1. Assertive Continuing Care for Adolescents
Mark D. Godley, Ph.D., Susan H. Godley, Rh.D.,
Michael L. Dennis, Ph.D., Rod Funk, B.S., and
Lora L. Passetti, M.A.
Chestnut Health Systems
Bloomington, IL
This work is supported by grants from the National Institute on Alcoholism & Alcohol Abuse, the SAMHSA Center for Substance Abuse Treatment, and the Illinois Division of Alcoholism & Substance Abuse. The opinions are those of the author and do not reflect official positions of the government.

2. Collaborators
Several colleagues at Chestnut served as co-investigators or collaborators on this study. Their contributions made this work possible:
Loree Adams, Becky Buddemeyer, Michael Dennis, Rod Funk, Susan Godley, Jen Hammond, Tracy Karvinen, Matt Orndorff, Lora Passetti, Laura Sloan, Ben Wells, Jen White, and Kelli Wright
And…
Drs. H. Perl & J. Hough, NIAAA; R. Muck & J. Buttler, CSAT; and M. Whitter, Illinois OASA
The measures used in this study included:
The GAIN -I at assessment - this is a biopsychosocial assessment tool used for clinical and research assessments covering substance use and a host of related life-health domains.
We are also using Alcosensors to assess breath alcohol content and accusign urinetests for cannabis and cocaine as well a collateral interview. All of theses measures are to assess the validity of the clients self report. Results to date suggest that caregivers underestimate patients self-reports much more so at intake than at follow up . In addition, there is no sign. Difference in agreement between the two groups on self-report and biological measures of substance use.
Supplemental asssessment forms are included to assess family environment and coping and service contact logs are included to track AAP model fidelity and utilization.

3. Questions Why is continuing care important?
What have we learned about continuing care in treatment programs?
What is an “assertive” approach to continuing care?
What is the critical roll of supervision in Assertive Continuing Care (ACC)?
How does ACC compare to standard practice in terms of implementation and outcome?

4. Why is Continuing Care Important?
Like many other illnesses, addiction is a chronic, relapsing condition.
Brown et al., 1989: 60% of youth relapsed in first 90 days after res. tx.
Dennis reports that most youth treated in the CYT outpatient study moved in and out of recovery.
The reason why we thought this was an important study and wrote the porposal to fund it was because…..(read the dot points)
NOTE: 60% relapse in 90 days 80% in 12 months
Several studies have shown strong correlations between aftercare participation and improved recovery status. Unforturnately, these studies lack adequate controls to attribute improvement to aftercare

5. Most Patients Alternate Between Relapse & Recovery (30 mo. follow up)
5% Sustained
Recovery
37% Sustained
19% Intermittent,
Problems
currently in
recovery
39% Intermittent,
currently not in
recovery
Source: Dennis et al, forthcoming

6. Hypertension Adherence to medication is less than 60%
Adherence to diet & exercise is less than 30%
Re-treated in 12 months: 50-60%
(McLellan, 2003; Treatment Research Institute)
The reason why we thought this was an important study and wrote the porposal to fund it was because…..(read the dot points)
NOTE: 60% relapse in 90 days 80% in 12 months
Several studies have shown strong correlations between aftercare participation and improved recovery status. Unforturnately, these studies lack adequate controls to attribute improvement to aftercare

7. Diabetes Adherence to medication is less than 50%
Adherence to diet & exercise is less than 30%
Re-treated in 12 months: 30-50%
(McLellan, 2003; Treatment Research Institute)
The reason why we thought this was an important study and wrote the porposal to fund it was because…..(read the dot points)
NOTE: 60% relapse in 90 days 80% in 12 months
Several studies have shown strong correlations between aftercare participation and improved recovery status. Unforturnately, these studies lack adequate controls to attribute improvement to aftercare

8. Asthma Adherence to medication is less than 30%
Re-treated in 12 months: 60-80%
(McLellan, 2003; Treatment Research Institute)
The reason why we thought this was an important study and wrote the porposal to fund it was because…..(read the dot points)
NOTE: 60% relapse in 90 days 80% in 12 months
Several studies have shown strong correlations between aftercare participation and improved recovery status. Unforturnately, these studies lack adequate controls to attribute improvement to aftercare

9. What Predicts Relapse in these Illnesses?
Poor adherence to behavior change requirements (diet, exercise, medication compliance)
Low Socioeconomic Status
Low Family Support
Psychiatric Co-Morbidity
(McLellan, 2003; Treatment Research Institute)
The reason why we thought this was an important study and wrote the porposal to fund it was because…..(read the dot points)
NOTE: 60% relapse in 90 days 80% in 12 months
Several studies have shown strong correlations between aftercare participation and improved recovery status. Unforturnately, these studies lack adequate controls to attribute improvement to aftercare

