Transcript Slide 1

Great Lakes ATTC
2009 Regional Advisory Board Meeting
April 16-17, 2009
Chicago, Illinois
Developing a Recovery Oriented System of Care:
Strategies and Lessons Learned
Ijeoma Achara PsyD
Purpose
• To review the need for a recovery focused
transformation of addiction Tx systems
• To explore different models of a Recovery
Oriented System of Care
• To examine effective strategies for system
and community leaders to create a recovery
oriented system of care
• To assist you in determining concrete next
steps for your community
© Performance Management Company, 2004
Those pushing often don’t have
a Vision of the future
Goals?
Leadershi
p feels
isolated
Vision?
Goals!
Inefficient Systems and Processes
Vision!
Waning Staff
Slow Progress forward…
Motivation?
People are working REALLY hard
© Performance Management Company, 2004
Potential Paradigm Shift
More of the Same?
Transformational ideas are always around us
Round Wheels are already in the wagon!
Best Practices already exist within our systems
What do We Know About Recovery?
Chronic Course
• Stable alcoholism recovery is not reached until 4-5 years of
sustained remission, longer for other drugs.
• Short periods of abstinence are really periods of brief dormancy
and not sustainable recovery.
• Linking reduces number of episodes of care and expedites reentry
• Post discharge continuing care enhances recovery outcomes but
only 1 in 5 clients receive such care.
Peer Support is Critical
• Enhances long-term recovery outcomes for a broad spectrum of
individuals.
Community Variables Impact Relapse
• Community recovery resources are just as important as individual
factors in tipping the scales of recovery maintenance versus
relapse
• Recovery can be initiated in an artificial environment, but
successful recovery maintenance can only be achieved in a
natural community environment
William White
What do We Know About Recovery?
• Family Inclusion and Support Promotes Long-term
Recovery
• Addressing Basic Needs is essential for long term
recovery
• A strong therapeutic relationship can overcome low
motivation for treatment and recovery.
• Those who drop out of treatment or who are
administratively discharged from treatment are
those who need treatment the most.
William White
What do We Know About
People’s Experiences in Tx?
Growing Body of Research Shows Improved
Effectiveness and Outcomes
• National Treatment Improvement Evaluation
Study
– 5 year study of treatment effectiveness of almost 4500
addiction clients nationwide reduced substance use
by 50%
– reduced criminal activity up to 80%
– increased employment and reduced homelessness
– improved physical and mental health
What do We Know About
People’s Experiences in Tx?
Research also highlights limitations of prevailing models
• High recidivism The majority (64%) of those entering
publicly funded treatment in the United States already have
one or more prior admissions, including 22% with 3-4 prior
admissions and 19% with 5 or more prior admissions
• High attrition during treatment ( more than half of those
admitted to tx do not complete, and 18% are
administratively discharged
• Low percentage of aftercare participation and low dose
of aftercare (less than 30% participate in 5 or more
sessions)
• Poor Outcomes (Of those who complete Tx, most resume
substance use)
• High readmission rates within 12 months
Conclusions from the Research
• The current structure of our service
systems do not maximize all that we
know about how to promote sustained
recovery
• The acute model that characterizes most
addiction treatment conflicts with
research findings on recovery stability
• We need to align our systems with what
we know are the critical factors
necessary for sustaining long term
recovery.
• We Need a New Paradigm!
ANY DEAD HORSES IN
OUR SYSTEMS?
Dakota tribal wisdom says that
when you discover you are riding a
dead horse, the best strategy is
to dismount. However, in human
services, we often try other
strategies with dead horses,
including the following:
Saying things like “This is the
way we have always ridden this
horse.”
Appointing a committee to
study the dead horse.
Arranging to visit other sites
to see how they ride dead
horses.
Harnessing several dead horses
together to establish a
continuum of dead horses.
Creating trainings to ensure
that we use best practices
to ride the dead horse.
Finding a consultant
knowledgeable about dead
horses.
Promoting the dead
horse to a supervisory position.
The real risk comes not
from changing, but from
trying to maintain the
status quo in a rapidly
changing world.
Strategies
That work
The Philadelphia Model
What are the Elements of a Recovery
Oriented System of Care? It….
