“Continuum of care” is a term that describes a system of substance abuse treatment where individuals begin at the care level that best fits their needs. As they progress, they can move to more or less intensive treatment as required. According to Mee-Lee and Shulman (2003), a successful continuum of care is characterized by smooth transitions between care levels, a consistent treatment approach across all levels, and efficient sharing of client information. The American Society of Addiction Medicine (ASAM) has defined five primary levels within this continuum for substance use disorder treatment:
- Level 0.5: Early Intervention Services
- Level I: Outpatient Services
- Level II: Intensive Outpatient/Partial Hospitalization Services (further divided into Level II.1 and II.5) – This is our focus: Intensive Outpatient Care Program
- Level III: Residential/Inpatient Services (subdivided into Levels III.1, III.3, III.5, and III.7)
- Level IV: Medically Managed Intensive Inpatient Services
It’s crucial to understand these levels not as separate entities, but as interconnected points within a comprehensive treatment journey (Mee-Lee and Shulman 2003).
While the core principles of treatment remain consistent across programs within each level, the specifics—such as treatment philosophies, services offered, settings, and client demographics—can vary. For example, an Intensive Outpatient Care Program in a rural area focusing on women with alcohol dependence will differ significantly from a similar program in an urban setting treating men with stimulant dependence. Despite these variations in intensive outpatient treatment (IOT) or Level II care, the continuum of care model aims to maintain a consistent and seamless treatment experience, facilitating smooth transitions for clients as they move through different stages of recovery.
Beyond the ASAM levels, outpatient treatment, including intensive outpatient programs, can be further categorized into four progressive stages that clients navigate, irrespective of their entry point into the treatment system:
- Stage 1: Treatment Engagement
- Stage 2: Early Recovery
- Stage 3: Maintenance
- Stage 4: Community Support
These stages will be discussed in more detail later, specifically in the context of intensive outpatient care programs and broader outpatient treatment approaches.
Understanding the Continuum of Care Concept
Mee-Lee and Shulman (2003) emphasize the importance of viewing treatment from a continuum perspective, urging clinicians and administrators to “envision admitting the client into the continuum through their program rather than admitting the client to their program” (p. 456). This approach encourages a forward-thinking mindset, prompting clinicians to proactively plan the next steps in a client’s recovery journey right from the outset. This early emphasis on the continuum of care is fundamental to effective treatment planning, ensuring both the immediate care and the seamless transition between different levels of support as the client progresses.
Intensive Outpatient Programs (IOPs) and Their Role in the Continuum
Intensive Outpatient Programs (IOPs) are characterized by their versatility and adaptability in terms of service range, intensity, duration, and delivery settings. This flexibility makes them exceptionally well-suited to address the diverse and evolving needs of individuals grappling with substance use disorders. Conceptually, an intensive outpatient care program serves as a crucial intermediate level of ambulatory care, fulfilling several key roles:
- Entry Point to Treatment: An intensive outpatient program can act as the initial point of contact for individuals entering substance abuse treatment. Following an assessment (placement criteria are discussed in chapter 5 of this TIP), if IOP is deemed appropriate, a personalized treatment plan is developed and treatment begins.
- Step-Down Care: IOPs provide a structured transition for individuals moving from more intensive settings like inpatient or residential facilities. Clients stepping down to an intensive outpatient care program may have achieved initial stabilization in a hospital or residential program and now require intensive, ongoing support to maintain abstinence and address underlying issues.
- Step-Up Care: For individuals who have not found success in standard outpatient treatment or community-based continuing care, an intensive outpatient program offers a more structured and intensive level of care. This step-up approach is designed to help clients regain abstinence, strengthen relapse prevention strategies, and address persistent challenges.
Facilitating Client Movement Along the Continuum
As an integral part of the continuum of care, intensive outpatient programs must be prepared to facilitate client transitions as their needs evolve. This may involve referring clients to external organizations for different levels of care or internal transfers within a comprehensive IOP that offers various services.
Any shift in setting, care team, or peer group carries a risk of treatment dropout. Experience suggests that internal transfers within the same organization, despite requiring administrative processes, often result in less disruption for the client compared to referrals to completely new provider organizations. When external referrals are necessary, enhanced coordination and robust case management become even more critical to ensure a smooth transition and prevent treatment disengagement.
Core Components of Intensive Outpatient Programs (Level II)
Having explored the broader context of intensive outpatient care programs within the continuum of care, it’s essential to delve into the specific characteristics of Level II treatment. This includes understanding the unique goals, intensity, duration, settings, and stages that define IOPs.