10. Why is Continuing Care Research in Addiction Treatment Important?
Existing studies reveal high levels of relapse after treatment
The evidence for continuing care is not yet clearly established (McKay, 2001)
Almost no continuing care studies of adolescents in the scientific literature
The reason why we thought this was an important study and wrote the porposal to fund it was because…..(read the dot points)
NOTE: 60% relapse in 90 days 80% in 12 months
Several studies have shown strong correlations between aftercare participation and improved recovery status. Unforturnately, these studies lack adequate controls to attribute improvement to aftercare

11. Time to Enter Continuing Care and Relapse after Residential Treatment (Adults)
100%
Relapse
2000
90%
80%
70%
1999
60%
Percent of Clients
50%
40%
30%
20%
10% 0% 10 20 30 40 50 60 70 80 90
Days from Discharge
Source: 1999 & 2000 Statewide TEDS and Godley et al 2004

12. Time to Enter Continuing Care and Relapse after Residential Treatment (Age 12-17)
100%
2000
90%
Relapse
80%
1999
70%
Percent of Clients
60%
50%
40%
30%
20%
10% 0% 10 20 30 40 50 60 70 80 90
Days after Residential (capped at 90)
Source: & 2000 Statewide TEDS and Godley et al., 2004

13. Linkage to Continuing Care After Residential Treatment (Adolescents)
1999
2000
Source: 1999 & 2000 Statewide TEDS

14. What does Continuing Care look like in actual practice?0% 0%
10%
10%
20%
20%
30%
30%
40%
40%
50%
50%
60%
60%
70%
70%
80%
80%
90%
90%
100%
100%
Weekly Tx
Actual UCC
Weekly 12 step meetings
Relapse prevention
Communication skills training
Problem solving component
Regular urine tests
Meet with parents 1-2x month
Weekly telephone contact
Contact w/ probation/school
Referrals to other services
Follow up on referrals
Discuss probation/school compliance
Adherence: Meets 8/12 criteria
Expected
Expected UCC

15. Barriers to Continuing Care
Typical referral process is passive, emulating medical clinics, and presumes the patient is motivated
Treatment Fatigue
Reimbursement methods do little to encourage continuing care
Assertive approaches shift the responsibility for linkage from the client to the provider

16. Examples of Assertive Approaches
Recovery Management Check-ups (Dennis, Scott, & Funk, 2003)
Multisystemic Therapy (Henggeler, 1999)
Tarrant Co. Juvenile Services-TCAP; Family Preservation (Woods & Haene, 2002)
Case Monitoring and Telephone Support (Foote & Erfurt, 1991; Stout et al., 1999)
Assertive Continuing Care Study (Godley et al., 2002)

17. Suggested Goals of CC Encouraging and Priming Prosocial Activities
Reduce Social Risk
Social Skill Development
Monitoring to Prevent Relapse*
Support*
Linkage to Other Services
Re-Intervention for Major Relapse*
*Essential CC Functions

18. A Controlled Study of the Effectiveness of Assertive Continuing Care
The measures used in this study included:
The GAIN -I at assessment - this is a biopsychosocial assessment tool used for clinical and research assessments covering substance use and a host of related life-health domains.
We are also using Alcosensors to assess breath alcohol content and accusign urinetests for cannabis and cocaine as well a collateral interview. All of theses measures are to assess the validity of the clients self report. Results to date suggest that caregivers underestimate patients self-reports much more so at intake than at follow up . In addition, there is no sign. Difference in agreement between the two groups on self-report and biological measures of substance use.
Supplemental asssessment forms are included to assess family environment and coping and service contact logs are included to track AAP model fidelity and utilization.

19. Point out that many residential centers serve large areas
Show weveral midwest states around Illinois then outline the 31 counties for AAP study

20. Research Questions
To determine the effectiveness of usual vs. assertive continuing care following residential treatment in:
engaging and retaining youth in continuing care services
linking youth to additional services
reducing AOD use and problems
This study was designed to answer whether the assertive aftercare protocol was better than usual aftercare services in
engaging and retaining youth in aftercare services
whether youth in the AAP condition would also attend more usual aftercare services; and
and whether assertive aftercare would significantly reduce alcohol and other drug use and problems when compared to usual aftercare.

