1. Increasing Attendance and Compliance With Incentives Maxine Stitzer, Ph.D. Johns Hopkins Univ SOM Improving Care Conference Johns Hopkins Center for Behavior and Health September 25, 2013

2. Presentation Outline Motivational Incentives: Definition and goals Utility in service access, entry and utilization Application feasibility issues

3. Motivational Incentives = Contingency Management Definition: Positive reinforcement delivered for desired behaviors to increase frequency of those behaviors –Can be social (attention; praise) or tangible reinforcers What ’ s the goal? –Counter ambivalence and barriers to service access –Guide people to better health and well-being by encouraging healthful and pro-social behaviors

4. Motivational Incentives positive reinforcement to promote desirable behavior change

5. Reward programs Acknowledges people for achieving a major goal or completing significant progress Rewards usually given to the “ best ” and most motivated people They don ’ t change the behavior of those struggling with drug use and/or treatment compliance

6. Reinforcement programs on the other hand, use incentives to … Break down goals into very small steps Reinforce each step along the way Make it easy to learn & earn Give reinforcements early and often Include the most troubled and difficult to reach most troubled & difficult to reach patients Reinforcement programs

7. Reward vs Reinforcement Reward goals Completing treatment Get a job Complete GED 30 days abstinent Reinforcement goals Attend treatment session Submit job application; go to interview Sign up for GED; attend a class One negative urine

8. Incentives in Substance Abuse Treatment: Efficacy Review Service access and entry Repeated service utilization Drug use cessation and relapse prevention

9. Service Access and Entry Getting people into the door

10. Immunization Rates Rate Rates increased when WIC food vouchers were given to those who had their children immunized (Hoekstra et al., 1998) Percent Immunized

11. Vouchers for Free Methadone Treatment (Sorensen et al., 2005) Opioid abusers (N = 126) receiving care in a hospital Randomly assigned to 4 conditions –Usual care referral –Case management for 6 months –Voucher for 6-months free methadone Tx –Combined voucher and case management

12. Vouchers for Free Methadone Treatment (Sorensen et al., 2006) Percent Receiving Services Six-Month Outcomes

13. Vouchers for Treatment Re-entry (Kidorf et al., Addiction, 2009) Incentives offered to needle exchange users (N = 188) for attending “treatment readiness” groups –$10 cash; $10 MacDonald; $3 bus pass per group attended If they entered Tx, $50 was paid to the program to cover initial fees

14. Vouchers for Treatment Entry (Kidorf et al., Addiction, 2009 INCENTIVES PERCENT ATTENDED SESSIONSENTERED TREATMENT

15. Care Continuity: Residential to OP (Aquavita et al., JSAT, 2013) Tested 3 methods of transition from 28-day residential to outpatient aftercare treatment (N = 260) –Usual care –Client incentive –Residential in-reach

16. Care Continuity Interventions Usual care –Select program; fax referral; make appt (optional) Client Incentive –$25 to show up; $75 more for continued attendance Residential in-reach –In-person meeting with OP counselor; sign contract; next day appt

17. Residential-To-Outpatient Transition Rates 84%* 74%*

18. Service Entry Summary Vouchers for free treatment have worked Direct payment to patients for entry not as effective as “warm hand-off”

19. Services Follow-Through

20. Receipt of HIV Test Results (Thornton R, Am. Econ Rev, 2008) PERCENT Rural Malawi residents (N = 2812) accepted free HIV testing All participated in a drawing where there could earn $0, $1, $2 or $3 if they returned for HIV test results INCENTIVES

21. Incentives for Treatment Entry Follow-Through (Corrigan et al., 2005) Substance users with traumatic brain injury (N = 195) with intake completed at an OP treatment program Outcome = return to sign an individual service plan (ISP) within 30 days Randomly assigned via phone delivered intervention –Attention control –Motivational interview –Barrier reduction- pay for taxi, bus, parking, etc –Incentives- $20 gift certificate upon ISP completion

22. Traumatic Brain Injured Sample Percent Signing ISP

23. Services Follow-Through Financial or transportation incentives can motivate people to follow up with the next step –Return for test results –Complete treatment ISP

24. Attendance Incentives: Encouraging People to Stay

25. Prizes Escalate With Consecutive Target Behavior Performance Sessions Attended # Prize Draws 1 2 4 5 3

26. Attendance Incentives in an HIV Drop-In Center (Petry et al., 2001) Average Attendance per Session Baseline CM intervention 0.7 7 (range 0-3) (range 2-12) Prize draws escalate with weeks of consecutive attendance during a 14 week intervention (n = 43)