Goals of Intensive Outpatient Programs
The specific aims of an intensive outpatient program are influenced by factors such as the target population, program scope, and underlying treatment philosophy. However, all effective IOPs share a set of overarching goals:
- Achieving Abstinence: A primary goal is to help clients achieve and maintain abstinence from substances of abuse.
- Promoting Pro-Recovery Behaviors: IOPs focus on fostering behavioral changes that are essential for sustained abstinence and the adoption of a healthy, substance-free lifestyle.
- Community Support Integration: Facilitating active engagement in community-based support systems, such as 12-Step fellowships or other peer support networks, is crucial for long-term recovery.
- Addressing Psychosocial Challenges: IOPs assist clients in identifying and effectively addressing a wide spectrum of psychosocial issues that can impact recovery, including housing instability, unemployment, and legal obligations.
- Building Positive Support Networks: Developing and nurturing a positive and supportive social network is a key goal, providing clients with encouragement and accountability.
- Enhancing Coping and Problem-Solving Skills: Intensive outpatient care programs equip individuals with improved problem-solving skills and effective coping strategies to navigate life’s challenges without resorting to substance use.
Treatment Intensity in IOPs
Compared to traditional outpatient treatment, intensive outpatient programs offer a higher frequency of contact and a greater intensity of services. This heightened level of care is designed to address the often chronic and severe nature of substance use disorders and the complex challenges faced by individuals in recovery. The precise number of hours and days per week of IOP participation is tailored to individual client needs. While state licensing bodies may mandate a minimum of 9 treatment hours per week, and ASAM defines IOP as at least 9 hours weekly for adults (Mee-Lee et al. 2001), program structures can vary. Although many IOPs provide structured programming for 9 or more hours per week, spread across 3 to 5 days, some may offer fewer hours. The consensus panel recommends a flexible range of 6 to 30 programming hours weekly, depending on individual client needs. Some clinicians find that more frequent, shorter sessions can be more beneficial, while others find longer, less frequent sessions, similar to partial hospitalization, are more effective for certain clients. Further research is needed to determine optimal treatment intensity and the factors that should guide decisions about increasing or decreasing intensity.
Duration of Intensive Outpatient Treatment
A commonly cited recommended minimum duration for the intensive outpatient phase of treatment is 90 days. However, research suggests that extended, lower-intensity outpatient care may be a cost-effective approach to improve treatment outcomes, as it is linked to reduced substance use and improved social functioning (Moos et al. 2001). The duration of IOP should be adjusted based on a comprehensive assessment of the client’s clinical needs, support system, psychiatric status, and other relevant factors. Notably, longer durations of care are generally associated with better overall treatment outcomes (Moos and Moos 2003).
Treatment Settings for IOPs
Intensive outpatient programs can be delivered in a variety of settings, provided they meet state licensing and certification criteria (Mee-Lee et al. 2001). The structure and services offered can differ between programs that solely provide IOP and comprehensive programs that offer multiple levels of care. IOPs within large hospital systems often have the advantage of providing integrated medical detoxification, pharmacotherapy, and treatment for co-occurring medical and psychiatric conditions. Intensive outpatient care programs located in correctional facilities play a vital role in treating substance use disorders among offenders and facilitating connections to step-down services in the community upon release. Other IOPs may be strategically situated near vocational training centers or within homeless shelters or modified therapeutic communities to improve accessibility for specific populations, such as welfare recipients.
Stages of Treatment within IOPs
Within the framework of intensive outpatient care or Level II treatment, services are often delivered in a staged, sequential manner. As clients progress in their recovery, the intensity and structure of services gradually decrease. This staged approach allows clients to assume increasing responsibility for their recovery while receiving less direct supervision from treatment staff. However, effective IOPs maintain the flexibility to increase service intensity if a client’s progress stalls or if increased support is needed.
Sequenced IOP treatment offers several benefits. It can enhance client motivation, provide a sense of accomplishment as clients reach milestones and progress through stages, and incentivize continued growth and recovery. Breaking down complex treatment information into smaller, manageable units within stages also allows for greater personalization and adaptation to each client’s cognitive and psychological functioning and stage of readiness.
Intensive outpatient care can be broadly divided into two core stages that align with a client’s treatment progress: Stage 1 – Treatment Engagement and Stage 2 – Early Recovery. It’s important to note that specific definitions of IOP stages, as used by different states or health insurers, may include additional stages, fewer stages, or variations in the blending of goals and services within stages.