21. Who was eligible to participate in the study?
Adolescents admitted to residential treatment (ASAM Level 3 care)
Length of stay of 7 days or longer (not required to have a successful discharge)
Reside in one of our “aftercare target counties”

22. ACC Study Research Design
Intervention N
Intake
Residential 3
mo after 6
mo after 9
mo after
Treatment
discharge
discharge
discharge
Plus
from RT
from RT
from RT
Aftercare
Assertive
102 O T O O O
UCC+ACC 3 6 9
Continuing
Care
This slide shows the design for the study. The two groups are randomly assigned to receive what we are calling and assertive aftercare protocol or usual aftercarel after leaving residential treatment. All patients are follow-up up at 3, 6, and 9 months after discharge. At the three month interview we also interview a caregiver (usually a parent) and collect a urine specimen for testing.
Usual 81 O T O O O
UCC 3 6 9
Continuing
Care
Note O = participant interview
T = treatment
No line between rows means randomization

23. Core Measures GAIN-I and GAIN M90 Form 90 TLFB BAC and Urine tests
Collateral Assessment Form
The measures used in this study included:
The GAIN -I at assessment - this is a biopsychosocial assessment tool used for clinical and research assessments covering substance use and a host of related life-health domains.
We are also using Alcosensors to assess breath alcohol content and accusign urinetests for cannabis and cocaine as well a collateral interview. All of theses measures are to assess the validity of the clients self report. Results to date suggest that caregivers underestimate patients self-reports much more so at intake than at follow up . In addition, there is no sign. Difference in agreement between the two groups on self-report and biological measures of substance use.
Supplemental asssessment forms are included to assess family environment and coping and service contact logs are included to track AAP model fidelity and utilization.

24. Recruitment and Follow-up
81% of eligible clients agreed to participate
93% of all participants were interviewed at baseline, 3, 6, and 9 months
96% of all follow-up interviews were completed within two weeks of due date

25. Demographic Characteristics

26. Baseline Substance Use Characteristics

27. Residential Treatment
Approach
Length of Stay
Average LOS - 49 days for both groups
1- 3 weeks: 25% ACC - 28% UCC
4-12 weeks: 68% ACC - 71% UCC
13+ weeks: 6% ACC % UCC
Rate of Successful Completion
50% ACC - 53% UCC
Assignment based on ASAM - most severe do get assigned to Res
ASAM - no fixed LOS
Skill based groups
As you can see both groups stayed approximately the same amount of time and there were no significant differences in LOS
Discharge type was not sign. Different between groups and at least in our sample is not as strongly related to outcomes as pre-treatment status

29. Features of the Assertive Continuing Care Intervention
Home Visits
Sessions for patient, parents, and together
Sessions based on ACRA manual (Godley, Meyers et al., 2001)
Case Management based on ACC manual (Godley et al, 2001) to assist with other issues (e.g., job finding, medication evaluation)
ACRA is a behaviorally based intervention to increase prosocial day to day activities for youth. It is based on the straightforward premise that teaching and encourgaing youth to participate in prosocial activities and goals reduces the liklihood of relapse. ACRA uses functional analysis of using behaviors and social behaviors as well as pt. Self assessment to generate GOC. Techniques include prosocial activity priming and sampling problem solving, and communication skills training with pt and caregiver. CM srvcs include transportation, linkage to other services such as GED, alternative school, or psychiatric services, and priming prosocial activities with patients.

30. Monitoring ACC Implementation
Weekly Case Review Tracking Form
Therapist Skillfulness Rating Form
Procedure checklists completed independently by therapist and supervisor
100% of sessions taped until certification

31. Monitoring Implementation
Simple monitoring systems work best
Monitor client contact and intervention procedures
Monitor total caseload weekly
Weekly feedback on caseload

32. ACC Weekly Case Review CASE No. D/C Status/Date Status Date to Close
Weeks
in Tx
#client #
parent
together HS
FA-
Use
FA-PS
GOC A
AP /13/2001 E
5/8/2001 13 12 4 3 1 B
AS 2/15/2001 D
5/10/2001 6 2 C
AP /26/2001
5/21/2001 11 9
AS /13/2001
6/5/2001 7
AP /19/2001
6/11/2001 8 F G
AP /19/2001 N
7/12/2001 H
AP /27/2001
7/20/2001 I
AP /26/2001
7/19/2001

33. Engagement & Retention
94% of ACC vs. 54% of UCC group enrolled
ACC averaged 14.1 aftercare sessions vs. 6.3 sessions for the UCC group
ACC median sessions 10 compared to 2 for UCC group
No difference in average UCC sessions between groups
ACC significantly more likely to receive referrals to other human service providers
Slide 17 - Engagement & Retention Outcomes
We found a significant difference for engagement with 92 % of the AAP group vs. 59% of the UA group enrolled in aftercare programs - both rates compare favorably to our statewide rate of 32%
In addition, the AAP group received more than twice as many aftercare sessions as the UA group - and this also was statistically significant.
We were unable, however, to confirm our hypothesis that that the AAP case manager would be able to link more patients to usual aftercare services than those in the UA group…..In many AAP cases we are aware that the patient didn’t want to enroll in services with another provider, thus AAP may actually work against receiving other treatment services. Finally, it appears that AAP patients are no more likely than UA patients to participate in GED or school.

