Ala. Admin. Code r. 580-9-44-.17

Level II.1: Intensive Outpatient Treatment

This regulation establishes operating standards for Level II.1 Intensive Outpatient Treatment programs for substance use disorders in Alabama, corresponding to ASAM level 2.1. Operators must develop written program descriptions, admission criteria (including ASAM PPC-2R dimensional criteria), core service arrays, staffing requirements, and documentation protocols. Specific sub-program requirements are detailed for adolescent, co-occurring disorders, and women-with-dependent-children populations. Service intensity must range from 9 to 19 hours per week for adults and 6 to 19 hours per week for adolescents.

Ala. Admin. Code r. 580-9-44-.17 - Level II.1: Intensive Outpatient Treatment 

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(1)
 Rule Compliance. Each Level II.1
 Intensive Outpatient Program shall comply with the following rules and the
 rules specified in this chapter. 
(a)
 Program
 Description. The entity shall develop, maintain and implement a written program
 description that defines the Level II.1 Intensive Outpatient Program it
 provides to include the following specifications:
 
1.
 Location. The entity shall specifically
 identify and describe the setting in which Level II.1 Intensive Outpatient
 Services shall be provided. Services may be provided in any appropriate setting
 that protects the client's right to privacy, confidentiality, safety and meets
 the DMH facility certification standards.

2.
 Admission Criteria. The entity shall
 develop, maintain and implement written criteria for admission to its Level
 II.1 Outpatient Program and the following specifications: 
 
(i)
 The entity's admission criteria shall
 specify the target population for the Level II.1 Program which shall include,
 at a minimum, individuals whose assessed severity of illness initially warrants
 this level of care including but not limited to: 
 
(I)
 Individuals who have fairly stable to
 stable mental and/or physical health problems; and

(II)
 Who have supportive living
 arrangements.

(ii)
 The
 entity shall provide written documentation in individual case records that each
 client admitted to receive Level II.1 Intensive Outpatient Services meets: 
 
(I)
 The diagnostic criteria for a substance
 dependence disorder as defined in the most recent edition of the Diagnostic and
 Statistical Manual for Mental Disorders; and

(II)
 The dimensional criteria for admission
 to this level of care as defined in the most recent edition of the ASAM
 PPC-2R.

(iii)
 Adolescent
 Program Specific Criteria: The entity shall provide written documentation in
 individual case records that each adolescent admitted to receive Level II.1
 Intensive Outpatient Services meets:
(I)
 The
 diagnostic criteria for a substance use disorder as defined in the most recent
 edition of the Diagnostic and Statistical Manual for Mental
 Disorders.

(II)
 The adolescent
 dimensional criteria for admission to this level of care as defined in the most
 recent edition of the ASAM PPC-2R.

(iv)
 Co-occurring Disorders Program Specific
 Criteria: The entity shall provide written documentation in individual case
 records that each client admitted to receive Level II.1 Intensive Outpatient
 Services in a Co-occurring Enhanced Treatment Program meets: 
 
(I)
 The diagnostic criteria for a substance
 dependence and mental illness disorder as defined in the most recent edition of
 the Diagnostic and Statistical Manual for Mental Disorders; and

(II)
 The dimensional criteria for admission
 to this level of care as defined in the most recent edition of the ASAM
 PPC-2R.

(v)
 Women and
 Dependent Children Program Specific Criteria: The entity shall provide written
 documentation in individual case records that each client admitted to receive
 Level II.1 Intensive Outpatient Services in a Women and Children Program: 
 
(I)
 Meets the diagnostic criteria for a
 substance dependence disorder as defined in the most recent edition of the
 Diagnostic and Statistical Manual for Mental Disorders.

(II)
 Meets the dimensional criteria for
 admission to this level of care as defined in the most recent edition of the
 ASAM PPC-2R.

(III)
 Is pregnant;
 or

(IV)
 Has care and custody of
 dependent children; or

(V)
 Has lost
 custody of dependent children and has the potential for family
 reunification.

3.
 Core Services. Each Level II.1 Intensive
 Outpatient Program shall demonstrate the capacity to provide a basic level of
 skilled treatment services appropriate to the needs of its clientele. 
 
