Identifying Levels of Care

This article provides an overview of the different levels of care in behavioral healthcare, as well as the care coordination services you can request from Rula’s Care Coordination team, and when to refer clients to a higher level of care.

What are “Levels of Care” in behavioral healthcare?

Just like medical care, behavioral healthcare has different levels of intensity. There are two main categories: inpatient and outpatient.

• Inpatient care is more intensive and typically recommended for people in a mental health crisis. They need immediate safety measures to prevent harm to themselves or others.
• Outpatient care is more routine and suitable for people with less severe symptoms, not severe enough to need inpatient treatment.

Clinicians consider several factors to determine the best level of care for each client. Additionally, specialized services like addiction treatment may have even more varied levels of care.

Lower Levels of Care

Clients with less intensive needs or those seeking support for non-urgent issues are typically suited for a lower level of care. Here are some signs this level of care might be appropriate:

• Mild symptoms: Your client’s symptoms are manageable and don't require immediate intervention.
• Non-urgent issues: The concerns don't pose an immediate risk of harm to themselves or others.
• Recent problems: The issue is new, and it's unclear how long it will last.

Outpatient Care

Outpatient care is the most common level of mental healthcare. It allows clients to receive treatment while living at home and maintaining their daily routines. Here's what outpatient care typically involves:

• Therapy sessions: Clients typically meet with a therapist one or two times a week, with the duration varying based on individual needs.
• Medication management: Some clients may also receive medication management from a psychiatrist, primary care physician, or nurse practitioner, with appointments ranging from every few weeks to a few months.

Some treatment centers offer "wrap-around care," which combines various outpatient services like individual therapy, group therapy, medication management, and on-call crisis services. These services can be provided by:

• Private practices
• Community mental health centers
• Hospital-based outpatient programs

Beyond wrap-around care, there are many other types of outpatient mental healthcare available:

• Self-help: Books, online resources, and self-guided programs.
• Support groups: Connecting with others facing similar challenges.
• Therapy Apps: Smartphone apps offering guided activities or exercises.
• Individual therapy: One-on-one sessions with a therapist.
• Psychiatry: Medication management from a psychiatrist.
• "À la carte" care: Combining different outpatient services based on individual needs.

Generally, the most independent form of mental healthcare involves individuals seeking out and managing their own resources. This might include self-help materials, support groups, or therapy apps.

Higher Levels of Care

Higher levels of behavioral healthcare provide more intensive treatment and support than traditional outpatient therapy. These programs are typically used when someone needs more structure and supervision than outpatient care can offer.

Common categories of more intensive mental healthcare include:

• Crisis stabilization units and other short-term inpatient crisis care
• Acute inpatient treatment (intensive psychiatric hospitalization)
• Subacute inpatient treatment (long-term residential care)
• Nursing home treatment or round-the-clock care
• Intensive outpatient treatment programs
• Partial hospitalization or day treatment
• Intensive community-based support services
• Community-based crisis intervention services

Residential Treatment

Residential treatment provides intensive mental healthcare in a safe, supervised environment. Unlike a Partial Hospitalization Program (PHP) where clients go home at night, residential clients stay overnight. Here's what residential treatment involves:

• 24/7 supervision: Trained professionals provide constant care in a home-like setting, not a hospital.
• Therapy and support: Clients receive treatment from therapists, psychiatrists, nutritionists, and other specialists.
• Length of stay: Residential programs typically last 90 days or longer.

Who Needs Residential Treatment?

Residential treatment is suitable for individuals who meet some or all of these criteria:

• Formal diagnosis: A licensed mental health professional has diagnosed a condition causing significant challenges in daily life.
• Potential for improvement: Treatment is expected to lead to recovery and improved functioning.
• High risk: The individual is highly likely to need more restrictive care, such as inpatient hospitalization if not residential treatment.
• Safe alternative: A comprehensive evaluation suggests residential treatment can safely replace a higher level of care.
• Willingness to participate: The individual can follow program rules, accept supervision, and actively engage in treatment. Refusal to participate in treatment itself becomes a treatment focus if cooperation with other aspects of the program is present.

Inpatient/Acute Care

Inpatient care is the most intensive level of mental healthcare, provided in a hospital setting. It's reserved for severe situations where someone's safety or ability to function is at risk. Here's what inpatient care involves:

• Close monitoring: Clients are closely monitored by medical professionals due to severe symptoms.
• Medication adjustments: Inpatient care can be used to manage major medication changes safely.
• Short-term treatment: Stays typically last a few days or weeks until clients can transition to a less intensive program.

Who Needs Inpatient Care?

Inpatient care is suitable for individuals experiencing some or all of these criteria:

• Immediate safety risk: Suicidal thoughts with a plan and means, or violent threats/actions towards oneself or others.
• Severe self-harm: Recent life-threatening self-mutilation or risky behavior.
• Psychosis: Disorganized or psychotic behavior that significantly impacts daily life and safety.
• Severe medication side effects: Life-threatening side effects from psychotropic medications.
• Extreme impairment: Severe limitations in daily functioning that require intensive treatment.

Additional considerations

• Clients must be medically stable to receive inpatient care.
• The goal is to help clients improve and transition to a lower level of care.
• Willingness to participate in treatment is important.

