Transcript Sustained Recovery Management

Applying the Principles of Chronic Illness
Care To Drug Addiction Treatment
Sustained Recovery Management
Department of Alcohol & Drug Services
The Chronic Care Model
1. Community
Resources & Policies
3. SelfManagement
Support
Informed,
Activated
Patient
2. Health System
Health Care Organization
4. Delivery
System
Design
Productive
Interactions
5. Decision 6. Clinical
Support
Information
Systems
Prepared,
Proactive
Practice Team
Improved Outcomes
Wagner, EH. Effective Clinical
Practice 1998;1:2-4.
Community
Health System
Resources and Policies
Organization of Health Care
No links with or only passive
referrals to community
agencies or resources
Leadership concerned about the bottom line
and favor more frequent, shorter visits.
No organized QI functional oversight
SelfManagement
Support
No systematic approach;
didactic in orientation
Uninformed,
Passive
Patient
Delivery
System
Design
Reliance
on short
visits
Decision
Support
No agreement
on good care;
traditional
referrals
Frustrating
Problem-Centered
Interactions
Clinical
Information
Systems
Don’t know
pts or what
they need
Unprepared
Practice Team
Crummy (suboptimal)
Functional and Clinical Outcomes
Wagner, EH. Effective Clinical Practice 1998;1:2-4.
Our Evolving System of Care
• Shifted from a system of fragmented and isolated treatment
providers to a managed and coordinated system of care
 Standardized language and forms
 Created a continuum of care
 Individualized client-driven treatment versus
program-driven
 Focus on meeting client where they are at
• Developed a continuous quality improvement process
• Implemented UniCare - a system-wide data base program
• Implemented clinical standards of care from evidence-based
research
• Making the shift from traditional acute care treatment to the
chronic care model with post-treatment check-ups
How We Apply the Chronic Care Model
2. Working collaboratively with other health
providers and County Departments to develop
integrated case managed care
1. The Innovative Partnership with the
addiction treatment provider network, Drug
Courts, Health & Hospital System
2. Health System
Health Care Organization
1. Community
Resources & Policies
3. Sustained
recovery
monitoring,
patient
education and
self
management
support
3. SelfManagement
Support
Informed,
Involved
Patient
4.
Delivery
System
Design
5.
Decision
Support
Productive
Interactions
6. Clinical
Information
Systems
Prepared,
Proactive
Practice Team
6. Research
and
development
for planning
delivery and
evaluation of
the care
system,
UniCare data
base
Functional & Clinical Outcomes
4. A managed and coordinated system of
care that reduces avoidable inpatient,
hospital and jail admissions, continuous
quality improvement systems
5. Application of nationally recognized
evidence-based treatment practices
Self-Management Support
Empower and Prepare Patients to
Manage Their Recovery and Health Care
• Group & individual instruction on the chronic
nature of addiction , self-monitoring, situational
complications, and relapse prevention
• Client-driven care planning with identified
goals and “how-to’s”
• Training in “staged-based treatment”
• A culture that fosters the importance of
individualizing the goals & management
of addiction and sustained recovery
• Patient is a part of their care planning
• “Within-session” rating scales for counseling
therapy immediate feedback
Delivery System Design
Assure the Delivery of Effective, Efficient
Clinical Care and Self-Management Support
• A managed and coordinated system of care
• Client-driven and outcomes-informed treatment
• ASAM PPC-2R framework for the system of care
• Internal certification for all providers and
stakeholders
• Management system infrastructure including
Operations and Clinical Supervisors collaborative
• Recovery management and patient as member of the
treatment care team
Decision Support
Promote Clinical Care that is Consistent with
Scientific Evidence and Patient Preferences
• Established evidence-based and target-driven
management protocols based on national guidelines for:
• sustained recovery management
• relapse prevention management
• Multiple options available for most protocols such that
management can accommodate patient preference
Clinical Information Systems
Clinical Information Systems
Organize Patient Data
to Facilitate Efficient and Effective Care
• Common clinical language based on ASAM
• Real time “within-session” rating scales for counseling therapy
immediate feedback
• UniCare system-wide data base program
• Quality Improvement division to manage care system efficiency
• The Learning Institute continuing educational opportunities
The Health System
Create a Culture, Organization and Mechanisms
that Promote Safe, High Quality Care
• Established visionary leadership and commitment
from multiple levels of DADS
• Established plans for a system re-design,
incorporating the ideas and skills of provider
leadership with a mandate to include the principles of the
Chronic Care Model
• Established Departmental support to assess the
efficiency & outcomes of new and innovative care
management programs
The Community
Mobilize Community Resources
to Meet Needs of Patients
• Partnerships with Mental Health, Social Services,
Public Health, Justice Services, and Medical
Services
• The Learning Institute educational forums
• Development of a Social Medicine program
Community Awareness &
Education
•
•
•
•
•
Treatment Works! month
Recovery awareness campaigns
Community education (Learning Institute)
Internship programs
Solutions for Wellness program (from the
UMDNJ)
Our Future . . .
Utilize the Chronic Care model (CCM) to
design an approach that will:
• Improve the patient experience including
quality and access;
• Make work life more fulfilling for providers;
• Allow and encourage all team members to
fully utilize their skills and potential; and
• Reduce total healthcare expenditures
of high cost patients
The Need and the Challenge:
To transform the current system of care, from
one that is essentially reactive - responding
mainly when a person is sick - to one that is
proactive and focused on keeping a person as
healthy as possible.