(i)
 At a minimum, the Level II.1 Intensive
 Outpatient Program shall directly or by referral provide the following core
 services:
(I)
 Placement assessment.

(II)
 Individual counseling.

(III)
 Group counseling.

(IV)
 Family counseling.

(V)
 Psychoeducation.

(VI)
 Mental health consultation.

(VII)
 Recovery support services.

(VIII)
 Peer counseling services.

(IX)
 Medication management.

(X)
 Alcohol and/or drug
 screening/testing.

(XI)
 Smoking
 cessation.

(XII)
 Sign language
 interpreter services.

(XIII)
 HIV
 early intervention services.

(XIV)

 Case management:
I.
 Case planning.

II.
 Linkage.

III.
 Advocacy.

IV.
 Monitoring.

(ii)
 Adolescent Program Specific Criteria:
 Each Level II. 1 Adolescent Intensive Outpatient Program shall document the
 capacity to provide each of the core services to include the following
 services: 
(I)
 Activity therapy.

(II)
 Academic and vocational
 services.

(III)
 Vocational
 services.

(iii)

 Co-occurring Disorders Program Specific Criteria: Each level II.1 Co-occurring
 Disorders Intensive Outpatient Program shall document the capacity to provide
 each of the core services to include the following services: 
 
(I)
 Basic living skills.

(II)
 Crisis intervention services.

(III)
 Intensive case management.

(IV)
 Academic and vocational
 services.

(iv)
 Women and
 Dependent Children Program Specific Criteria: Each Level II.1 Women and
 Dependent Children Intensive Outpatient Program shall document the capacity to
 provide each of the core services and/or arrange for the following services: 
 
(I)
 Transportation.

(II)
 Child sitting services.

(III)
 Developmental delay and/or prevention
 services.

(IV)
 Activity
 therapy.

(V)
 Parenting skills
 development.

4.

 Therapeutic Component Implementation. The entity shall document implementation
 of regularly scheduled treatment sessions that are provided in an amount,
 frequency and intensity appropriate to the client's assessed needs and
 expressed desires for care. 
(i)
 Service
 strategies for each Level II.1 Intensive Outpatient Program shall include, at a
 minimum: 
(I)
 Implementation of individualized
 counseling plan strategies.

(II)

 Ongoing individualized assessment.

(III)
 Motivational enhancement and engagement
 strategies.

(IV)
 Relapse prevention
 strategies.

(V)
 Interpersonal
 choice/decision-making skill development.

(VI)
 Health education.

(VII)
 Random drug screening.

(VIII)
 Medication administration and
 monitoring.

(IX)
 Gender responsive
 treatment.

(ii)

 Adolescent Program Specific Criteria: Each Level II. 1 Adolescent Intensive
 Outpatient Program shall document the capacity to provide the service
 strategies and the following therapeutic components: 
 
(I)
 Adolescent specific evidence based
 therapeutic interventions.

(II)

 Client education on key adolescent development issues including, but not
 limited to, adolescent brain development and the impact of substance use,
 emotional and social influence on behavior, value system development,
 puberty/physical development, sexuality and self-esteem.

(III)
 Recreation and leisure time skills
 training.

(IV)
 Family, community
 and school reintegration services.

(V)
 Academic or vocational
 services.

(iii)

 Co-occurring Disorders Program Specific Criteria: Each Level II.1 Co-occurring
 Disorders Outpatient Program shall document the capacity to provide the service
 strategies and the following therapeutic components: 
 
(I)
 Groups and classes that address the signs
 and symptoms of mental health and substance use disorders.

(II)
 Groups, classes and training to assist
 clients in becoming aware of cues or triggers that enhance the likelihood of
 alcohol and drug use or psychiatric decompensation and to aid in development of
 alternative coping responses to those cues.

(III)
 Dual recovery groups that provide a
 forum for discussion of the interactions of and interrelations between
 substance use and mental health disorders.

(IV)
 Intensive Case
 Management.

