1. Continuing Care and 3-Year Outcomes in Adolescents: Moving Toward a Disease Management Model Cynthia Campbell, PhD 1 Constance Weisner, DrPH, LCSW 1, 2 Felicia Chi, MPH 1 Stacy Sterling, MSW, MPH 1 AcademyHealth June 9, 2008 Washington DC 1 Division of Research, Northern California, Kaiser Permanente 2 Department of Psychiatry, University of California San Francisco Funded by National Institute on Drug Abuse, National Institute on Alcohol and Alcoholism, Robert Wood Johnson Foundation and the Center for Substance Abuse Treatment

2. Continuing Care: What is it?  Typically presented as aftercare services  Additional chemical dependency (CD) treatment after usual care  6 mos - 1year  Stepped down, lower intensity  Other psychosocial services  Any type of intervention between treatment system and patient (McKay, 2005)  12 step programs  Adolescents are less likely to attend  Associated with better SU outcomes (McKay, 2005)

3. Literature  Recovery Management Checkups  Dennis, Scott et al.  Quarterly assessments over two years after intake  Those with problems referred to linkage managers  Used MI approach to address SU and other problems  Aim is for ongoing monitoring and linking them back to SU treatment  More likely to return to treatment; longer retention; improved outcomes  Assertive Continuing Care  Dennis, S. Godley, M. Godley  Specific to adolescents  Assertive case management for 90 days post discharge  Community outreach, home based  Associated with improved participation in continuing care, and outcomes  Telephone interventions  McKay et al  Evidence of association with improved outcomes, although might be more appropriate for less severe patients (McKay et al., 2001)

4. Treatment Outcomes Stronger in Short Term  Substance use is a chronic problem but treatment is episodic  Typically less than 90 days  Effects of index treatment decrease over time  Treatment careers of multiple uncoordinated episodes (Hser et al., 1997)  Low engagement with continuing care among adolescent patients  How to think of ongoing services for adolescents?

5. Disease Management Approach  Conceptual approach grounded in the chronic disease management framework  Individual with a serious chronic problem (e.g., diabetes) is treated in specialty care, and when stabilized returns to PC for management and monitoring  referred back to specialty care for services as needed in the course of their health care  Similarly, SU is a chronic condition requiring ongoing care or management delivered in more than one setting (McLellan, 2000; McLellan, 2002; Hser et al, 2007 )  A person may do well after treatment, but then relapse

6. What might an integrated care model for substance use problems look like? Lessons from disease management Screen and treat in PC if moderate problem Continue monitoring Specialty care if needed Back to PC for monitoring Continuing care Von Korff M, Gruman J, Schaefer J, Curry SJ, Wagner EH. Collaborative management of chronic illness. Ann Intern Med. 1997;127:1097-102. Bodenheimer T, Wagner EH, Grumback K. Improving primary care for patients with chronic illness. JAMA 2002; 288:1775- 9.

7. The Case for Primary Care  Post-CD treatment primary care management  There is little coordination with CD treatment by PC after treatment  Specialty treatment does not last someone’s whole life, but they will have ongoing medical care  Another opportunity to engage  Population also has a high level of medical conditions, even in adolescents  Need to have these addressed as well Institute of Medicine, “Improving the Quality of Health Care for Mental and Substance-Use Conditions,” 2006

8. What are adolescents like by the time they get to treatment?

9. Setting: Northern California Kaiser Permanente (KP)  Private, group-model managed care health plan  Serves 3.5 million members in 15 counties (about 40% of population in the region)  ~400,000 members aged 12-18  16 hospitals, 23 outpatient clinics  ~500 pediatricians  Integrated health care system (medical, psychiatry, chemical dependency services)

10. Study Design and Data Sources  Baseline interviews with adolescents (and a parent) at intake to CD treatment at 4 Kaiser sites (Oakland, Sacramento, Vallejo, Vacaville)  Follow-up interviews with adolescents and parents at 6 months and 1,3, and 5 years (Response rates = 92%, 92%, 86% and 85%, respectively)  Clinical ICD-9 diagnoses from automated records  Health plan administrative utilization and cost databases