27. Attendance: Group Therapy for Methadone Patients (Sigmon & Stitzer, 2005) Patients were assigned to attend orientation (N = 44) or cocaine (N = 58) groups 2X per week for 12 wks Prize draws could be earned on an escalating schedule for attendance; max earnings = $170

28. Cocaine Group Attendance in Methadone Maintenance Transition Clients Consistent Clients Percent Sessions Attended

29. Attendance in OP Treatment (Petry et al., 2012) Participants (N = 215) were cocaine abusers urine negative at entry to outpatient psychosocial counseling treatment Randomly assigned –Usual care –Escalating prize draws over 12 weeks; max earnings = $250

30. Attendance in OP Treatment $250 in prize draws (Petry et al., 2012) Sessions attended

31. Care Continuity Study: Client Incentive Increased OP Attendance First 30 Days *

32. Incentives for Session Attendance Positive incentives have clearly been useful for increasing rates of attendance in substance abuse treatment settings and could be effectively used in health care settings

33. Abstinence Incentives: Initiating and Sustaining Drug Abstinence Majority of research has used drug abstinence during treatment as target by reinforcing drug negative urine tests

34. Voucher Reinforcement for abstinence initiation and maintenance in cocaine abusers Principle of alternative reinforcement: –Benefits of abstinence are long-term –Making abstinence today a more attractive option Points earned for cocaine negative urine results –Escalating schedule of point earnings –Trade in points for goods –$1000 available over 3 months

35. Voucher Incentives for Outpatient Drug-free Treatment of Cocaine Abusers Higgins et al. Am. J. Psychiatry, 1993 Cocaine negative urines

36. Methadone Maintenance Sample: Percent Stimulant Negative Urines 0 20 40 60 80 100 1357911131517192123 Study Visit Percentage of stimulant negative urine samples Abstinence Incentive Usual Care OR=1.98 (1.4-2.8)

37. Abstinence Incentives Promotes initial abstinence when drug use is on-going Promotes increased duration of drug-free treatment participation after drug use stops (relapse prevention) Positive impact on long-term outcomes –Longer during-treatment abstinence translates into better long-term outcome (Higgins et al., 2000)

38. Cross-Substance Generality CocaineOpioids Methamphetamine Alcohol Marijuana Nicotine (Tobacco smoking)

39. Summary Positive incentives in the form of vouchers or prize draws can be therapeutically helpful in several ways to promote: –services access and entry –continued involvement in services –abstinence and relapse prevention

40. Potential Application in Health Care Access specialty services –e.g. vaccinations; prenatal and pediatric care Keep follow-up medical appointments Address drug use as a barrier Take prescribed medicines Promote healthy lifestyle change

41. Incentives can help overcome barriers and move patients along a motivational continuum What ’ s in it for them? People like immediate gratification Long-term benefits to health are theoretical, largely intangible and in the future Incentives bring benefits forward in time and make them tangible

42. Can you do it? Traditional barriers to implementation are coming down Attitudes Cost/financing Training resources

43. Why pay people to do what they should be doing anyway? Because they aren ’ t doing it! Incentives are a practical fix to a therapeutic conundrum They change the therapeutic dynamic for difficult patients toward acknowledging and celebrating success rather than blaming or dwelling on failure

44. Does everyone need incentives? Principle of “ justice ” suggests incentives should be given to everyone but- Incentives have best application for those who struggle with adherence despite lower-intensity interventions such as appointment reminders

45. Financing Ideally, incentives would be built into the budget and offset by health care cost savings Meanwhile, there are some work-arounds –Community donations (women and children) –Staff donations of goods and/or money –Small grants or agency-funded pilot projects

46. Dollar Stores are full of great things! Incentive prizes don’t need to be costly but do need to be desirable know your audience Ask patients what they want!

47. Implementation Needs Planning Who will be offered incentives? How will program be structured? –How much and for how long? Who will manage and coordinate the program? How will incentives be purchased and financed? Where can staff get training and advice? How will impact be evaluated?

48. Training Resources NIDA CTN Blending Products provide principles and tools for structuring an incentive program –Identifying effective reinforcers –Constructing fishbowls –Escalating schedules Expert consultants are also available through CTN and Addiction Technology Transfer Centers (ATTC)

49. Training Resources NIDA Blending Products –PAMI –MI PRESTO (includes CD) –www.ctndisseminationlibrary.org Petry Manual –Contingency Management for Substance Abuse Treatment. A guide to Implementing This Evidence- Based Practice (Taylor & Francis, 2012)

50. Incentive programs are feasible to implement And they will make a difference!