Stage 1: Treatment Engagement
Goals and Duration: A paramount goal during the initial stage of an intensive outpatient care program is to foster client retention. A significant number of individuals drop out of treatment after only a few sessions, making engagement crucial. In Stage 1, counselors focus on comprehensively assessing the client’s presenting problems related to substance abuse, physical and mental health, social functioning, and support network. Counselors also clearly explain program rules and expectations and work to stabilize any immediate crises the client may be experiencing. Exhibit 3-1 outlines the specific goals, typical duration, counselor activities, and completion criteria for the Treatment Engagement stage of IOP.
Stage 2: Early Recovery
Goals and Duration: Stage 2 of intensive outpatient care, Early Recovery, is characterized by a highly structured environment. It incorporates educational components, active group participation, and the development of new, healthy behaviors to equip clients with essential recovery skills. This stage focuses on relapse prevention, and building a sustainable substance-free lifestyle. Exhibit 3-2 details the goals, duration, counselor activities, and completion criteria for the Early Recovery stage within an intensive outpatient program.
Exhibit 3-2. Goals, Duration, Activities, and Completion Criteria of Stage 2
Goals of the early recovery stage: • Maintain abstinence. • Demonstrate ability to sustain behavioral changes. • Eliminate drug-using lifestyle and replace it with treatment-related routines and drug-free activities. • Identify relapse triggers and develop relapse prevention strategies. • Identify personal problems and begin to resolve them. • Begin active involvement in a 12-Step or other mutual-help program. Duration of the early recovery stage: 6 weeks to about 3 months Counselor activities of the early recovery stage: • Assist clients in following their individual plans to achieve and sustain abstinence. • Assist clients in identifying relapse triggers and developing strategies to avoid or cope with triggers. • Support evidence of positive change. • Initiate random drug tests and provide rapid feedback of results. • Assist clients in successfully integrating into a 12-Step fellowship or other mutual-help program. • Help clients develop and strengthen a positive social support network. • Encourage participation in healthful recreation and social activities. • Continue pharmacotherapy, if appropriate, and other medical and psychiatric treatments. • Offer education on topics such as hepatitis C and HIV infection, anger management, and parenting. • Continue assessments for other issues requiring intervention. • Educate clients and family members on addiction, the recovery process, and relapse. • Provide family and multifamily counseling. • Introduce families to 12-Step and other mutual-help programs appropriate for them; help families integrate into support groups. Completion criteria: Clinical indications that support the client’s transition from the early recovery stage of IOT to the next level of care include the client’s having • Sustained abstinence for 30 days or longer • Completed goals as indicated in the treatment plan • Created and implemented a relapse prevention and continuing care plan • Participated regularly in a support group • Maintained a sober social support network • Obtained stable, drug-free housing • Resolved medical, psychiatric, housing, and peer situations that may trigger relapse
Transitioning to Outpatient Treatment
Effective substance abuse treatment, within a continuum of care framework, necessitates ongoing, less intensive, and gradually reduced contact with treatment systems, mirroring the management of other chronic health conditions (McLellan et al. 2000). Planning for the transition from an intensive outpatient program to less intensive outpatient treatment is a critical phase that requires careful attention from both the client and counselor, as it represents a period of heightened risk for dropout. This step-down in care intensity may be offered within a comprehensive IOP by the same treatment team and at the same facility. Alternatively, clients may transition to outpatient treatment delivered by a separate community-based program through established referral pathways. This is often referred to as standard, traditional, or, as in this guide, simply outpatient treatment.
Compatible Care Models
The consensus panel emphasizes that whenever feasible, clients stepping down from intensive outpatient care programs should be referred to outpatient programs that utilize a compatible treatment model (e.g., 12-Step, cognitive-behavioral therapy, or integrated approaches). This compatibility ensures that clients encounter consistent treatment goals, methodologies, and philosophies, minimizing potential confusion and maximizing the benefits of continued treatment. In situations where a transition to a program with a different treatment philosophy is necessary, it is crucial to thoroughly orient the client to these differences. This proactive approach helps ensure a smoother transition and allows the client to effectively engage with and benefit from the new program’s approach.
Transition Planning for Step-Down Care
A well-structured individual transition plan is essential to facilitate a seamless step down from intensive outpatient care to outpatient treatment. This plan serves as a vital bridge between the client’s current IOP provider and their subsequent care. To develop an effective transition plan, the IOP counselor can:
- Engage the client actively: Involve the client from the early stages of IOP in developing their transition plan. This includes collaboratively setting goals, establishing measurable progress criteria, and identifying specific activities that will form part of their ongoing outpatient treatment.
- Maintain Community Resource Knowledge: Develop and maintain a comprehensive understanding of the available services and resources within the community. This includes outpatient programs, support groups, and other relevant services.