34. Results: Improved Adherence
20%
20%
30%
30%
100%
100% 0% 0%
10%
10%
40%
40%
50%
50%
60%
60%
70%
70%
80%
80%
90%
90%
Weekly Tx
ACC * p<.05
Weekly 12 step meetings
Relapse prevention*
Communication skills training*
Problem solving component*
Regular urine tests
Meet with parents 1-2x month*
Weekly telephone contact*
Contact w/ probation/school
Referrals to other services*
Follow up on referrals*
Discuss probation/school compliance*
Adherence: Meets 8/12 criteria*
UCC

35. Reduced Relapse: Marijuana
1.0 .9 .8 .7 .6 .5
Proportion Remaining Abstinent .4
ACC .3 .2
UCC .1
0.0 30 60 90
120
150
180
210
240
270
Days to First Marijuana Use p<.05

36. Reduced Relapse: Alcohol
1.0 .9 .8 .7 .6 .5
Proportion Remaining Abstinent .4
ACC .3 .2
UCC .1
0.0 30 60 90
120
150
180
210
240
270
Days to First Alcohol Use (p<.05)

37. Days of Alcohol Use (out of 90)5 10 15 20 25 30 35 40 45
Pre-treatment
ACC Phase
Post ACC
Days
ACC (N=93)
UCC (N=76)

38. Days of Marijuana Use (out of 90)45 40 35 30 25
ACC
Days
UCC 20 15 10 5
Pre-treatment
ACC Phase
Post ACC

39. Days Since Residential Discharge
Can Assertive Continuing Care (ACC)
Help “Unmotivated” Patients?
1.0
Did not attend CC (n=36)
“Unmotivated”
Assertive Continuing Care (n=96; 94% Attended CC)
Attended CC
(n=42)
0.9
0.8
0.7
0.6
Patients Remaining Abstinent
0.5
0.4
Usual Continuing Care:
Abstinent
0.3
0.2
0.1
Proportion Remaining
0.0 30 60 90
120
150
180
210
240
270
Godley et al., 2004
Days Since Residential Discharge

40. Conclusions Failure to link to CC is the norm in actual practice
For those who do link retention beyond 4 hours of service is less than 50%
ACC is clearly superior to UCC in linking and retaining youth in continuing care
ACC clients receive more referrals to ancillary services than UCC clients
ACC was significantly better in preventing relapse than UCC
The assertive aftercare protocol was designed to engage and retain youth in aftercare by virtue of its home- based services approach. As you can see this proved successful and also resulted in improved substance use outcomes.
However, to datewe have not seen significant improvements in other areas that we hope to eventually impact such as fewer days of criminal activity, improved school and work attendance.
We are currently cleaning data for over 70 additional cases and will be closing recruitment in the next three months. At that time we will also begin analyzing the 6 and 9 month outcomes. We have learned that the AAP model is feasible to deliver and suspect that it should be an alternative not an addition to usual aftercare. We have also learned that our geographical territory while necessary for recruiting sufficient numbers of patients into the study is too large for one case manager to handle.

41. Next Steps for Research
Additional research is necessary to further improve relapse prevention effectiveness
We need to test models of continuing care following outpatient treatment
We need to test ways of improving 12 step attendance among adolescents
We need to better address the co-occurring problems of adolescents
Research is needed to test longer term models of CC with adolescents-particularly decreasing levels of contact for monitoring, support, and re-intervention
The assertive aftercare protocol was designed to engage and retain youth in aftercare by virtue of its home- based services approach. As you can see this proved successful and also resulted in improved substance use outcomes.
However, to datewe have not seen significant improvements in other areas that we hope to eventually impact such as fewer days of criminal activity, improved school and work attendance.
We are currently cleaning data for over 70 additional cases and will be closing recruitment in the next three months. At that time we will also begin analyzing the 6 and 9 month outcomes. We have learned that the AAP model is feasible to deliver and suspect that it should be an alternative not an addition to usual aftercare. We have also learned that our geographical territory while necessary for recruiting sufficient numbers of patients into the study is too large for one case manager to handle.

42. Contact Information
Mark D. Godley, Ph.D.
Chestnut Health Systems
720 W. Chestnut St.
Bloomington, IL
ext.3401

43. Introduction Our Background
Experience with adolescents involved in residential and outpatient treatment
Is it Aftercare or Continuing Care?
The measures used in this study included:
The GAIN -I at assessment - this is a biopsychosocial assessment tool used for clinical and research assessments covering substance use and a host of related life-health domains.
We are also using Alcosensors to assess breath alcohol content and accusign urinetests for cannabis and cocaine as well a collateral interview. All of theses measures are to assess the validity of the clients self report. Results to date suggest that caregivers underestimate patients self-reports much more so at intake than at follow up . In addition, there is no sign. Difference in agreement between the two groups on self-report and biological measures of substance use.
Supplemental asssessment forms are included to assess family environment and coping and service contact logs are included to track AAP model fidelity and utilization.