Department of Alcohol & Drug Services

Applying the Principles of Chronic Illness Care To Drug Addiction Treatment

Sustained Recovery ManagementSustained Recovery Management

ProductiveInteractions

Prepared,Proactive

Practice Team

4. DeliverySystemDesign

5. DecisionSupport

6. ClinicalInformation

Systems

3. Self-Management

Support

2. Health SystemResources & Policies

1. Community Health Care Organization

Improved Outcomes

Informed,Activated

Patient

The Chronic Care ModelThe Chronic Care Model

Wagner, EH. Effective Clinical Practice 1998;1:2-4.

Uninformed,PassivePatient

FrustratingProblem-Centered

Interactions

UnpreparedPractice Team

Crummy (suboptimal)Functional and Clinical Outcomes

DeliverySystemDesign

Reliance on short

visits

Decision Support

No agreement on good care;

traditional referrals

ClinicalInformation

SystemsDon’t know pts or what they need

Self-Management

SupportNo systematic approach;

didactic in orientation

Health SystemResources and PoliciesNo links with or only passive referrals to communityagencies or resources

Community Organization of Health CareLeadership concerned about the bottom lineand favor more frequent, shorter visits.No organized QI functional oversight

Wagner, EH. Effective Clinical Practice 1998;1:2-4.

Our Evolving System of Care

Standardized language and forms Created a continuum of care Individualized client-driven treatment versus program-driven Focus on meeting client where they are at

• Shifted from a system of fragmented and isolated treatment providers to a managed and coordinated system of care

• Developed a continuous quality improvement process

• Implemented UniCare - a system-wide data base program

• Implemented clinical standards of care from evidence-based research

• Making the shift from traditional acute care treatment to the chronic care model with post-treatment check-ups

ProductiveInteractions

Prepared,Proactive

Practice Team

4. DeliverySystemDesign

5. DecisionSupport

6. ClinicalInformatio

nSystems

3. Self-Management

Support

2. Health SystemResources & Policies

1. Community Health Care Organization

Functional & Clinical Outcomes

Informed,InvolvedPatient

How We Apply the Chronic Care Model1. The Innovative Partnership with the addiction treatment provider network, Drug

Courts, Health & Hospital System

5. Application of nationally recognized evidence-based treatment practices

3. Sustained recovery

monitoring, patient

education and self

management support

2. Working collaboratively with other health providers and County Departments to develop

integrated case managed care

4. A managed and coordinated system of care that reduces avoidable inpatient,

hospital and jail admissions, continuous quality improvement systems

6. Research and

development for planning delivery and evaluation of

the care system,

UniCare data base

Self-Management SupportSelf-Management SupportEmpower and Prepare Patients to Empower and Prepare Patients to

Manage Their Recovery and Health CareManage Their Recovery and Health Care

• Group & individual instruction on the chronic nature of addiction , self-monitoring, situational complications, and relapse prevention• Client-driven care planning with identified goals and “how-to’s”• Training in “staged-based treatment”• A culture that fosters the importance of individualizing the goals & management of addiction and sustained recovery• Patient is a part of their care planning• “Within-session” rating scales for counseling therapy immediate feedback

Delivery System DesignDelivery System Design

• A managed and coordinated system of care• Client-driven and outcomes-informed treatment • ASAM PPC-2R framework for the system of care• Internal certification for all providers and

stakeholders• Management system infrastructure including

Operations and Clinical Supervisors collaborative• Recovery management and patient as member of the

treatment care team

Assure the Delivery of Effective, Efficient Clinical Care and Self-Management SupportAssure the Delivery of Effective, Efficient

Clinical Care and Self-Management Support

Decision SupportDecision SupportPromote Clinical Care that is Consistent with Scientific Evidence and Patient Preferences

Promote Clinical Care that is Consistent with Scientific Evidence and Patient Preferences

• Established evidence-based and target-driven management protocols based on national guidelines for:

• sustained recovery management• relapse prevention management

• Multiple options available for most protocols such that management can accommodate patient preference

Clinical Information SystemsClinical Information Systems

Organize Patient Data Organize Patient Data to Facilitate Efficient and Effective Careto Facilitate Efficient and Effective Care

• Common clinical language based on ASAM

• Real time “within-session” rating scales for counseling therapy immediate feedback