11. Treatment Programs  Each offers 1-year program  Same modalities of other CD programs in the country  Intensive, structured outpatient treatment  Abstinence based  Breathalyzer and urine screens  Services include group therapy, education, relapse prevention, family therapy.  Individual counseling with a CD clinician available as needed  Require participation of a parent or guardian  Attendance at 12-step programs expected and monitored  3 Phases  Eight weeks more intensive treatment  4 months of relapse prevention/continuing recovery  6 months of after care to maintain abstinence  Few stay that long, true across the literature

12. Adolescent CD Patients & Matched Controls Sample: 419 adolescents (143 girls, 276 boys) Mean age of initiation (11.5) Age ranged from 13 to 17 years (mean = 16.15) Ethnicity: 6% Asian 9% Native American 16% African-American 20% Hispanic 49% White Matched Controls:  2,084 adolescents from the health plan  No documented alcohol or drug history  Matched on gender, age, length of health plan enrollment, and catchment area Sterling S, Weisner C. Chemical dependency and psychiatric services for adolescents in private managed care: Implications for outcomes. Alcohol Clin Exp Res. May 2005;25(5):801-9.

13. Substance use (%) at Treatment Entry (N=419) Substance use (%) at Treatment Entry (N=419) % Any alcohol 85 5+ drinks of alcohol at one time 45 Marijuana 92 Tobacco 76 Hallucinogens 25 Stimulants 21 Party drugs 20 Sedatives 10 Painkillers 25 Cocaine (powder or crack) 17 Inhalants 12 Heroin 2  Girls had significantly higher use than boys of alcohol, stimulant, sedative, cocaine, heroin and party drugs Sterling S, Kohn C, Lu Y, Weisner C. Pathways to substance abuse treatment for adolescents in an HMO. Journal of Psychoactive Drugs. Dec 2004;36(4):439-453.

14. Medical Conditions among Adolescent CD Treatment Intakes (%) Tx IntakesControlsp-value Abdominal Pain10.65.7<.001 Respiratory System Cond.54.537.8<.0001 Gastroenteritis6.53.9<.05 Conjunctivitis6.93.2<.001 Muscle Pain8.43.9<.0001 Scoliosis3.11.3<.01 Benign Uterine Cond.7.73.2<.0001 Injury & Poisoning49.636.4<.0001 Urinary Tract Infection3.42.0<.05 STDs4.81.5<.0001 *One-third of parents reported that their child had chronic health problems (asthma and allergies most commonly). Past pregnancies: 15% of girls Mertens JR, Flisher AJ, Fleming MF, Weisner CM. (2007). Medical conditions of adolescents in alcohol and drug treatment: comparison with matched controls. Journal of Adolescent Health Feb ;40(2):173-9.

15. Mental Health Conditions of Adolescents in CD Treatment & Matched Controls (%) Tx Intakes Controlsp-value Depression 36.34.2<.0001 Anxiety Disorder 16.32.3<.0001 Eating Disorders 1.20.43.067 ADHD 17.23.0<.0001 Conduct Disorder 19.31.2<.0001 Conduct Disorder (w/ODD) 27.32.3<.0001 Any Psychiatric DX 55.59.0<.0001

16. Gender Differences in Mental Health Comorbidities: Adolescents in CD Treatment (in %) **<.01

17. HIV Risk Behaviors among Adolescents in CD Treatment 14*3Male homosexual activity or female related sexual activity 37 52 39 43 Sex with multiple partners, past 6 months + never/inconsistent condom use 53*35 Never/inconsistent condom use (of those reporting ever having sex) 11Sharing needles or works 42Injection drug use (IDU) Girls (N=143) % Boys (N=276) % Risky Behaviors Ammon L, Sterling S, Mertens J, Weisner C. Adolescents in private chemical dependency programs: who are most at risk for HIV? J Subst Abuse Treat. Jul 2005;29(1):39-45.

18. Adolescent Chemical Dependency Patients: HIV Risk Behaviors  Rate of at least 1 reported HIV risk behavior was 47%  Boys who drank 5 or more drinks in a day at least once during the past 6 months were 4 times more likely than other patients to engage in multiple HIV risk behaviors.  Girls who used narcotic analgesics (painkillers) without prescription at least once during the previous 6 months were 5 times more likely to engage in multiple HIV risk behaviors. Ammon L, Sterling S, Mertens J, Weisner C. Adolescents in private chemical dependency programs: who are most at risk for HIV? J Subst Abuse Treat. 2005;29(1):39-45.