(iv)
 Women
 and Dependent Children Program Specific Criteria: Each Level II.1 Women and
 Dependent Children Intensive Outpatient Program shall document the capacity to
 provide the service strategies and the following therapeutic components: 
 
(I)
 Specific services which address issues of
 relationships, parenting, abuse and trauma.

(II)
 Primary medical care, including prenatal
 care.

(III)
 Primary pediatric care
 for children.

(IV)
 Therapeutic
 interventions for children which address their developmental needs and issues
 of sexual abuse and neglect.

(V)

 Outreach to inform pregnant women of the services and priorities.

(VI)
 Interim services while awaiting
 admission to this level of care.

(VII)
 Recreation and leisure time skills
 training.

(VIII)
 Academic and
 vocational services.

(IX)
 Financial
 resource development and planning.

(X)
 Family planning
 services.

5.

 Documentation: For each day in attendance, an individualized progress note
 shall be recorded to reflect services provided in Level II.1.

6.
 Support Systems. Each Level II.1 Intensive
 Outpatient Program shall develop, maintain and document implementation of
 written policies and procedures which govern the process used to provide client
 access to support services on site or through consultation or referral, which
 shall include:
(i)
 Medical, psychiatric,
 psychological, laboratory and toxicology services.

(ii)
 Medical and psychiatric consultation
 shall be available within twenty-four (24) hours by telephone or, if in person,
 within seventy-two (72) hours.

(iii)
 Direct affiliation with or coordination
 through referral to more and less intensive levels of care and supportive
 housing services.

(iv)
 Emergency
 services shall be available by telephone twenty-four (24) hours a day, seven
 (7) days a week.

(v)
 Mutual
 self-help groups that are tailored to the needs of the specific client
 population.

(vi)
 Referral for other
 services as according to the client's assessed needs.

7.
 Program Personnel. Each level II.1
 Intensive Outpatient Program shall employ an adequate number of qualified
 individuals to provide personalized care for its clientele and to meet the
 program's goals and objectives.
(i)
 Direct
 Care Personnel. All direct care personnel shall be qualified as a qualified
 paraprofessional to provide the specific services delineated in the entity's
 operational procedures for this level of care.

(ii)
 Clinical Personnel. The entity shall
 maintain an adequate number of clinical personnel to sustain the Level II.1
 Intensive Outpatient Program as delineated in its operational
 procedures.

(iii)
 Administrative
 Support Personnel. The entity shall maintain an adequate number of support
 personnel to sustain the program's administrative functions.

(iv)
 Every client in a Level II.1 Program
 shall be assigned to a specific primary counselor for care
 management.

(v)
 Each primary
 counselor shall maintain a case load not to exceed thirty (30) clients with
 active cases at any one time.

(vi)

 Adolescent Program Specific Criteria.
(I)

 Direct Care Personnel. All direct care personnel shall be qualified, as a
 qualified paraprofessional to provide the specific services delineated in the
 entity's operational plan for this level of care.

(II)
 Clinical Personnel. The entity shall
 maintain an adequate number of clinical personnel to sustain the Level II.1
 Adolescent Intensive Outpatient Program as delineated in its operational
 plan.

(III)
 Administrative Support
 Personnel. The entity shall maintain an adequate number of support personnel to
 sustain the program's administrative functions.

(IV)
 Every client in a Level II.1 Adolescent
 Intensive Outpatient Program shall be assigned to a specific primary counselor
 for care management.

(V)
 Each
 primary counselor shall maintain a case load not to exceed thirty (30) clients
 with active cases at any one time.

(vii)
 Co-occurring Disorders Program Specific
 Criteria.
(I)
 The Level II.5 Co-occurring
 Enhanced Partial Hospitalization Program shall have access to psychiatric
 services (led by a qualified psychiatrist or nurse practitioner) that are fully
 capable of evaluating, diagnosing and prescribing medications to clients with
 co-occurring disorders. On-call psychiatric services shall be available
 twenty-four (24) hours a day, seven (7) days a week.

(III)
 Treatment organization/agency shall
 have access to an Alabama licensed physician, full time, part time, or on
 contract, who shall be available to the program for client care and shall
 assume liability for the medical aspects of the program.

