ASAM LEVEL OF CARE DETERMINATION TOOL Instructions: For each dimension, indicate the intensive level consistent with sound clinical judgment, based on the client’s severity/functioning and service needs. Dimension 1: Dimension 3 Dimension 5 Dimension 2 Dimension 6 ASAM Criteria of Care- ASAM Dimension 4 Substance Use, Acute Emotional, Behavioral, Relapse, Continued Biomedical Condition Recovery/Living Withdrawal Management Level Intoxication, or Cognitive Condition Readiness to Change Use, or Continued and Complications Environment Withdrawal Potential and Complications Problem Potential Severity / Impairment Rating Mild* Mod Sev Mild* Mod Sev Mild* Mod Sev Mild* Mod Sev Mild* Mod Sev Mild* Mod Sev *Mild or None Ambulatory Withdrawal Management 1-WM without Extended On-Site Monitoring Ambulatory Withdrawal Management 2-WM with Extended On-Site Monitoring Clinically Managed Residential Withdrawal 3.2-WM Management Medically Monitored Inpatient Withdrawal 3.7-WM Management Medically Managed Intensive Inpatient 4-WM Withdrawal Management ASAM Criteria Level of Care- Other Treatment and Recovery Services Early Intervention 0.5 Outpatient Services 1 Intensive Outpatient Services 2.1 facility Partial Hospitalization Services 2.5 health Clinically Managed Low-Intensity 3.1 Residential Services Clinically Managed Population-Specific 3.3 mental High-Intensity Residential Services to Clinically Managed High-Intensity 3.5 Residential Services Medically Monitored Intensive Inpatient 3.7 referral Services Medically Managed Intensive Inpatient 4 Services Opioid Treatment Program OTP Consider
ASAM LEVEL OF CARE DETERMINATION TOOL Instructions: For each dimension, indicate the intensive level consistent with sound clinical judgment, based on the client’s severity/functioning and service needs. ASAM Criteria of Care- Withdrawal Management ASAM Level Dimension 1: Substance Use, Acute Intoxication, Withdrawal Potential Dimension 2 Biomedical Condition and Complications Dimension 3 Emotional, Behavioral, or Cognitive Condition and Complications Dimension 4 Readiness to Change Dimension 5 Relapse, Continued Use, or Continued Problem Potential Dimension 6 Recovery/Living Environment Severity / Impairment Rating *Mild or None Mild* Mod Sev Mild* Mod Sev Mild* Mod Sev Mild* Mod Sev Mild* Mod Sev Mild* Mod Sev Ambulatory Withdrawal Management without Extended On-Site Monitoring 1-WM Ambulatory Withdrawal Management with Extended On-Site Monitoring 2-WM Clinically Managed Residential Withdrawal Management 3.2-WM Medically Monitored Inpatient Withdrawal Management 3.7-WM Medically Managed Intensive Inpatient Withdrawal Management 4-WM ASAM Criteria Level of Care- Other Treatment and Recovery Services Early Intervention 0.5 Consider referral to mental health facility Outpatient Services 1 Intensive Outpatient Services 2.1 Partial Hospitalization Services 2.5 Clinically Managed Low-Intensity Residential Services 3.1 Clinically Managed Population-Specific High-Intensity Residential Services 3.3 Clinically Managed High-Intensity Residential Services 3.5 Medically Monitored Intensive Inpatient Services 3.7 Medically Managed Intensive Inpatient Services 4 Opioid Treatment Program OTP
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