1. Always On Time: A Flexible Appointment-Less Service Designed to Support the Successful Engagement and Retention of Persons Not Well-Suited to Traditional Outpatient Care Brendan Kelly, LMSW, CAAC Curtis Bryant, Peer Support Cyndi Musto RN, MA, LLP, CCS-M Arbor Circle Corporation, Grand Rapids, MI

2. Substance Use Disorders (SUDs) In 2008, an estimated 22.2 million persons aged 12 or older were classified with substance dependence or abuse in the past year. (NSDUH, 2008))

3. Severe Mental Illness In 2002, 17.5 million adults aged 18 or older were estimated to have severe mental illness (SMI) in the prior year. (NSDUH, 2004)

4. Co-Occurring Disorders (CODs) About 23 percent (4 million) of adults with SMI in 2002 also were dependent on or abused alcohol or an illicit drug (Co- Occurring Disorders). (NSDUH, 2004)

5. Access To Care Over 50% of adults with co-occurring SUD and SMI (approx 2 million persons) received no treatment of any kind in last year. 34 % received mental health treatment only 12% received both mental health and substance use treatment.

6. Gap Clients Quadrant III population identified as not severe enough for Mental Health Case Management, but often too severe for successful engagement in outpatient treatment. Results in inadequate service provision and high utilization of crisis services. Typically not covered under other funding sources (3 rd party, Medicaid, Medicare).

7. Risk Factors Associated With COD Higher use of Emergency Rooms. More likely to seek treatment, but less likely to complete. Higher risk of co-morbid physical health issues: HIV, Hep C, TB Higher risk of incarceration. Higher risk of suicide. Higher risk of homelessness.

8. Difficulties with Traditional Treatment No shows/ late attendance/ frequent cancellations. Long absences from treatment. Repeated process of engagement, disengagement and re-engagement (often in crisis). Bounce between treatment providers. Frequent discharges from treatment due to non-attendance.

9. Barriers To Treatment Success External: – Variable employment schedule. – Homelessness/unstable housing. – Lack of transportation. – Lacks telephone/internet. – Intermittent incarceration. Internal: – Moderate to severe substance use. – Mental illness – Crisis orientation – Low/inconsistent motivation.

10. Always On Time (AOT) Collaborative Initiative Between Network 180 (CMH) in Kent County, and Arbor Circle. Grant Funded (explain grant) Dates

11. AOT Treatment Is: Stage-Matched Individualized Comprehensive Cost-effective Consistent with IDDT/COSIG and ROSC.

12. Criteria Co-Occurring Disorder (Quadrant III) – High Substance Use and Moderate Mental Illness. History of unsuccessful discharge from treatment for non-compliance. (dropout) Experience barriers to regularly scheduled treatment attendance. Population uses more crisis services and may have long history of treatment, with few positive outcomes.

13. Harm Reduction Goal is to improve engagement/retention. Enhance protective factors/reduce risk factors. Facilitate engagement in traditional services when ready/able, while maintaining structure to prevent recurrence of barriers. Philosophy is to provide what client needs, at the time they need it, and for as long as they need it.

14. Access No Wrong Door Referral from existing OP clinicians identifying Quadrant III individuals as at-risk of treatment failure and dropout. – Crisis prone, inconsistent attendance, frequently late for scheduled sessions, resulting in shortened/staff-cancelled sessions. Jail referral upon re-integration. Referral by Network 180 and Peer agencies

15. Staffing Therapist Peer Support/Recovery Coach Supports Coordination Parallel to existing programs: – OP, IOP, Psychiatric Services, Specialty Programs.

16. Expectations of Staff Therapist – Assessment, Individual and group therapy, case coordination. Peer Support – Recovery coaching/mentoring, supports coordination.

17. Structure Clients can schedule appointments or drop- in to be seen anytime during business hours. Availability of primary AOT Therapist, Peer Support Staff, or back-up clinicians at all times. Daily therapy/support group.

18. No expectation of compliance. Client can attend sessions as often as they perceive need. Session length is determined by client. – I.e. 5 minute check-in or traditional 50 minute session. Level of care is adjusted as client is ready – Can increase/decrease intensity as desired.

19. Implementation Typical 6-month service authorizations expanded to 12 months. Standard discharge expectation if no service within 30 days is suspended. Layered authorization allows AOT services as both primary treatment, or concurrent with other traditional services. AOT therapist as case manager: – Individual Tx, coordination of all care.

20. Service Expectations Identified clients are seen with less than two business day wait- often same day contact with AOT clinician or Peer Support. Peer Support is integral part of assessment and treatment. AOT clinician completes comprehensive needs assessment, and coordinates and monitors access to collateral services.

21. Peer Support Peer Support provides recovery coaching, as well as supports coordination. Facilitates referral and access to: – Employment support, Primary Care Physicians, housing support, food, transportation, etc. – Supports clients in applying for Medicaid and other available benefits. Use of telephone/internet in order to expedite access to supports. Meet clients at support meetings to help bridge transition into new settings.

22. Outcomes Reduced wait time for treatment. Immediate return to treatment after absence instead of waiting for intake. Facilitated access to services. Service Coordination.

23. Cost-Effectiveness Goals Efficiencies in system lead to savings: Drop in availability reduces no show for scheduled appointments. Immediate return to treatment within 12 month auth bypasses costly intake process and enhances retention. Despite higher cost of COD Tx, long-term cost reduction from effective intervention leading to reduced use of crisis services, health-risks, incarceration, etc.

24. Outcomes Studies indicate use of recovery support can double duration of treatment adherence.

25. Thank You!