Levels of Care

Trying to decipher an individual’s clinical needs is difficult in and of itself. Trying to find the best people, program, facility or level of care to treat that client can be even tougher. The following are the different types or treatment programs and providers out there.

The least restrictive level of care. Typically refers to individual, group and family counseling 1-3 times per week with a therapist, counselor or psychiatrist in private practice or as an associate of a larger counseling clinic. Depending on the orientation of the clinician and the willingness of the client, these can be longstanding therapeutic relationships.

Partial Program
Usually taking place in a hospital setting lasting 3-4 hours per day. At first an individual goes 5 days per week tapering down as they become more stable. Length of programs is short in duration between 2-6 weeks. Most often these programs are group only (or may include 1 individual session per week) and are cognitive behaviorally based. Often used as a follow up to an inpatient psychiatric stay or a hospital detox.

Intensive Outpatient Program (IOP)
May be in a hospital setting or in an outpatient counseling center. Often these take the place of an inpatient or residential treatment stay and are considered Primary Care. They are cognitive behaviorally based and offer a lot of psycho-education around the addiction or mental health diagnosis, often including a 12-step component. Most therapy takes place in groups although many will offer limited individual counseling on an as needed basis. Typical program length is 4-8 weeks. The number of days per week will range between 3 and 5 and will meet from 3-8 hours per day. Some IOPs for substance abuse may provide ambulatory detox under the supervision of a Dr. in an effort to avoid inpatient hospitalization.

Day Program
May take place in a hospital setting or as part of a residential treatment center, usually 6-8 hours per day. Most therapy takes place in groups. Often 1-3 individual counseling sessions are offered each week. This model may be used as a step down from detox, hospitalization, inpatient or residential treatment and often deals with dual diagnosis. These programs tend to be more process oriented and experiential than the IOP or Partial programs.

Depending on the acuity of the addiction, the type of substances used and the orientation the physician, detox can take place on an outpatient, inpatient, residential or hospital setting. Hospital detoxes are typically 3-7 days in length while lower levels of care typically take longer due to the possibility of medical complications. Detoxification should always occur under the supervision of a physician.

High to moderately acute level of care. Although treatment may not always take place in a traditional hospital setting, 24 hour nursing care is provided with a physician on call 24 hours per day. Inpatient is highly structured with many restrictions to assure the safety of the patients and may occur on locked units. A high priority is placed on stabilizing self destructive behaviors, medications and suicidal ideation. Medical models are most often used and therapy is based on a cognitive behavioral and psycho-educational approach. Length of stay will vary from just a few days to 4 weeks. A caution when checking insurance, inpatient benefits usually refer to this level of care and are defined by 24 hour nursing care. Residential benefits are often a separate category and not covered. Many clients have been unpleasantly surprised to find out their coverage was denied when they thought an RTC was considered inpatient.

Residential Treatment Center (RTC)
Programs are usually 4-8 weeks in duration although many do offer longer lengths of stay. Individuals live on campus with staff supervision 24 hours per day. There are often many restrictions placed on the client regarding dress, phone use, television, unsupervised off campus passes, visitation and fraternization with members of the opposite sex. Treatment planning usually begins with the intake assessment which takes place prior to the client’s admission. A thorough psychiatric evaluation and medication consultation typically occurs within 48 hours of the client’s arrival. Therapy takes place mostly in groups however 1-3 individual sessions are often included each week.

RTC’s usually include a highly structured family program. Different treatment modalities are used often combining didactic, cognitive, process, insight oriented, experiential and expressive therapies. Direct therapy hours will range from 25-40 per week and are augmented by several community based activities and recreational groups. Many treatment centers utilize the 12-steps as a component in their programs while others offer alternatives to treating addictions from that perspective. Some treatment centers that are considered residential because they offer housing for their clients use a Day Program model and transport clients to local apartments. The living arrangements may or not be supervised overnight by staff. If your client needs staff supervision I recommend that question should be asked directly.

Extended Care
Quite similar to residential and sometimes these terms are interchangeable depending on the level of care the client is coming from. However, typically extended care programs offer a less intensive therapeutic program between 12-15 hours of direct therapy per week, offer a less restrictive setting allowing clients to earn additional privileges along the way and may or may not be staffed 24 hours per day. Additionally many extended care programs accommodate lengths of stay of 90 days or more.

Transitional Living
Similar to extended care offering 10-12 hours of structured therapeutic groups per week. Typically the focus of therapy is on topics like communication skills, healthy boundaries, creating healthy support networks and life skills. Clients are able to work, go to school and volunteer. They have a lot of opportunity to spend time in their community and practice the skills of recovery they have learned while still having a strong therapeutic environment to return to. Length of stay will vary from 1-3 months.

Halfway House
At one time this term was used specifically to refer to homes for those recently released from prison. For the most part this is no longer true and halfway houses serve clients from every walk of life although some states (specifically CA and MA) do still use the old definition. More commonly they are sober living environments with some structure such as required house meetings, peer run step study groups, attendance at a certain number of 12-step meetings per week, part time work and ongoing sobriety.

No therapy is provided although they can help residents find counselors in the community and many do not allow psychotropic medications. Halfway houses are usually very affordable (about the same amount as renting an apartment in that community) and one can stay there for up to one year. The term halfway house does refer almost exclusively to those in recovery from substance abuse. This level of care is very difficult to find for those who are not chemically dependent.

Sober Living (Also referred to as Recovery Residences)
The least restrictive form of a supportive living environment. The programs are peer run by a house manager and the only requirement is sobriety. Many do not require residents to attend 12 step meetings. This is a great opportunity for clients to practice “real life” while remaining in a safe, sober home. Often there is no limit to length of stay and these homes are between $500.00 and $1,000.00 per month.

All of the above are generalizations and each program will have its own unique structure, schedule, qualifications of staff, length of stay, therapeutic orientation and mission.

Most states have licensing requirements for treatment centers, treatment programs, psychotherapists, psychiatrists or a certification process for addiction counselors. Some require masters degrees and others do not. If your state does not require licensing (and even if it does) I recommend researching any potential treatment providers credentials thoroughly. If considering an inpatient, residential or extended care stay it is strongly suggested you inquire as to how their licensing reads.