1. Promotes Community Integration and mobilizes
the community as a resource for healing
2. Facilitates Family Inclusion
3. Facilitates a Culture of Peer Support and
Leadership
4. Values Partnership and Transparency
5. Provides holistic, Individualized, Person
Directed Tx which Supports Multiple Pathways
to Recovery
6. Creates Mechanisms for Sustained Support
What Does a Recovery Oriented
System of Care Actually Look Like?
System Level
Organizational Level
Program Level
Getting Out of the
Treatment Box
Community Integration
• System Level
–
–
–
–
Faith Based Initiative
Community Coalitions
Inclusive Trainings
Aligning funding so services can take
place in the community rather than on
site
• Organizational Level
–
–
–
–
Linkages with indigenous healers
Unit of intervention – beyond individual
Role is to build recovery capital
Address Stigma
Community Integration
• Program Level
– Assess community recovery capital
– Assertively link people to appropriate
resources
– Don’t create artificial settings for activities
that can occur in natural settings
– Engage people in healing their community
• If my neighborhood’s tore up, what’s going
to happen to me when I go out there. Some
programs tell you to stay away from people,
places and things that’ll trigger you. I can’t
do that. I live in a sober house. Next door’s
a crack house and across the street is the
package store. This place is tore up! What
am I supposed to do? If my community
don’t get better, I ain’t getting better.
Client in Amistad Village Project,
New Haven, CT
Peer Culture, Support and
Leadership
• The most undervalued/used resource is the knowledge,
skills and abilities of PIR.
System Level Strategies
– Peer Specialists Initiative
– PIR training on starting support groups
– Recovery Centers
– Storytelling Training
– Informal and formal (paid) peer support is a part
of all services in the system.
– Leadership Academy
– Inclusion in system development, consultants,
training, program evaluation
Peer Culture, Support and
Leadership
• Organizational Strategies
– Consumer Advisory Groups
– PIR involved with change management teams
– Hiring PIR and facilitating partnerships
– PIR involved with program development – what
helps and what hurts
• Program Strategies
– PIR led groups
– PIR provide continuing care/support e.g. telephonic
aftercare
– perform active recovery coaching
– facilitate early re-engagement
Individualized, Person Directed Tx
• System
– Re-writing CBEs
– Person centered planning trainings
Program
– Program fits person, not person working rigid
program
– Menu of services and supports
– Goals- broader focus than symptom reduction, life
goals are primary focus
– Collaborative
• Treatment goals and strategies are not determined
by the professional based on the presenting
problems, but determined in collaboration with PIR
and directed by PIR
– Self determination is valued over compliance
Sustained Support
• We expand the points of intervention so that
there is a greater continuum of care from preengagement to “aftercare”
• Outreach and early identification plays a critical
role - people don’t have to hit rock bottom before
having interactions with system
• Readiness is not an all or nothing thing,
emphasis is on pre- action stages of engagement
• The burden for successful engagement is on the
provider and not on the person in recovery
• Motivation is not a requirement of services, it is
an outcome
William White
Sustained Recovery Supports
• Systems Level
– System facilitates mechanisms for boosters, ongoing
support and early re-intervention
• Organizational Level
– A culture of community and belonging is created
– Flexible structure and roles
• Program Level
– Low threshold engagement, even for those “not
ready” for tx
– Providers recognize that early post treatment
recovery is when PIR are most fragile. As such,
treatment relationships do not end with graduation,
telephonic aftercare, recovery coaches,
– Staff and PIR conduct assertive outreach and followup
– PIR not administratively discharged for being
symptomatic
Meet People Where They Are
– My clients don’t hit bottom; they live
on the bottom. If we wait for them to
hit bottom, they will die. The obstacle
to their engagement in treatment is
not an absence of pain; it is an
absence of hope. —Outreach Worker
(Quoted in White, Woll, and Webber
2003)
How do You Structure a
ROSC?
The Additive Model
Challenges and Benefits of the
Additive Model
Challenges – Change at the Margins
• Oftentimes the focus primarily centers on pre and post
treatment supports, treatment context does not change
• Rigid boundaries between treatment and the community,
so tx is still taking place in an artificial environment
• Recovery supports are disconnected appendages or
adjuncts to treatment
• No connection between Tx and other peer and community
supports, therefore the burden is still on individuals to
navigate complex systems
Benefits
• More community based supports are available!!!
