1. Topeka, Kansas Promoting Sustained Recovery Through Post- Treatment Recovery Supports November 16, 2011 Ijeoma Achara, PsyD Achara Consulting Inc.

2. Achara Consulting November 16, 2011 Overview The role of recovery-support services (RSS) The need for post-treatment RSS Connecting RSS to the changing healthcare environment Models and approaches to developing post-treatment RSS Strategies for successful implementation

3. Achara Consulting November 16, 2011 What are Recovery Support Services? Non-clinical services that assist individuals and families to recover from alcohol or drug problems Social support, allied service providers, and human services contributing to an improved quality of life Flexibly staged prior to, during, and after treatment (Kaplan, SAMHSA, 2008)

4. Achara Consulting November 16, 2011 Examples of Recovery Support Services? Transportation Employment services and job training Outreach Pre-treatment engagement services Housing assistance and services Child care Family/marriage education Peer support services Recovery education and coaching Life skills training and supports Spiritual and faith-based support Care coordination and assertive linkages to community resources Parent education and child development; Continuing care and post-treatment supports (recovery check-ups)

5. Achara Consulting November 16, 2011 4 Overlapping Stages of RSS Continuum of Recovery Pre-Recovery Engagement Recovery Initiation & Stabilization Recovery Maintenance Enhancement of Quality of Life in Long-term Recovery (William White)

6. Achara Consulting November 16, 2011 Systemic Challenges at Each Stage of Recovery Pre-Recovery Engagement Unmet Need Low Pre-Treatment Initiation Rates Recovery Initiation and Stabilization Limited Engagement and Retention Inadequate Service Dose Recovery Maintenance Lack of Continuing Care Recovery Outcomes Revolving Door Enhancement of Quality of Life Why Recovery Support Services?

7. Achara Consulting November 16, 2011 Evolving Trends and Future Directions SAMHSA’s strategic Priorities Redirection of Block Grants Healthcare Reform Service integration with primary care Why Recovery Support Services?

8. Achara Consulting November 16, 2011 What’s the Connection?

9. Achara Consulting November 16, 2011 ROSC/RMBH-PC Integration Chronic Care Approach Sustained healing relationships, post- tx montioring, support and early re- intervention Ongoing relationship with care provider Individualized approaches with a focus on dose, scope and quality Individualized, stepped care Attraction via assertive outreach/engagement Enhanced access via open scheduling, enhanced hours, new mechanisms for communication, universal screening Holistic ServicesWhole person orientation Community Health and wellnessPublic health approach focused on population health outcomes

10. Achara Consulting November 16, 2011 ROSC/RMBH-PC Integration Strengths Based ApproachesSolution focused approaches Peer Support (navigating systems, linkage to community resources, coaching, recovery planning, problem solving, etc). Wellness Programs Collaborative service relationshipsCollaborative care and shared decision making Expanded composition of service teamsShift from individual practitioner model to team-based approach Expanded locus of service delivery, services delivered in natural environments e.g. Person Centered health homes Choice, Self directionActivated patients (Patient education and self management/ self-care Recovery Support ServicesCare Management, “Enabling Services”

11. Achara Consulting November 16, 2011 Emerging Healthcare Models Slide Acknowledgement: National Council on Community Behavioral Health

12. Achara Consulting November 16, 2011 The Value of Specialty Addiction Treatment The Value of specialty addiction providers will depend on their ability to: Be accessible Be efficient Have the capacity for electronic health records Produce Outcomes Engaged clients and natural support network Help clients self manage their wellness and recovery Greatly reduce need for disruptive/high cost services Effectively promote sustained recovery Slide Acknowledgement: MTM Services, David Lloyd, Presented at National Council 2011 Conference

13. Achara Consulting November 16, 2011 Post Treatment RSS What’s going well now?

14. Achara Consulting November 16, 2011 Approaches to Post-Treatment RSS Multi-media (face to face, technology based, mail) Home visits Peer Support groups Linkage to mutual aid societies Recovery check-ups Peer leadership councils Recovery centers Contingency Management Clinic based individual and group sessions Mail Internet-based RSS Assertive Linkages to natural supports Telephone-based RSS Recovery Community Organizations Embedded within primary care settings

15. Achara Consulting November 16, 2011 What’s the Difference? Implementing a Practice versus Developing a Culture

16. Achara Consulting November 16, 2011 3 Approaches to Integrating RSS Adding peer and community based recovery supports to the existing treatment system. Practice and Administrative alignment in selected parts of the system/organizatio n – e.g. pilot projects/programs. Cultural, values based change drives practice, community, policy and fiscal changes in all parts and levels of the system. Everything is viewed through the lens of and aligned with recovery oriented care. ADDITIVESELECTIVETRANSFORMATIONAL

17. Achara Consulting November 16, 2011 Setting the Stage PRACTICE CONTEXT CONCEPTS Aligning Concepts: Changing how we think Aligning Practice: Changing how we use language and practices at all levels; implementing values based change Aligning Context: Changing regulatory environment, policies and procedures, community support

18. Achara Consulting November 16, 2011 Attraction and Assertive Outreach Global Assessment vs. Categorical Assessment Recovery Planning Expanded Service Team Collaborative Service Relationships Appropriate Service Dose, Scope and Quality Expanded Locus of Service Delivery Assertive Linkage to communities of Recovery and Natural Support Post-Treatment, Monitoring, Support and Early Re- Intervention Conceptual Alignment: Recovery Management Approach Setting the Stage