- Foster Interagency Relationships: Cultivate strong working relationships with staff at key community agencies, such as justice organizations and employers. These relationships can streamline the transition process, facilitate necessary arrangements, and proactively address potential barriers for the client during this critical phase.
- Ensure Information Transfer: Obtain the client’s informed written consent to facilitate the secure and timely transfer of essential clinical information and documents to the receiving outpatient treatment program.
It is recommended that the responsibility for client care is clearly transferred and formally acknowledged before the IOP provider relinquishes clinical responsibility to ensure continuity of care and accountability.
Key Aspects of Outpatient Treatment (Level I)
For individuals transitioning from intensive outpatient care programs, outpatient treatment provides the necessary ongoing support to solidify relapse prevention skills and address the personal, relational, vocational, legal, and other challenges frequently encountered in early recovery.
Goals of Outpatient Treatment
The overarching goals, engagement strategies, and recovery services offered in outpatient treatment are fundamentally similar to those in intensive outpatient programs. The primary distinction lies in the intensity and duration of services provided.
Comparing IOP and Standard Outpatient Treatment
A study by McLellan and colleagues (1997) compared key components of 6 intensive outpatient programs and 10 standard outpatient treatment programs. Both types of programs commonly provided group and individual abstinence counseling, relapse prevention education, and drug and alcohol education. However, significant differences emerged in treatment intensity and service offerings. IOP durations in the study ranged from 30 to 90 days, with 3 to 5 sessions per week, and session lengths ranging from 3 to 6 hours. In contrast, outpatient programs had treatment durations of 45 to 60 days, offering 1 to 2 sessions weekly, with sessions lasting 1 to 2 hours. While IOPs provided a greater emphasis on substance abuse counseling, outpatient programs were more likely to offer a broader range of services, including medical appointments, family therapy, psychotherapy, and vocational counseling (McLellan et al. 1997).
Although standard outpatient treatment duration is often around 60 days, it is strongly recommended that clients engage in periodic follow-up sessions on a long-term basis. Research consistently demonstrates that the most favorable outcomes in substance use disorder treatment are observed among individuals who participate in continuing care, such as methadone maintenance or Alcoholics Anonymous-style support programs (McLellan et al. 2000). Given the variability in funding availability for follow-up appointments, outpatient treatment programs should prioritize developing service models that effectively support the delivery of these crucial ongoing sessions.
Step-Down to Maintenance Stage
Clients successfully completing Stages 1 and 2 of intensive outpatient care are well-positioned to step down to outpatient treatment programs and enter Stage 3—Maintenance. By this stage, they have typically demonstrated a solid commitment to change, achieved stabilization, sustained abstinence, and developed foundational relapse prevention skills.
Stage 3: Maintenance
Goals and Duration: Stage 3, the Maintenance stage within outpatient treatment, is designed to build upon the progress achieved during the initial stages of IOP (Stages 1 and 2). This stage focuses on solidifying abstinence, refining relapse prevention strategies, and promoting overall well-being. Exhibit 3-3 presents the goals, duration, counselor activities, and completion criteria associated with the Maintenance stage of outpatient treatment.
Exhibit 3-3. Goals, Duration, Activities, and Completion Criteria of Stage 3
Goals of the maintenance stage: • Solidify abstinence. • Practice relapse prevention skills. • Improve emotional functioning. • Broaden sober social networks. • Address other problem areas. Duration of the maintenance stage: About 2 months to 1 year Counselor activities of the maintenance stage: • Continue teaching and helping clients practice relapse prevention skills and refine plans to address relapse triggers. • Help clients acknowledge and quickly contain “slips” to keep them from becoming full-blown relapses. • Support clients as they work through painful feelings (e.g., sadness, anxiety, loneliness, shyness, shame, guilt). • Teach clients new coping and problemsolving skills that increase self-esteem and improve interpersonal relationships, including better communication skills, anger management skills, and making amends. • Help clients identify vocational or educational needs, improve work-related functioning, resolve family conflicts, and initiate new recreational activities. • Facilitate client linkages with community resources that foster clients’ interests and offer needed services for accomplishing life goals. • Assist clients in making and sustaining positive lifestyle changes. • Encourage continuing participation in support groups and ongoing work with a sponsor. • Emphasize the importance of spirituality or altruistic values that help clients see beyond themselves and work for community goals. • Continue monitoring random drug test results and providing feedback on results. • Continue pharmacotherapy, as needed, and other medical or psychiatric assistance. • Avoid complacency. Completion criteria: Clinical indications that support the client’s transition from the maintenance stage to continuing care include the client’s having • Sustained abstinence (30 days or longer) • Improved relationships with family, friends, and significant others • Improved coping and problemsolving skills • Obtained drug-free, stable housing • Continued participation in a support group • Obtained ongoing assistance with other problems, if necessary
Transition to Continuing Community Care
Upon successful completion of Stage 3, clients are ready to transition from formal outpatient treatment to continuing community care. Maintaining engagement within a system of ongoing support that aligns with their individual needs significantly increases the likelihood of sustaining abstinence and long-term positive lifestyle changes. Participation in continuing community care is strongly correlated with improved recovery outcomes (Miller et al. 1997; Ritsher et al. 2002). Therefore, continuing care planning is a central responsibility for intensive outpatient program staff, particularly for clients stepping down to less intensive care within the same program. For IOPs that refer clients to external programs for step-down care, it is crucial to ensure, through referral agreements and procedures, that the receiving outpatient program is committed to robust continuing care planning.
