A validity study of the Washington Circle continuity of care performance measure Mark D. Godley Bryan R. Garner Rodney R. Funk Lora L. Passetti Susan H. Godley Chestnut Health Systems Bloomington, IL 2008 Research Society on Alcoholism Conference Washington, D.C.

This work was supported by the National Institute of Alcohol Abuse and Alcoholism (2 R01-AA010368) Dr. Margaret Mattson, Project Official Dr. Peter Delany, Past Project Official Acknowledgement

What is the Washington Circle? Formed in 1998 by the Center for Substance Abuse Treatment, the Washington Circle (WC) is a multi- disciplinary group of providers, researchers, managed care representatives, and public policy representatives.Formed in 1998 by the Center for Substance Abuse Treatment, the Washington Circle (WC) is a multi- disciplinary group of providers, researchers, managed care representatives, and public policy representatives. Goals of the WC were to:Goals of the WC were to: Develop and pilot test performance measures for substance abuse treatment programsDevelop and pilot test performance measures for substance abuse treatment programs Promote adoption of these measures by public and private stakeholdersPromote adoption of these measures by public and private stakeholders

What are the Washington Circle Performance Measures? Identification – number of individuals with a substance abuse or dependence diagnosis who received a substance abuse treatment service during the year among those who were eligible for servicesIdentification – number of individuals with a substance abuse or dependence diagnosis who received a substance abuse treatment service during the year among those who were eligible for services Initiation – number of individuals with an outpatient index service (i.e., first treatment service preceded by a 60 day service-free period) during the year who received a second treatment service (other than detoxification or crisis service) within 14 days after the index outpatient serviceInitiation – number of individuals with an outpatient index service (i.e., first treatment service preceded by a 60 day service-free period) during the year who received a second treatment service (other than detoxification or crisis service) within 14 days after the index outpatient service Engagement – number of individuals with an outpatient index service during the year who received two additional services (other than detoxification or crisis service) within 30 days after initiation.Engagement – number of individuals with an outpatient index service during the year who received two additional services (other than detoxification or crisis service) within 30 days after initiation.

Washington Circle Continuity of Care Performance Measure Continuity of care after… Assessment ServiceAssessment Service DetoxificationDetoxification Short-term ResidentialShort-term Residential Long-term ResidentialLong-term Residential InpatientInpatient Continuity of Care is defined as the number of individuals with an additional service within 14 days after discharge from the previous service. Source: Garnick, Lee, Horgan, & Acevedo (2007)

Current Research on the Relationship between Washington Circle Performance Measures and Outcomes Harris, Humphreys, & Finney (2006)Harris, Humphreys, & Finney (2006) Used data from 5,723 patients who had received substance abuse treatment from one of 110 Veterans Affairs programs.Used data from 5,723 patients who had received substance abuse treatment from one of 110 Veterans Affairs programs. Found higher rates of initiation were significantly related to greater improvements in reports of drug use (but not alcohol use).Found higher rates of initiation were significantly related to greater improvements in reports of drug use (but not alcohol use). Neither identification nor engagement was significantly related to improvements in either alcohol or drug use.Neither identification nor engagement was significantly related to improvements in either alcohol or drug use. Garnick et al., (2007)Garnick et al., (2007) Used data from 5,169 outpatient clients included in the Oklahoma Department of Mental Health and Substance Abuse Services (ODMHSAS) database.Used data from 5,169 outpatient clients included in the Oklahoma Department of Mental Health and Substance Abuse Services (ODMHSAS) database. Although initiation alone was not significantly associated with being arrested or incarcerations, clients who initiated and engaged were significantly less likely to be arrested or incarcerated in the following year.Although initiation alone was not significantly associated with being arrested or incarcerations, clients who initiated and engaged were significantly less likely to be arrested or incarcerated in the following year.

Study Goals Overall Goal: Conduct a validity test of the Washington Circle performance measure for Continuity of CareOverall Goal: Conduct a validity test of the Washington Circle performance measure for Continuity of Care Subgoals are to test whether:Subgoals are to test whether: Assertive Continuing Care (ACC) approaches improve compliance with the WC Continuity of Care measure regardless of whether they fail to successfully complete residential treatment;Assertive Continuing Care (ACC) approaches improve compliance with the WC Continuity of Care measure regardless of whether they fail to successfully complete residential treatment; Continuity of Care improves abstinence outcomes regardless of residential discharge type.Continuity of Care improves abstinence outcomes regardless of residential discharge type.

Why study continuity of care? Like many illnesses, alcohol or other drug dependence is characterized by periods of remission and relapse (McLellan et al., 2000; Scott et al., 2005)Like many illnesses, alcohol or other drug dependence is characterized by periods of remission and relapse (McLellan et al., 2000; Scott et al., 2005) 60-70% of youth relapse in first 90 days after res. tx. (Brown et al., 1989; Godley et al., 2002)60-70% of youth relapse in first 90 days after res. tx. (Brown et al., 1989; Godley et al., 2002) Dennis et al., (2004) found that two thirds of youth treated in the CYT outpatient study moved in and out of recovery during the post-treatment study phase.Dennis et al., (2004) found that two thirds of youth treated in the CYT outpatient study moved in and out of recovery during the post-treatment study phase. McKay (2005) reports benefit from extended interventions that provide care consistent with patient need.McKay (2005) reports benefit from extended interventions that provide care consistent with patient need.