The Current System of Care for Addiction
as an Acute Illness
Completion of care, discharged,
passive referrals to self-help meetings,
community support and case is closed.
Detox
Residential
Outpatient
Transitional
housing
The traditional continuum of care system stops short of
providing continuing care services – an essential element
in treating chronic conditions
Toward A System of Care for Addiction as a
Chronic Illness
Treatment Intensity
As personal responsibility
increases, treatment
intensity decreases
Continuing Care Services (CCS): Frequency of
contact determined at each post-treatment session
Detox
Residential
Outpatient
Brief
Transitional
Community
intervention
housing
support
From CCS risk assessment:
Via telephone
E-counseling, or
Face-to-face
Education
Brief intervention
Brief counseling
Readmission
Continuing Care Services Approach: PostTreatment Check Ups
• Follow-up visits focus on incremental
behavioral changes & addressing
recovery issues
• Once acute treatment issues have been stabilized,
patient moves to continuous care services with
instructions for recovery management
• Patient always welcome to return
A Conceptual Model: DADS Services Continuum
Determinants of Progress in Tx:
Patient motivation, responsibility, choice (Dim 4)
Predisposing factors
Enabling factors/barriers
Illness/Need factors (Dim 2, 3)
System of Care characteristics
Prepare client for sustained recovery monitoring
Detox
Residential
Outpatient Transitional
housing
Brief
Community
Intervention
support
Identify within-session patient and
therapist behaviors that predict
subsequent dropout or relapse
(ORS/SRS)
Teach patients to be proactive, not
reactive, to their disease.
Continuous monitoring:
 Healthy lifestyle
 Self management support
 Patient & family education
 Regular follow ups with provider
 Support groups
What We’re Working On
What does it look like, how often, by whom and with what type of contact, at what cost, using
what type of risk assessment scale, data collection needs, and ways to expedite re-admission if
needed ???
A Shift from Acute Care to a more sustained recovery
management model. Where we’ve placed the initial focus
for a system redesign
What the
Hot Group
has been
working on
STATE AND COUNTY SYSTEM CHANGES NEEDED TO
SUPPORT SUSTAINED RECOVERY MANAGEMENT
At the STATE Level:
• Obtain authorization for a post-treatment recovery support
phase of care (aka, continuing care services)
• CalOMS DISCHARGE requirements for recovery support
phase clients
• Provide reimbursement for recovery support phase of
treatment
STATE AND COUNTY SYSTEM CHANGES NEEDED TO
SUPPORT SUSTAINED RECOVERY MANAGEMENT
At the County Level:
• Streamline the readmissions process. Change readmission
requirements for CCS pts returning to treatment at same clinic and
with same counselor
• Develop a simple data collection plan for post-treatment
checkups. What is it we want to know about these people?
• Contact documentation forms. NOTE: These need to be really
simple and brief.
• Add more levels of care for continuous recovery monitoring (i.e.
brief intervention, 1-2 episodes of OP treatment, etc.)
Toward A System of Care for Addiction as a
Chronic Illness
• Streamline the readmissions process for CCS clients
•Additional level of care for CCS
Continuing Care Services (CCS)
Detox
Residential
Outpatient
Brief
intervention
CCS priority admissions over waitlist.
Readmission back to “home clinic” as a
pre-auth to bypass Gateway.
Transitional
Community
housing
support
References
American Society of Addiction Medicine. www.asam.org
Dennis, M.L., Scott, C.K., & Funk, R. (2003). An Experimental Evaluation of
recovery Management Checkups For People With Chronic Substance Abuse
Disorders. Evaluation and Program Planning, 26, 339-352.
Flaherty, Michael. (2006). A Shift From An Acute Care to a Sustained Care
Recovery Management Model. Institute for Research, Education and Training in
Addictions.
Foote, A. & Erfurt, J.C. (1991). Effects of EAP Follow-Up On Prevention of
relapse Among Substance Abuse Clients. Journal of Studies on Alcohol, 18,
143-161.
McKay, J.R., Lynch, K.G., Shepard, D.S.,& Pettinati, H.M. (2005). The
Effectiveness of Telephone Based Continuing Care For Alcohol and Cocaine
Dependence: 24 Month Outcomes. Archives of Gen Psych, 62. 199-207.
References
McLellan, A.T., McKay, J.R., Forman, R., Cacciola, J., and Kemp, J. (2005).
Reconsidering the Evaluation of Addiction Treatment: From Retrospective Follow-Up to
Concurrent Recovery Monitoring. Addiction, 100(4), 447-458.
Miller, W.R., Westerberg, V.S., Harris, R.J., & Tonigan, J.S. (1996). What Predicts
Relapse? Prospective Testing of Antecedent Models. Addiction, 91, S155-S172.
Nestler EJ, Malenka RC. The addicted brain. Scientific American. March 2004.
Neuroscience of Psychoactive Substance Use and Dependence. Geneva: World Health
Organization; 2004.
White, W. & Kurtz, E. (2006). Linking Addiction Treatment and Communities of
Recovery: A Primer for Addiction Counselors and Recovery Coaches. Pittsburgh, PA:
IRETA/NeATTC.
White, W. & Kurtz, E. (2005). The Varieties of Recovery Experience. Chicago, IL: Great
Lakes Addiction Technology Transfer Center.