Continuing community care, encompassing 12-Step support groups, faith-based communities, or other community organizations, is sometimes overlooked by treatment providers due to the challenges of maintaining engagement with clients after formal treatment concludes. However, the substantial benefits of thoughtfully planning for clients’ integration into community support groups warrant increased attention to these efforts. To ensure clients have access to a comprehensive continuum of care, treatment programs must be knowledgeable about available support groups and community resources and introduce this information to clients early in the treatment process. Other key responsibilities for providers include ensuring a smooth transition of case management responsibilities, actively supporting clients’ initial engagement in continuing community care, contributing to the expansion of community-based services, and proactively re-engaging clients who may drop out of continuing care back into treatment.
Continuing Community Care: The Long-Term Recovery Journey
Continuing community care following intensive outpatient programs and step-down outpatient treatment is vital for all clients, especially those with co-occurring long-term psychiatric, social, or medical conditions. Rebuilding a healthy, productive, and stable life is a multi-year process, and sustained recovery for many individuals necessitates ongoing support.
Once a client has achieved stable abstinence and has begun to address other significant challenges that could jeopardize their recovery, they can transition into continuing community care. Stage 4—Community Support—involves the client’s active participation in 12-Step or other mutual-help groups and ongoing engagement with psychologists, case managers, or community-based agency staff, with a reduced level of direct support and involvement from the formal treatment program.
Services within Continuing Community Care
As part of continuing care services, programs may offer alumni meetings and provide booster or check-up counseling sessions at the IOP or outpatient treatment facility. Periodic phone check-ins can also be a valuable component of ongoing support (McKay et al. 2005). Other aspects of continuing care may include connecting clients with relevant community resources as needed, such as vocational training, recreational therapy, family therapy, or medical care.
Stage 4: Community Support
Goals and Duration: This final stage of the continuum of care, Community Support, is built upon a detailed and individualized discharge plan designed to support long-term recovery within the community using readily accessible resources. Exhibit 3-4 outlines the goals, duration, counselor activities, and completion considerations for this stage.
Exhibit 3-4. Goals, Duration, Activities, and Completion Criteria of Stage 4
Goals of the community support stage: • Maintain abstinence. • Maintain a healthy lifestyle. • Develop independence from the treatment program. • Maintain social network connections. • Establish strong connection with support groups and pursue healthy community activities. • Establish recreational activities and develop new interests. Duration of the community support stage: Years, ongoing Counselor activities of the community support stage: • Assist clients in developing a realistic, comprehensive, and individualized plan for continuing recovery. • Acquaint clients with local resources that allow them to • Sustain abstinence • Continue participating in 12-Step or other mutual-help groups • Obtain medical or psychotherapeutic assistance as needed • Continue pharmacotherapy as needed • Start or continue vocational or educational training or other courses • Seek and obtain employment • Strengthen social support networks • Manage stress • Prevent or respond to relapse • Enjoy abstinence • Provide information about and encourage attendance at alumni or booster sessions at the IOT or outpatient treatment program to review recovery status. • Provide a biannual checkup during which a comprehensive assessment is conducted of clients’ recovery and status. Completion criteria: Clients may need community support for the rest of their lives to remain abstinent or recover from relapses.
Intensity and Duration of Continuing Community Care
The duration of continuing community care is highly individualized. The chronic, relapsing nature of substance use disorders often means that individuals may remain in this stage of care for extended periods, potentially years. Relapses may occur, necessitating a return to outpatient treatment or intensive outpatient care programs before re-engaging in continuing community care to maintain long-term abstinence and recovery.