(VI)
 Treatment staff that provide therapy and
 ongoing clinical assessment services to individuals diagnosed with co-occurring
 disorders shall have, at a minimum:
I.
 A
 master's degree in a behavioral health related field with a minimum of two (2)
 years' work experience with individuals who have co-occurring disorders, mental
 health or substance use disorders.

II.
 Specialized training to work with
 individuals who have co-occurring disorders.

(V)
 All other direct care personnel in a
 Level II.1 Co-occurring Enhanced Intensive Outpatient Program shall be
 qualified as a qualified paraprofessional to provide the specific services
 delineated in the entity's operational plan for this level of care.

(VI)
 Clinical Personnel. The entity shall
 maintain an adequate number of clinical personnel to sustain the Level II.1
 Co-occurring Enhanced Outpatient Program as delineated in its operational
 plan.

(VII)
 Administrative Support
 Personnel. The entity shall maintain an adequate number of support personnel to
 sustain the program's administrative functions.

(VIII)
 Every client in a Level II.1
 Co-occurring Intensive Outpatient Program shall be assigned to a specific
 primary counselor for care management.

(IX)
 Each primary counselor shall maintain a
 case load not to exceed twenty (20) clients with active cases at any one
 time.

(viii)
 Women and
 Dependent Children Program Specific Criteria: 
 
(I)
 Direct Care Personnel. All direct care
 personnel shall be qualified as a qualified paraprofessional to provide the
 specific services delineated in the entity's operational plan for this level of
 care.

(II)
 Clinical Personnel. The
 entity shall maintain an adequate number of clinical personnel to sustain the
 Level II.1 Women and Dependent Children Intensive Outpatient Program as
 delineated in its operational plan.

(III)
 Administrative Support Personnel. The
 entity shall maintain an adequate number of support personnel to sustain the
 program's administrative functions.

(IV)
 Every client in a Level II.1 Women and
 Dependent Children Program shall be assigned to a specific primary counselor
 for case management.

(V)
 Each
 primary counselor shall maintain a case load not to exceed twenty (20) clients
 with active cases at any one time.

8.
 Training. The entity shall provide written
 documentation that all Level II.1 Program personnel satisfy the competency and
 training requirements as specified in Rule
 
580-9-44-.02
(3)
.

9.
 Service Intensity. 
 
(i)
 The entity shall document that the amount
 and frequency of Level II.1 Intensive Outpatient Services are established on
 the basis of the unique needs of each client served and shall be available a
 minimum of nine (9) hours but no greater than nineteen (19) hours each
 week.

(ii)
 Adolescent Program
 Specific Criteria. The entity shall document that the amount and frequency of
 Level II.1 Intensive Outpatient Services for adolescents are established on the
 basis of the unique needs of each client served and shall be available a
 minimum of six (6) hours but no greater than nineteen (19) hours each
 week.

10.
 Length of
 Service: The entity shall provide written documentation that the duration of
 treatment in each Level II.1 Intensive Outpatient Program shall vary as
 determined by:
(i)
 The severity of the
 client's illness.

(ii)
 The client's
 ability to comprehend the information provided and use that information to
 implement treatment strategies and attain treatment goals.

(iii)
 The appearance of new problems that
 require another level of care; or

(iv)
 The availability of services at an
 assessed level of need, when Level II.1 service have been utilized as interim
 services.

11.
 Service
 Availability: The entity shall provide written documentation describing the
 process utilized to establish the hours of service availability for its Level
 II.1 Intensive Outpatient Programs. At a minimum, this process shall: 
 
(i)
 Include consideration of the needs of the
 target population, including work, school and parenting
 responsibilities.

(ii)
 Include
 consideration of transportation accessibility.

(iii)
 Not be based solely on standard eight
 (8) to five (5), Monday through Friday office
 hours.

Notes

Ala. Admin. Code
 r. 
580-9-44-.17

 New Rule: Filed January
 26, 2012; effective March 1, 2012.

Amended by
 
Alabama
 Administrative Monthly Volume XLI, Issue No. 04, January 31,
 2023
, eff. 
3/17/2023
.

Author:
 Substance Abuse Services Division

Statutory Authority:

Code of Ala.
 1975
, §
 
22-50-11
.

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