19. Achara Consulting November 16, 2011 Addiction/Chronic Illness Compliance Rate (%) Relapse Rate (%) Alcohol30-5050 Opioid30-5040 Cocaine30-5045 Nicotine30-5070 Insulin Dependent Diabetes Medication Medication<5030-50 Diet and Foot Care Diet and Foot Care<5030-50 Hypertension Medication Medication<3050-60 Diet Diet<3050-60 Asthma Medication Medication<3060-80 Slide Acknowledgment: William White. Data Source: O’Brien CP, McLellan AT. Myths about the Treatment of Addiction (1996). The Lancet, Volume 347(8996), 237-240. Conceptual Alignment: Chronic Care Philosophy Setting the Stage

20. Achara Consulting November 16, 2011 Conceptual Alignment: Timing of Recovery Stability Stability of alcoholism recovery is not reached until 4 to 5 years of sustained remission Relapse in alcoholism recovery is rare after 7 years Stability of recovery from other substances may take longer People are particularly vulnerable during the first 90 days following treatment Recovery is more sustainable with time in recovery Setting the Stage

21. Achara Consulting November 16, 2011 Conceptual Alignment: Core Principles of Post-Tx RSS Post-Tx RSS do not require longer Tx episodes but an extended period of check-ups and support Create easy mechanisms for early re-intervention Responsibility for continued contact lies with professionals Support needs to be saturated within periods of greater vulnerability (e.g. the first 90 days after tx) Focus on convenience Provide ongoing assistance in building recovery and problem solving obstacles to recovery Setting the Stage

22. Achara Consulting November 16, 2011 Setting the Stage Flexible and individualized plan Use assertive linkages, not passive referrals Use multi-media approaches Emphasize continuity of contact in primary service relationship Embed Post-Tx RSS in the person’s natural environment Facilitate delivery by counselors, recovery coaches, and trained volunteers Conceptual Alignment: Core Principles of Post-Tx RSS

23. Achara Consulting November 16, 2011 Characteristics of Effective Peers Credibility with other peers Creative with limited resources Knowledge of individual/family addiction and recovery Knowledge of the local community and recovery support resources Knowledgeable about multiple pathways of recovery Capable of initiating and sustaining healthy, respectful (non- exploitive) recovery support relationships Able to work collaboratively with others Has good self-care rituals and the ability to ask for and utilize supervisory guidance

24. Achara Consulting November 16, 2011 Implementation of Post-Tx RSS Set Expectation Explore past experiences with post-tx RSS Identify and assemble recovery support team/ “recovery circle” Conduct a recovery capital assessment Increase your and client’s awareness of community-based resources Review menu of post-tx RSS options Support individual and family in developing a Continuing Care Plan Clearly identify roles of all members of team Clearly identify various contexts for Post-tx RSS Assertively connect people to relevant resources in the community Monitor and evaluate person’s initial and ongoing responses to resources/strategies Individual Level

25. Achara Consulting November 16, 2011 Implementation of Post-Tx RSS Make the processes transparent and participatory Identify a guiding group or point person/s Create a sense of urgency – Why? Establish a shared vision for post-tx RSS. What will your menu of services include? Identify the resources available to you currently or in the future (counselors, recovery coaches, community partners, volunteers, peer leadership councils, recovery community organizations, etc) Determine who will provide which types of support Identify a few priorities “what’s the low hanging fruit?” Determine how incentives may be used to support these priorities Implement your prioritized strategies Study the results (focus groups, outcome data, staff observations, etc) Make the necessary changes Learn from implementation science: Staff need training, feedback and coaching (Miller, 2004) Organizational Level

26. Achara Consulting November 16, 2011 Implementation of Post-Tx RSS To what extent… Has your organization shifted from an acute to a chronic care approach to tx? Are peers integrated as a part of your service teams? Do you have a mobilized cadre of volunteers to support a culture of continuing care? Do you have a recovery-oriented work environment? Organizational Level: Factors to Consider

27. Achara Consulting November 16, 2011 Spotlight on Telephone-based RSS Benefits Orientation Session Timing of Calls Wording of Questions You didn’t drink, did you?’ Have you drank any alcohol in the past seven days?’ How many days in the past seven did you drink any alcohol? (Carise)

28. Achara Consulting November 16, 2011 Step by Step Telephone Session Overview Acknowledge client and focus of call Review Progress Assessment Worksheet Provide feedback Review client’s progress/goals Identify future high-risk situations Discuss focus for remainder of call Problem-solving Set goals Schedule next phone call The Arkansas Continuing Care Program Telephone Monitoring and Adaptive Counseling - Clinician Manual (2008). The manual was adapted with permission from the work of James R. McKay, Ph.D. by the Mid- America ATTC

29. Achara Consulting November 16, 2011 Case Study How might things look different?

30. Achara Consulting November 16, 2011

31. Post Treatment RSS in Primary Care

32. Achara Consulting November 16, 2011 Let’s Go For It!!!

33. Achara Consulting November 16, 2011 Contact Information Ijeoma Achara, PsyD Achara Consulting Inc. ijeoma.achara@yahoo.com