Over this weekend, I spent a fair amount of time moving up and down the ladder, arranging lights on our trees.  I managed to stay focused enough to avoid any terrible falls, but the thought did cross my mind that the concept of a ‘ladder’ is useful to my patients.  Clinical care, especially that which involves substance-use disorders, can be compared to a wooden ladder.  Some forms of care are intense, regimented, and involve multidisciplinary teams (i.e. rehab).  Others are more fluid, free, and less-structured (i.e. classical outpatient therapy).

In working with patients, we often discuss the concept of ‘treatment matching.’  This process, designed by the American Society of Addiction Medicine, involves identifying multiple focus areas for each person where clinical needs are warranted.  For example, a person may be struggling with mental health problems and a difficult recovery environment.  Another patient may be highly motivated for care but need medically supervised detoxification from alcohol.  It is my job to work with patients to help ‘match’ their needs with appropriate services.  We work over time for them to move up and down the ladder of medical care.

The highest rungs of the ladder are described as ‘medically managed’ or ‘medically monitored.’  An example of this is CeDAR (University of Colorado Hospital – Center for Dependency, Addiction, and Rehabilitation), where there is 24/7 nursing and physician support, full-time housing, and multiple staff from different fields.  This is usually required for complex patients with psychiatric, medical, and basic stability needs.

The next level down is called ‘partial hospitalization’ and provides about 40 hours of care per week, but the patient still lives at home.  He or she has been stabilized and now is working to integrate goals of care with everyday life.  Partial hospitalization (or day treatment) programs are useful for those with primary psychiatric or substance use disorders.

Further down the ladder, we reach a modality of care called intensive outpatient.  An intensive outpatient program usually involves three group therapy meetings per week for around 3 months.  The total clinical care averages to be about 9 hours per week.  At this point, the patient is stable, is able to maintain much of a daily routine or career, and needs some additional support and accountability to address interpersonal or other recovery goals.  Intensive outpatient programs are often covered by insurance plans, are highly effective, and are available in multiple different sites around the Denver area.  Please talk to me about these programs.

Finally, the ladder rung right about the grass is general outpatient care.  At this point, the patient is medically and psychiatrically stable, is motivated for healthy behaviors, and has insight about his or her needs.  The majority of patients only need this level of care and can be successful with it.

I’ve outlined these four rungs of the ladder with the anticipation that a patient will be descending, but this is not always the case.  There is no shame in someone needing to take a step up the ladder.  I have had many patients who need to strengthen care at different times.

Happy Thanksgiving to everyone and be safe on those ladders!

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