Making the decision to enter an inpatient drug rehabilitation program is a major life choice. Individuals who enter these programs are often demonstrating strong commitments to attempting to deal with their substance use disorder, and the treatment in these programs is often intense. Individuals may be admitted on the same day they are evaluated if there are certain circumstances that warrant this, and the program is able to admit them (if they have the space and resources for the individual). In many cases, same-day admittance is crucial, and individuals should be admitted without hesitation if they meet the admission criteria.
Programs that have the space and resources to admit an individual often simply require that the individual displays an immediate need or desire to get into drug rehabilitation. Special circumstances that show that same-day admittance is crucial can include the following situations:
- The person has suffered an overdose.
- Some other immediate medical emergency associated with the individual’s drug abuse has occurred.
- Individuals who display some acute and potentially serious mental health issues, such as psychosis as a result of using drugs, or individuals who have serious co-occurring mental health disorders often need to be admitted on the same day they are evaluated. Individuals who are actively suicidal would most likely not be admitted to a drug rehabilitation program immediately, but instead would be admitted to a formal psychiatric unit if they meet the requirements; treatment for their substance abuse would initially occur on that unit.
- In many cases where individuals who have chronic histories of addictive behaviors have come to the sudden conclusion that they need help, the intake personnel of the facility may want to admit the person immediately before they change their mind. In some cases, family members may have convinced the individual to get help, and they may petition for immediate admission to the program.
The Process of Admission
An admission to an inpatient rehabilitation program occurs over three basic phases. Even a same-day admission would require that the individual complete the following process:
1. Initial assessment/evaluation: The first component of admission is the assessment/evaluation of the person. These assessments are routinely performed by intake supervisors or personnel; however, in the case of a rush admission, one of the therapists, nurses, or other trained personnel may perform the duty. The intake consists of evaluating any current state of intoxication in the individual, if they are actively undergoing withdrawal symptoms, and gathering information regarding their family, social contacts, current situation, physical health, mental health, and substance use disorder history.
2. Stabilizing the client: Once the intake assessment is completed, the person’s immediate needs are addressed, such as treating any current intoxication of drugs or alcohol, beginning a program of withdrawal management if necessary, and addressing any acute issues that need immediate attention.
3. Recovery preparation: Once the acute needs are addressed, the individual is then placed in the appropriate program. Many individuals will need to undergo physician-assisted withdrawal management (medical detox). After this, treatment providers will implement a plan to address issues that drove an individual’s addictive behavior and prepare the individual to become involved in ongoing treatment, such as therapy, support group participation, reentering the community, etc.
The evaluation and stabilization process may have to be completed rather quickly if individuals have acute issues that need immediate attention. Both of these components of admission also help to define the level of care that the facility will provide to the client. It is very important for anyone who enters an inpatient substance use disorder rehabilitation program to understand their rights regarding the treatment they will receive.
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Rights of the Client
Any client who is admitted to any treatment program has the right to be able to fully participate in the level of care they receive and to make choices about the type of care they are going to get (if they are capable of understanding these issues and making decisions). It is important that clients understand that treatment programs should not interfere with their freedom to participate in their lives or interfere with their civil rights unless they agree to temporarily become involved in these types of restricted treatments. Individuals who are not able to make informed decisions themselves have the right to be represented by a relative or attorney who can make decisions for them. This is referred to as the principle of least restrictive care. According to this principle:
- The setting that the client is treated in should be the least restrictive setting regarding its interference with their ability to participate in important activities in their lives and regarding their civil rights.
- Clients in treatment can refuse care and have the right to disagree with treatment recommendations.
- Clients in treatment need to be informed of all aspects of their treatment planning and of the intended treatment they receive.
- When individuals are deemed to be incapable of making decisions for themselves, the treatment program must abide by federal, state, and agency statutes when developing a plan of care for them. This often means assigning a legal representative (an attorney or a relative) to make decisions for the client and then referring to that entity regarding treatment plans, interventions, length of stay, discharge plans, etc.
Under certain circumstances, forced admission into a treatment center is allowed. The statutes that describe the conditions under which an individual may be forced into treatment vary in each state. Typically, individuals can be forced into treatment if they are deemed to be a danger to themselves or others, or if they are deemed unable to make informed decisions for themselves. Again, there is often quite a bit of uncertainty or debate regarding where the lines should be drawn between satisfying the rights of least restrictive care and forcibly applying treatment to individuals in these programs who are in immediate need of intervention for their own safety.
One of the approaches to dealing with these issues is that inpatient rehabilitation programs for substance use disorders will be able to offer significant variation in the level of services they provide. The levels of services that are provided to clients are stratified by different descriptions of varying levels of care, designed to meet specific needs of individuals, and aimed at satisfying the principle of least restrictive care.
Levels of Care
In some instances, same-day admission to an inpatient substance use disorder rehabilitation program may not be available in a particular facility, or following the comprehensive evaluation, it may be deemed that the individual is not suited for inpatient treatment. There are numerous options and levels of care that have been designed to accommodate the needs of individuals wishing to enter treatment for substance use disorders in the manner that provides the least restrictive care.