19. Outcome Argument for Continuing Care

20. One Reason for Continuing Care: Alcohol and Drug Use after Treatment  1 year after treatment – doing better, but many not abstinent*  61% abstinent from alcohol  59% abstinent from drugs  47% abstinent from both  36% in remission (non problematic use)  3 years after treatment  38% abstinent from alcohol  57% abstinent from drugs  30% abstinent from both  26% in remission * 30-day abstinence * Remission: used alcohol but no more than once/week and never more than 2 drinks, OR used marijuana, but only once/month or less, AND b) Used no other drugs (excluding tobacco); AND, c) Had no dependence/abuse symptoms

21. Initial Exploration of Continuing Care  Anchored in PC, with specialty CD and MH services as indicated  Initial specifications tested  1 or more PC visit each year after 1 yr FU  Subsequent MH or CD services if needed, either within or outside KP

22. Role of PC-based Continuing Care: To Return More Severe Teens to Treatment and Improve Outcomes  Three years after treatment:  1 or more PC visits/year was associated with abstinence and remission  32% abstinent vs. 18%  28% remitted vs. 14%  For those with any MH symptoms at 1 year, 1 or more MH visits was related abstinence (40% vs. 25%)  Among those not abstinent at 1 year, CD readmission were related to abstinence (40% vs. 33%)  1 or more PC visits was associated with a CD readmission and MH services after index CD treatment All p <.05

23. Cost Considerations for Continuing Care  Medical costs decrease after CD treatment for adults  Medical costs for adolescent CD patients did not decrease in the year after treatment as they do for adults Parthasarathy S, Weisner CM, Hu T-W, Moore C. Association of outpatient alcohol and drug treatment with health care utilization and cost: revisiting the offset hypothesis. J Stud Alcohol. Jan 2001;62(1):89-97. Parthasarathy S, Weisner C. (2006). Health care services use by adolescents with intakes into an outpatient alcohol and drug treatment program. The American Journal on Addictions 15(Supp 1):113-21.

24. Costs at 3 years  Overall, average costs increased in the year after treatment, then decreased  Costs are higher for the cases compared to the controls, although the difference has narrowed by 3 years  Looking at abstinence at 3 years, both abstainers and non-abstainers had higher average costs than the matched sample (p<.05)  Abstainers had higher costs in all departments except ER.  Could be a proxy measure for appropriate use

25. Disease Management Approach Screen and treat in PC if moderate problem Continue monitoring Specialty care if needed Back to PC for monitoring Continuing care Von Korff M, Gruman J, Schaefer J, Curry SJ, Wagner EH. Collaborative management of chronic illness. Ann Intern Med. 1997;127:1097-102. Bodenheimer T, Wagner EH, Grumback K. Improving primary care for patients with chronic illness. JAMA 2002; 288:1775- 9.

26. What Could This Look Like in PC? Two approaches 1.Training PC providers to screen for problems, especially in those who have been in treatment or diagnosed 2.“Patient-centered” approach (IOM)  Empowers patient  Educates patient and family about importance of managing SU problems similar to medical problems  Addresses stigma, communication, how to raise the issue with providers

27. Summary  Primary care is important after CD treatment as well - keeping primary care in the loop after treatment  Treatment is not a “magic bullet” and even “aftercare” ends at some point  Important for individuals in becoming accustomed to talking about alcohol and other behavioral problems to physicians as a life pattern  Future Research

28. COLLABORATORS  Felicia Chi, MPH  Sujaya Parthasarathy, PhD  Lyndsay Ammon, PhD Cand.  Charlie Moore, MD  David Pating, MD  Steve Allen, PhD  Ken Athey, LCSW  Michael Leotaud, LCSW  Agatha Hinman, CA  Georgina Berrios, BA  Melanie Jackson-Morris, BA  Yun Lu, MPH  Cynthia Perry-Baker, BA  Gina Smith-Anderson, BA  Barbara Pichotto, BA, CADAC Northern California Kaiser Permanente Adolescent Medicine and Chemical Dependency Rehabilitation Programs* *Thanks to clinicians, patients and family members for participating in these studies

29. Are there opportunities for PC intervention?

30. Utilization Patterns during 24 Months prior to Treatment Intake