Code of Colorado Regulations
500 - Department of Human Services
502 - Behavioral Health
2 CCR 502-1 - BEHAVIORAL HEALTH
Chapter 4 - Behavioral Health Outpatient and High Intensity Outpatient Services
Section 2 CCR 502-1-4.8 - Level 2-Withdrawal Management (Level 2-WM): Ambulatory Withdrawal Management with Extended On-Site Monitoring Services Standards

Universal Citation: 500 CO Code Regs 2 CCR 502-1-4.8

Current through Register Vol. 48, No. 6, March 25, 2025

A. This part 4.8 is established to create standards for agencies seeking a sub-endorsement to provide outpatient Level 2-Withdrawal Management (Level 2-WM) services in accordance with Chapter 6 of the ASAM Criteria.

B. Agencies providing Level 2-WM services must meet the standards in this part 4.8. Agencies providing Level 2-WM services may:

1. Also engage in outpatient behavioral health services by meeting the standards for the outpatient sub-endorsement(s) selected by the agency; or

2. Provide only Level 2-WM services and coordinate with other providers for ongoing and concurrent outpatient behavioral health treatment services.

4.8.1 Service Delivery and Setting

A. Level 2-WM is an outpatient withdrawal management service that complements individualized behavioral health treatment services.

B. Individuals may participate in Level 2-WM for a period of time in which it is determined to be medically appropriate. Admission to Level 2-WM services must not hinder the individual's ability to participate in concurrent behavioral health services. This includes the potential process of admitting to, and discharging from, such withdrawal management services one (1) or more times by the individual.

C. Level 2-WM services are generally provided in a day hospital-type setting, general health care facility, or an agency providing substance use disorder or mental health treatment.

D. Level 2-WM services offered by agencies that do not provide behavioral health services within their agency structure must be affiliated with BHEs or other necessary providers to ensure the treatment needs of all individuals served can be met. Documentation of this affiliation must be presented to the BHA, upon request. Referral(s) will be provided in collaboration with the individual and their choice(s) for referred services.

E. Support systems

1. Agencies must:

a. Have the ability to obtain a comprehensive medical history and physical examination at the time of admission to Level 2-WM services;

b. Have twenty-four (24)-hour access to emergency medical consultation services, should emergency services become indicated;

c. Have the ability to provide or assist in accessing transportation services for individuals who lack safe transportation; and

d. Have the ability to coordinate services with behavioral health personnel, within the agency or through referral.

F. Diagnostic criteria

1. Individuals participating in Level 2-WM services typically exhibit a moderate withdrawal severity rating on standardized withdrawal severity scales as well as mild/stable psychiatric symptoms for emotional, behavioral, and cognitive conditions.

2. Individuals may also present with a higher withdrawal severity rating on standardized withdrawal severity scales or with higher psychiatric symptom requirements, with sufficient protective factors and other support system(s) in place to safely participate in Level 2-WM services.

3. Due to the safety concerns inherent with withdrawal, individuals with complicated withdrawal severity ratings may not be appropriate for Level 2-WM services.

a. If the medical personnel determines that an individual meeting the above criteria can be safely and effectively served in a Level 2-WM setting, the rationale and plan for safe management and services must be documented in the individual's record.

4. Individuals may be more advanced in their readiness to change and may require assistance with transportation or other engagement barriers.

5. Individuals may participate in Level 2-WM services without a formal substance use disorder diagnosis if collateral information indicates a high probability of such diagnosis. The agency must ensure further evaluation of this probable diagnosis, either completed within the agency or through referral to a behavioral health provider.

G. Agencies must:

1. Provide safe management and documentation of signs and symptoms of intoxication and withdrawal; and

2. Ensure that discharge planning begins at the time of admission to Level 2-WM services, to allow for necessary care coordination and transition into ongoing or concurrent treatment services to occur successfully based on screening or assessment of needs.

4.8.2 Personnel

A. Level 2-WM services are primarily provided by medical professionals who are acting within the scope of their practice and are trained in assessing and managing intoxication and states of withdrawal. This may include, but is not limited to:

1. Authorized practitioners; and

2. Nurses.

B. Level 2-WM is an outpatient service that requires daily monitoring of withdrawal symptoms and assessments of progress. This requires medical personnel to be readily accessible and able to evaluate an individual's needs and safe placement in Level 2-WM.