Intensive Short-Term Treatment programs

Intensive Outpatient Programs (IOP)

An IOP is a structured program offering several hours of therapy most days of the week (typically 3-4 hours a day, a few days a week). This level of care allows you to return home each night. Here's what IOPs typically involve:

• Group therapy: Connect and learn from others facing similar challenges.
• Psychoeducation: Gain knowledge about mental health and recovery.
• Individual therapy: Address your specific needs and goals with a therapist.
• Psychiatry services (optional): Medication management from a psychiatrist, if needed.
• Experiential therapy (optional): Explore creative therapies like music or art therapy.

Participation in IOPs is voluntary, allowing you to manage your recovery alongside daily life. For details on specific IOP variations, please refer to the Therapist Help Center Article titled Intensive Outpatient Program.

Partial Hospital Programs (PHP)

A PHP is a more intensive level of care compared to an IOP. It's often used as a first step before transitioning to an IOP within the same program. Here's what sets PHPs apart:

• Increased time commitment: Clients typically attend for 5-6 hours, 5 days a week, compared to an IOP's schedule.
• Similar program structure: PHPs offer group therapy, individual therapy, psychoeducation, and potentially other services like those found in IOPs.

Like IOPs, PHP participation is voluntary, and clients return home each night. For details on specific program variations, please refer to the Therapist Help Center Article titled Intensive Outpatient Program. 

Where does therapy fit into all of this?

Therapy is a versatile treatment option that can address a wide range of mental health concerns. It can be used independently or alongside more intensive programs like IOPs or inpatient care.

The Right Care at the Right Time

Mental health needs can change over time. Therapists help clients find the most appropriate level of care based on their current needs. This might involve individual therapy, couples therapy, or family therapy.

When to Consider More Support

If symptoms worsen or safety becomes a concern, therapists may recommend a higher level of care, such as an IOP or inpatient program. Additional services might also be helpful in these situations.

What about referring my clients to Psychiatry?

Referrals to psychiatry can be an option as an adjunct service in support of interdisciplinary treatment and/or a higher level of care, depending on your client’s circumstances. Please click HERE for information about referring clients to psychiatry.

Care Coordination at Rula

Here are the care coordination services you can request from Rula’s Care Coordination team.

Higher Level of Care (HLOC)

If your client requires more intensive mental healthcare, we can help find appropriate programs and resources. Our Care Coordinators are here to support you! 

We’re able to assist with finding resources and care for the following HLOC programs:

• Intensive Outpatient Programs (IOP): Structured therapy programs offering several hours of therapy most days of the week.
• Partial Hospitalization Programs (PHP): More intensive than IOPs, with clients attending for longer hours each day.
• High-Acuity Rematching: If a client's needs seem beyond your scope of practice (e.g., psychosis, recent suicide attempt, domestic violence, threatening behavior), our team can help facilitate a rematch with a more suitable therapist within Rula's network.

Adjunct Services

Care Coordinators are also able to assist with linking clients to adjunct services such as:

• Group therapy
• Psychological testing
• Psychiatry (medication evaluations)
• Support groups

Continuity of Care

At Rula, our philosophy of care is that telehealth is appropriate for most people seeking outpatient care; however, we recognize there are clinical exceptions. 

Our ability to directly connect a client with in-person providers is limited. However, we can provide external resources to help your client find an in-person therapist. For clients with severe or persistent symptoms, or those considered high-risk, we recommend exploring IOP or PHP programs which offer more intensive in-person care.

When should I refer my client for HLOC?

Therapy and psychiatry offer a wide range of approaches to address various mental health needs. Many people find success with either individual therapy or medication management alone. However, if symptoms become severe or persist despite routine outpatient care, a higher level of care might be necessary.

For example, talk therapy or monthly medication management might not be enough for someone at immediate risk of harming themselves or others. But depending on the situation, a combination of both could be an effective treatment option.

As a therapist, you can adjust the frequency of sessions and the type of therapy used. Nurse practitioners can continue medication management and refer clients to additional resources when needed.

Here are some tips to ensure a smooth referral process and avoid delays in your client's care:

• Explain the Why: Before submitting a referral, discuss the reasons behind your recommendation with your client. This helps them understand why a higher level of care might be beneficial.
• Shared Decision-Making: Present referrals as an option to explore further support and explain the benefits of an assessment. Empower your client to feel in control of their care decisions. If your client hesitates to seek assessment initially, let them know the option remains open. During future sessions, remind them of the value of a formal diagnosis for treatment planning.
• Respectful Communication: Use the pronouns your client prefers.
• Addressing Concerns: Discuss potential barriers like cost, insurance coverage, and appointment wait times.
• Monitor Your Email: Care Coordinators might email you if any information is missing from the referral. Checking your email regularly helps avoid delays in your client's care. Emails from Care Coordination will come from care@rula.com. 

How to interpret assessment scores?

For information regarding using, interpreting, and discussing measurement-informed care (MIC) with your clients, please see the below articles:

• Measurement Informed Care (MIC) at Rula
• Interpreting GAD-7 scores
• Interpreting PHQ-9 scores
• Interpreting C-SSRS scores
• Reviewing Measurement-Informed Care in Session with Clients

Also, check out these clinical care guidelines which offer a brief summary of the evidence-based, best practices for the effective treatment of the following disorders in adults. 

• Generalized Anxiety Disorder (GAD) (PDF / Help Center article)
• Major Depressive Disorder (MDD) (PDF / Help Center article)
• Posttraumatic Stress Disorder (PTSD) (PDF / Help Center article)
• Attention-Deficit/Hyperactivity Disorder (ADHD) (PDF / Help Center article)
• Adjustment Disorder (PDF / Help Center article)

How can I make sure I’m clearly documenting the clinical rationale for a HLOC request?

Please check out the article HERE.