Source: 2000 Statewide DARTs 2000 Continuing Care Following Residential Treatment for Adolescents in Illinois

Why do so many patients fail to initiate continuing care? May never get a referral if ASA/AD discharge type Referral to another provider organization is hit or miss Even transferring to another counselor within agency can be a problem. Low Motivation/Treatment Fatigue - ready to be finished Logistical/financial disincentives Providers view it as the patients responsibility

53% Have Unfavorable Discharges - Adolescents Source: Data received through August 4, 2004 from 23 States (CA, CO, GA, HI, IA, IL, KS, MA, MD, ME, MI, MN, MO, MT, NE, NJ, OH, OK, RI, SC, TX, UT, WY) as reported in Office of Applied Studies (OAS; 2005). Treatment Episode Data Set (TEDS): Discharges from Substance Abuse Treatment Services, DASIS Series: S-25, DHHS Publication No. (SMA) , Rockville, MD: Substance Abuse and Mental Health Services Administration. Retrieved from

Who Links to Continuing Care? Source: CSAT ART GranteesWilcoxon (Gehen) statistic (df=2)=79.83, p < % 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Days from Residential Discharge Percent of Clients Linked Planned / transfer within agency Planned / Referred to other agency Unplanned Discharge

Assertive Continuing Care Experiments Samples: 183 adolescents in Study 1 and 342 in Study 2 meeting DSM IV dependence on alcohol, marijuana or other drug; meets ASAM Level 3 placement criteria, residential stay of 7+ days, returning to target counties, not a ward of state. Instruments:Global Appraisal of Individual Needs (GAIN); BAC and Urine tests for Cannabis and Cocaine; Collateral Interviews Design:Random Assignment to either UCC or different ACC conditions. Active CC phase was 90 days after residential discharge Follow-up:Over 90% of all participants received a follow up interview at 3, 6, and 9 months after residential treatment

Features of Assertive Conditions Meet once with client before res. discharge Clinician is responsible for initiating CoC within 14 days of discharge. Different conditions recd either A-CRA (Godley et al., 2001), CM (Petry, 2000), or A-CRA+CM Sessions usually in the community (home/school) Clinician helps patients comply with or obtain needed services Limited transportation if needed to access referral resources, job interviews, etc.

Compliance to WC Continuity of Care Standard 2 = 19.17, p <.001, d=.40 2 = 19.17, p <.001, d=.40

Effect of CoC Compliance on Days of Abstinence F = 17.10, p <.001, d=.44 Alcohol F = 10.74, p <.001, d=.35 Marijuana

Continuity of Care by Completion Status & Condition 2 = 6.51, p <.01, d=.31 2 = 6.51, p <.01, d=.31 Residential Completers Residential Non-Completers 2 = 17.71, p <.001, d=.59 2 = 17.71, p <.001, d=.59 NearlyDoubled

Percent of Days Abstinent from Alcohol by Completion Status Interaction for Completion by CoC F = 5.90, p <.05, f-index=.14 ACCUCC Main Effect for CoC F = 5.18, p <.05, d=.42 N=62N=27N=22 N=40 N=134 N=25 N=89 N=50 23 of these 25 (93%) adolescents received CoC more than 14 days after discharge 6 of these 27 (22%) adolescents received CoC more than 14 days after discharge

Percent of Days Abstinent from Marijuana by Completion Status Interaction for Completion by CoC F = 3.19, p =.075, f-index=.11 ACCUCC Main Effect for CoC F = 4.11, p <.05, d=.36 N=62 N=27N=22N=40N=134N=25N=89 N=50

Support for the WC CoC performance measure was found Continuity of Care was significantly higher among adolescents assigned to ACC, regardless of residential treatment completion status. Continuity of Care was significantly higher among adolescents assigned to ACC, regardless of residential treatment completion status. Continuity of Care was found to be significantly associated with higher rates of abstinence from both Alcohol and Marijuana. Continuity of Care was found to be significantly associated with higher rates of abstinence from both Alcohol and Marijuana. Future research on continuing care should include patients who do not successfully complete treatment. Conclusions

The outcome data is based on self-report Continuity of Care (CoC) within 14 days was imputed for a sub-sample of the UCC condition, The sample is from two midwestern treatment sites, predominantly caucasian males, limiting generalizability Study Limitations

Future Research Directions Additional research is necessary to determine the clinical significance of these findings. Additional validity studies are necessary, especially to test whether CoC is robust even if the 14 day standard is not met.Additional validity studies are necessary, especially to test whether CoC is robust even if the 14 day standard is not met. Similar research with adults is needed. What patient subgroups do not seem to need it (i.e., they do fine w/out CoC)?What patient subgroups do not seem to need it (i.e., they do fine w/out CoC)? What patient subgroups appear to need CoC but do not benefit from it?What patient subgroups appear to need CoC but do not benefit from it?

For More Information To Download this presentation, go to: Mark D. Godley, Ph.D. Chestnut Health Systems 720 W. Chestnut St. Bloomington, IL ext.3401