4.8.3 Service Provisions

A. Agencies must develop policies and procedures to address service delivery expectations. These policies and procedures must address, but are not limited to the following:

1. Consultation with specialized clinical and medical professionals for individualized Level 2-WM care;

2. Coordinating an individual's transition into other Levels of care determined to be appropriate through triage, screening, evaluation, and/or assessment processes completed during their Level 2-WM services. This may include collaboration with emergency behavioral health services, such as Colorado Crisis Services, as appropriate;

3. Conducting or arranging for laboratory and/or toxicology tests to be completed;

4. Responding to individuals who are assessed as being a current threat to themselves or others, including the appropriate use of law enforcement;

5. Communication with intoxicated individuals leaving Level 2-WM services against personnel recommendations, including the use of emergency commitments; and

6. Circumstances under which individuals may be discharged from Level 2-WM services, other than completing withdrawal management or leaving against personnel recommendations.

B. Admission procedures for Level 2-WM services must include at a minimum:

1. Collection of information regarding the degree of alcohol and/or other drug intoxication as evidenced by breathalyzer, urinalysis, self-report, observation, or other evidence-based or best practices;

2. A pregnancy screening for pregnancy-capable individuals;

3. Taking of vital signs; and

4. Administration of a validated clinical withdrawal assessment tool.

C. Therapies offered by the agency must include a range of treatment approaches and support services based on the screening or assessment of the individual's treatment needs. Treatment services may include but are not limited to:

1. Screening;

2. Assessment;

3. Group and individual counseling;

4. Motivational enhancement;

5. Family therapy;

6. Educational groups;

7. Occupational and recreational therapy;

8. Addiction pharmacology;

9. Mental health and physical health pharmacology, as needed;

10. Medication management;

11. Peer, social and recovery support;

12. Care coordination; and

13. Support for the development of life skills.

D. If the agency does not provide a treatment approach or support service necessary to meet the individual's treatment needs, the agency must ensure that care coordination occurs.

E. Agencies must provide additional service planning for managing individuals with medical conditions, suicidal ideation, pregnancy, psychiatric conditions, and other conditions which place individuals at additional risk during withdrawal management.

F. Agencies must provide assessments of individual readiness for treatment and services based on the service plan and the assessments and interventions shall be documented in the individual's record.

G. Medication-assisted treatment (MAT) for withdrawal management

1. Agencies must continue individuals on their medication-assisted treatment regimen and will only remove individuals from medications treating opioid use disorders at the individual's request or if it is deemed medically appropriate by an authorized practitioner.

2. Agencies must inform individuals receiving services about access to medication-assisted treatment. Upon the individual's consent, the agency must provide medication-assisted treatment directly.

3. Agencies must obtain a controlled substance license pursuant to section 21.300 of 2 CCR 502-1 from the BHA if they plan to dispense, compound, or administer a controlled substance from stock medication in order to treat a substance use disorder or to treat the withdrawal symptoms of a substance use disorder.

a. A controlled substance license is not required if the agency intends to provide medication-assisted treatment (MAT) services through prescription writing only, under an independent prescriber's license.

4.8.4 Documentation and Timeliness

A. Upon admission to Level 2-WM services, the agency must complete the following requirements, keeping documentation of timely completion in the individual's record:

1. Conduct a physical examination of the individual. This may be conducted by an authorized practitioner;

2. Conduct an addiction-focused history of the individual. This may be conducted by an authorized practitioner; and

3. Utilize screening tools in the process of gathering sufficient biopsychosocial and ASAM dimensional criteria as outlined in Chapter 6 of the ASAM Criteria, to inform an individualized, withdrawal management-focused service plan.

B. Implementation of the service plan, including any amendments to the service plan and the individual's clinical response to the services provided, must be maintained in the individual's record during the time they remain engaged in Level 2-WM services. This may include serial medical assessments, withdrawal rating scales and/or flow sheets that are conducted, as needed.

C. The service plan and progression tracking may be indicated in progress notes that align with the existing medical model for documentation.

D. Individuals may engage in a pattern of admitting to, and discharging from, Level 2-WM services in a repeated and fluid manner throughout a concurrent behavioral health episode of care. Documentation specific to these engagement milestones for Level 2-WM services may be reflected in the existing medical model documentation and does not require a formal discharge summary as detailed in part 2.10.A.5 and 2.10.A.6 of these rules.

E. Considerations for discharge from Level 2-WM services include, but are not limited to:

1. Resolution or diminishing of withdrawal symptoms, that allow the individual to be safely served at a lower service level, such as Level 1-WM;

2. Symptoms that have not improved or have intensified after engaging in Level 2-WM services and the individual requires a higher service, such as Level 3-withdrawal management (Level 3-WM); or

3. The individual is unable to participate in Level 2-WM and may require a different support system or delivery mechanism.

F. If a different level of care is required, the agency providing Level 2-WM services must initiate a referral to the appropriate level of care.

Disclaimer: These regulations may not be the most recent version. Colorado may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.

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