The American Society of Addiction Medicine (ASAM) offers descriptions of different levels of care for individuals entering treatment for substance abuse related issues in its manual The ASAM Criteria: Treatment for Addictive, Substance-related, and Co-occurring Conditions. The levels of care are briefly described here, and individuals wishing to enter treatment for a substance use disorder can often immediately be placed in treatment at any of these levels, depending on their needs and situation:
Level .5: Early intervention (adolescents and adults): This level of care is designed to be delivered to individuals who may be at risk for developing a substance abuse-related issue, but do not meet the formal diagnostic criteria for having a substance use disorder. These individuals may be using certain substances, experiencing problems related to their substance use, have toxic environments, etc. Often, the intervention at this level consists of prevention and psychoeducational services as well as counseling.
Level 1: Outpatient services (adolescents and adults): Outpatient treatment services at this level of care are described as being fewer than nine hours of treatment for adults per week and fewer than six hours of treatment per week for adolescents. Treatment can be delivered in a varied manner, including therapy, medical management, support group intervention, etc.
Level 2.1: Intensive outpatient program (IOP; adolescents and adults): At this level of care, adults receive nine or more hours of care/treatment per week (six or more hours for adolescents). IOPs are designed to deliver the type of intensive treatment that parallels the care that occurs in an inpatient setting; however, in IOPs, clients are not deemed to require 24-hour supervision. Clients attend treatment during the day and then return to their homes in the evening.
Level 2.5: Partial hospitalization services (PHS; adolescents and adults): At this level of care, treatment of 20 hours or more per week is provided, but individuals again do not require 24-hour supervision and either return home or live in a facility separate from the treatment center. Typically, treatment is delivered during the day in a hospital or clinic and then individuals return to their normal environment or a community housing facility.
Level 3.1: Clinically managed low-intensity residential services (adolescents and adults): These services provide 24-hour care, structure, and support with trained personnel and at least five hours of intervention per week. Individuals in these services abide by the rules of the facility and receive varied services that include mental health treatment, addiction-related treatment, and living support.
Level 3.3: Clinically managed population-specific high-intensity residential services (for adults only): Individuals in this level of treatment receive 24-hour care with counselors. These individuals often have significant developmental or disability-related issues, such as cognitive impairments, and cannot use facilities that allow significant freedom. Thus, these types of facilities are designed to stabilize any potential dangerous issues, provide significant around-the-clock supervision, and provide appropriate treatment.
Level 3.5 and level 3.7: Clinically managed medium-intensity residential services (adolescents); clinically managed high-intensity residential services (adults): Individuals placed in this level of care receive 24-hour care with trained counselors. Supervision is provided to prevent any potential dangerous issues with these groups and to prepare them for outpatient care later.
Level 4: Medically managed intensive inpatient services (adolescents and adults): At this level of care, individuals receive daily care from a physician, 24-hour nursing care, and intensive counseling for substance abuse. These individuals typically have very severe and unstable issues/conditions that require intensive supervision.
Placement in a particular level of care depends on the needs of the individual and the results of the initial evaluation. Alternatives to same-day admission to an inpatient substance abuse rehabilitation program could include the use of an IOP or a PHS if it is deemed that the person does not require 24-hour supervision. Individuals who apply for admission to an inpatient program, believe that they need inpatient services, and are not admitted to the program of their choice should investigate other programs that may be able to admit them immediately. Some individuals may find that they can receive very intensive attention by getting involved in an IOP and attending several 12-Step group meetings per day; these are essentially free as 12-Step groups are run by donations and most members donate $1 per meeting, but people do not need to donate every time they attend a meeting.
There may be other issues that must be considered before an individual is admitted to a particular program.
- In some cases, individuals may need to negotiate payment plans or borrow money if they do not have insurance that covers the treatment they desire.
- Issues with disabilities (e.g., cognitive, psychological, or physical disabilities) may limit the type of program one can be admitted to.
- The need for 24-hour supervision is often considered when an individual requests same-day admission.
- Special considerations regarding the potential client’s need to care for physical dependents, such as children, should be taken into account.
- Legal issues, such as probation issues, court orders, etc., all need to be addressed in order to determine if one can be admitted into an inpatient rehabilitation program.
- Psychiatric issues, such as having a severe co-occurring psychiatric disorder or being suicidal, often limit the type of program one can gain admission to on the same day as the evaluation.
- Going through withdrawal or being significantly intoxicated at the time of admission will also dictate the type of program one will initially be placed in.
The referral source may also make a significant difference regarding whether one will be accepted to the program on the same day. For instance, insurance companies and intake personnel often give significantly more attention and credence to referrals made by physicians (e.g., psychiatrists, addiction medicine physicians, and other specialists like neurologists) compared to referrals made by therapists, case managers, social workers, family members, etc. When a same-day admission to a program is highly desirable, it can be advantageous to have a physician formally make the referral.
Most inpatient rehabilitation facilities offer same-day admission depending on the needs of the client and the results of an overall evaluation. Individuals requesting same-day admission to an inpatient substance use disorder rehabilitation service will be evaluated thoroughly and their needs assessed.
Any individual being admitted to any form of treatment has the right to receive the least restrictive care that best suits their needs. The purpose of becoming involved in an inpatient substance use disorder treatment program is to receive much-needed 24-hour supervision and to prepare one to eventually transition to outpatient therapy and relative independence. Some individuals may be more suited to intensive forms of outpatient treatment.