• Catalyst to start grassroots push for transformation
The Interactive Model
Challenges and Benefits of the
Interactive Model
Challenges: Interactive Model – Enhancements = Change
• Rigid boundaries still exist between the treatment setting and
peer driven and community supports
• Treatment setting is enhanced by presence of peer based
supports, but nature of treatment itself is unchanged.
• Primary focus is still on the treatment system and other
supports supplement the existing tx system
• Treatment system can protect itself from change
Benefits
• Additional recovery supports within tx context
• Increased collaboration/partnership between treatment,
community and PBRSS
• Assertive linkages are made promoting sustained recovery
Challenges and Benefits of
Transformative Model
Challenge: Paradigm shifts are difficult
• It takes intentional, sustained planning and effort to align all
levels of the tx system
Benefits: People get what they need, tx remains relevant
• The unit of intervention moves beyond the individual to the
family and community thereby creating a context to sustain
recovery and wellness
• Service philosophy changes and is consistent for tx and RS
• Treatment is no longer the primary focal point but one of
several critical resources that promote recovery
• The nature of treatment changes and there is regulatory and
fiscal alignment consistent with the vision of recovery
oriented care
Comparison of ROSC Models
Domain
Additive
Change in Tx
None
Comm. Health/ None
Interactive
Transformative
Low
Moderate
High
High
Prevention
Collaborative
Approach
Low
High
High
Relationship
w/ indigenous
Low
High
High
Community
Recovery
Capital
Peer culture/
leadership
High
High
High
High
High
High
Conceptual Framework Guiding the
Transformation Process
• Aligning Concepts:
Changing how we think
• Aligning Practice:
changing how we use
language and practices
at all levels;
implementing values
based change
• Aligning Context:
changing regulatory
environment, policies
and procedures
Aligning
Practice
Aligning
Concepts
Aligning Context
Conceptual Alignment
1.
Set the Context and Establish a Sense of Urgency
- Establish a baseline
- compare status with national/regional efforts
- seek out the voices of people in recovery
2. Form Powerful Guiding Coalitions
–
Change management team
–
RAC, OAS Advisory
3. Create a shared vision for change
4. Develop a conceptual framework for transformation that
encompasses all related initiatives
Conceptual Alignment
5. Over-communicate the vision
6. Develop participatory and transparent approaches
7. Create Forums for Knowledge Sharing and Exploration
of New Ideas
7. Address Perceived Loss and Facilitate Engagement
Practice Alignment
1. Establish Priorities
- community integration, peer support/leadership, sustained
recovery supports, holistic care, family incl.
2. Examine their implications for all levels of the system
3. Develop Mechanisms for Skill Building and Aligning Practices
with Priorities
- RFT, Tools for Transformation, Practice Guidelines
4. Empower all Stakeholders
5. Identify and mobilize the early adopters
- Invest in the enhancement/development of model
programs
Practice Alignment
6. Tackle the tough issues (regulatory changes, fiscal
alignment, risk and liability)
7. Create Short-term wins
8. Celebrate the successes
9. Begin to shift from invitation to expectation
Context Alignment
1.
2.
3.
4.
5.
6.
Align Organizational Structure
Learn what the barriers to recovery oriented care
are from your emerging practices
Address policy and fiscal issues for long-term
sustainability
Address Stigma
Strengthen the community and build Indigenous
recovery capital
Move beyond the choir – link it to other political
agendas
Where is Your System?
• Pre-contemplation
• Contemplation
• Preparation
• Action
• Maintenance
Stages of
Change
Major Focus of Alignment
PreContemplation
Contemplation
Conceptual
Preparation
Conceptual and Practice
Action
Practice and Contextual
Maintenance
Practice and Contextual
Conceptual
Three Types of Change
Developmental
Transitional
New
Old
State
Transition State
State
Three Types of Change (con’t)
Transformational
Wake-Up Calls
Reemergence
Through Visioning and
Learning
Growth
Chaos
Mindset
Forced to Shift
Birth
How Transformational Change is
Different
Transformational Change is unique
in three critical ways:
•
•
•
The future is unknown and only through
forging ahead will it be discovered.
The future state is so different than the
traditional state that a shift of mindset is
required to invent it.
The process and the human dynamics are
much more complex, partnership is critical!