions:
- What does visitation look like?
- What do expectations for working look like? Very few places should allow patients to work right off the bat. They should be in treatment at least a part of the day in the facility.
“You want structure, a regular schedule and rules set in place. There should be a clear system of progression and a graduation they have to go through. They should start in a more contained setting and get added privileges over time to the point where they’re launching. The launching process is vitally important”, Daniel says.
Important Questions to Ask Your Treatment Center at Every Level of Care
How often will my loved one see a medical provider? And who is that medical provider? Is it a physician? A nurse? A nurse practitioner? Who are my loved ones going to be working with?
A good treatment center should have a strong medical component—especially for those in early recovery. Many people in early recovery are medically mismanaged and haven’t yet received a proper diagnosis. They aren’t able to manage their medications safely. They will likely require daily access to an onsite medical provider who closely monitors their medication. Find out about the medical team, the clinical team and coordination between the family and the treatment center.
How do you manage trauma?
The likelihood of trauma co-occurring with addiction is incredibly high. It is essential for families to have access to therapists who specialize specifically in addiction treatment as well as experience dealing with family systems that struggle with addiction.
Is there gender-specific treatment? How do you handle gender-specific issues?
Addiction affects men and women differently. It is important to have therapists and clinicians who are specially trained in gender-specific issues surrounding addiction.
What curriculum do you use?
If the curriculum is not rooted in evidence-based practice—meaning that its research informed—than it is a big red flag. If it hasn’t been shown to be effective, than you may not be in the right place.
What does insurance cover exactly? What are going to be our biggest barriers to long-term stable recovery as a family?
There should be clear discharge plans, family therapy, individual therapy, group therapy, and medication management. Insurance should cover all of these services. It’s crucial to make sure that you’re advocating for your loved ones and your families and that your insurance company is covering their needs. The insurance companies work diligently to shift responsibility for coverage to the provider during any customer service call and seldom take responsibility for insurance denial which is why it is essential to have strong relationships with the treatment center so you can understand that they are making the best possible effort to get your loved one the care that they need. Insurance denials can be frustrating, scary, and overwhelming but know that a good treatment center will provide you with legitimate options for continued care and not just close the door on you.
“Transparency is key when looking for the right addiction treatment. Ask questions. If you find you are not getting a straight answer…it is not the right program. If they don’t know they should say they don’t know…they shouldn’t talk around it”, Daniel says.