Department of Alcohol & Drug Services Applying the Principles of Chronic Illness Care To Drug Addiction Treatment Sustained Recovery Management

Productive Interactions Prepared, Proactive Practice Team 4. Delivery System Design 5. Decision Support 6. Clinical Information Systems 3. Self- Management Support 2. Health System Resources & Policies 1. Community Health Care Organization Improved Outcomes Informed, Activated Patient The Chronic Care Model Wagner, EH. Effective Clinical Practice 1998;1:2-4.

Uninformed, Passive Patient Frustrating Problem-Centered Interactions Unprepared Practice Team Crummy (suboptimal) Functional and Clinical Outcomes Delivery System Design Reliance on short visits Decision Support No agreement on good care; traditional referrals Clinical Information Systems Don’t know pts or what they need Self- Management Support No systematic approach; didactic in orientation Health System Resources and Policies No links with or only passive referrals to community agencies or resources Community Organization of Health Care Leadership concerned about the bottom line and favor more frequent, shorter visits. No organized QI functional oversight Wagner, EH. Effective Clinical Practice 1998;1:2-4.

Our Evolving 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 Shifted from a system of fragmented and isolated treatment providers to a managed and coordinated system of care 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

Productive Interactions Prepared, Proactive Practice Team 4. Delivery System Design 5. Decision Support 6. Clinical Information Systems 3. Self- Management Support 2. Health System Resources & Policies 1. Community Health Care Organization Functional & Clinical Outcomes Informed, Involved Patient How We Apply the Chronic Care Model 1. The Innovative Partnership with the addiction treatment provider network, Drug Courts, Health & Hospital System 5. Application of nationally recognized evidence-based treatment practices 3. Sustained recovery monitoring, patient education and self management support 2. Working collaboratively with other health providers and County Departments to develop integrated case managed care 4. A managed and coordinated system of care that reduces avoidable inpatient, hospital and jail admissions, continuous quality improvement systems 6. Research and development for planning delivery and evaluation of the care system, UniCare data base

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 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 Assure the Delivery of Effective, Efficient Clinical Care and Self-Management Support

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 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 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 Create a Culture, Organization and Mechanisms that Promote Safe, High Quality Care

The Community Partnerships with Mental Health, Social Services, Public Health, Justice Services, and Medical Services The Learning Institute educational forums Development of a Social Medicine program Mobilize Community Resources to Meet Needs of Patients

Community Awareness & Education Treatment Works! month Recovery awareness campaigns Community education (Learning Institute) Internship programs Solutions for Wellness program (from the UMDNJ)

Our Future... 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 Utilize the Chronic Care model (CCM) to design an approach that will:

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.

DetoxResidential Outpatient Transitional housing Completion of care, discharged, passive referrals to self-help meetings, community support and case is closed. The traditional continuum of care system stops short of providing continuing care services – an essential element in treating chronic conditions The Current System of Care for Addiction as an Acute Illness

Treatment Intensity DetoxResidential OutpatientBrief Transitional Community intervention housing support Continuing Care Services (CCS): Frequency of contact determined at each post-treatment session From CCS risk assessment: Education Brief intervention Brief counseling Readmission Via telephone E-counseling, or Face-to-face As personal responsibility increases, treatment intensity decreases Treatment intensity personal responsibility Toward A System of Care for Addiction as a Chronic Illness

Continuing Care Services Approach: Post-Treatment 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

Detox Residential Outpatient Transitional Brief Community housing Interventionsupport Prepare client for sustained recovery monitoring 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 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 ???

What the Hot Group has been working on A Shift from Acute Care to a more sustained recovery management model. Where we’ve placed the initial focus for a system redesign

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.)

DetoxResidential Outpatient Brief Transitional Community intervention housing support Continuing Care Services (CCS) Toward A System of Care for Addiction as a Chronic Illness Streamline the readmissions process for CCS clients CCS priority admissions over waitlist. Readmission back to “home clinic” as a pre-auth to bypass Gateway. Additional level of care for CCS

References American Society of Addiction Medicine. 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, 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, 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,

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), 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 Neuroscience of Psychoactive Substance Use and Dependence. Geneva: World Health Organization; 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.