• UniCare system-wide data base program

• Quality Improvement division to manage care system efficiency

• The Learning Institute continuing educational opportunities

The Health System

• Established visionary leadership and commitment from multiple levels of DADS

• Established plans for a system re-design, incorporating the ideas and skills of provider leadership with a mandate to include the principles of the Chronic Care Model

• Established Departmental support to assess the efficiency & outcomes of new and innovative care management programs

Create a Culture, Organization and Mechanisms that Promote Safe, High Quality Care

Create a Culture, Organization and Mechanisms that Promote Safe, High Quality Care

The Community

• Partnerships with Mental Health, Social Services, Public Health, Justice Services, and Medical Services

• The Learning Institute educational forums• Development of a Social Medicine program

Mobilize Community Resources to Meet Needs of Patients

Mobilize Community Resources to Meet Needs of Patients

Community Awareness & Education

• Treatment Works! month• Recovery awareness campaigns• Community education (Learning Institute)• Internship programs• Solutions for Wellness program (from the

UMDNJ)

Our Future . . .

• Improve the patient experience including quality and access;

• Make work life more fulfilling for providers;

• Allow and encourage all team members to fully utilize their skills and potential; and

• Reduce total healthcare expenditures of high cost patients

Utilize the Chronic Care model (CCM) to Utilize the Chronic Care model (CCM) to design an approach that will:design an approach that will:

The Need and the Challenge:The Need and the Challenge:

To transform the current system of care, from one that is essentially reactive - responding mainly when a person is sick - to one that is proactive and focused on keeping a person as healthy as possible.

Detox Residential Outpatient Transitional housing

Completion of care, discharged, passive referrals to self-help meetings, community support and case is closed.

The traditional continuum of care system stops short of providing continuing care services – an essential element

in treating chronic conditions

The Current System of Care for Addiction as an Acute Illness

Tre

atm

ent

Inte

nsi

ty

Detox Residential Outpatient Brief Transitional Community intervention housing support

Continuing Care Services (CCS): Frequency of contact determined at each post-treatment session

From CCS risk assessment:  Education Brief intervention Brief counseling Readmission

Via telephoneE-counseling, orFace-to-face

As personal responsibility increases, treatment intensity decreases

Treatment intensity personal responsibility

Toward A System of Care for Addiction as a Chronic Illness

Continuing Care Services Approach: Post-Treatment Check Ups

• Follow-up visits focus on incremental behavioral changes & addressing recovery issues

• Once acute treatment issues have been stabilized, patient moves to continuous care services with instructions for recovery management

• Patient always welcome to return

Detox Residential Outpatient Transitional Brief Community housing Intervention support

Prepare client for sustained recovery monitoring

A Conceptual Model: DADS Services Continuum

Determinants of Progress in Tx: Patient motivation, responsibility, choice (Dim 4) Predisposing factors Enabling factors/barriers Illness/Need factors (Dim 2, 3) System of Care characteristics

Identify within-session patient and therapist behaviors that predict subsequent dropout or relapse (ORS/SRS)

Teach patients to be proactive, not reactive, to their disease.Continuous monitoring: Healthy lifestyle Self management support Patient & family education Regular follow ups with provider Support groups

What We’re Working OnWhat does it look like, how often, by whom and with what type of contact, at what cost, using what type of risk assessment scale, data collection needs, and ways to expedite re-admission if needed ???

What the Hot

Group has been working

on

A Shift from Acute Care to a more sustained recovery management model. Where we’ve placed the initial focus for a system redesign

STATE AND COUNTY SYSTEM CHANGES NEEDED TO SUPPORT SUSTAINED RECOVERY MANAGEMENT

At the STATE Level:

• Obtain authorization for a post-treatment recovery support phase of care (aka, continuing care services)

• CalOMS DISCHARGE requirements for recovery support phase clients

• Provide reimbursement for recovery support phase of treatment

STATE AND COUNTY SYSTEM CHANGES NEEDED TO SUPPORT SUSTAINED RECOVERY MANAGEMENT

At the County Level: 

• Streamline the readmissions process. Change readmission requirements for CCS pts returning to treatment at same clinic and with same counselor

• Develop a simple data collection plan for post-treatment checkups. What is it we want to know about these people?

• Contact documentation forms. NOTE: These need to be really simple and brief.

• Add more levels of care for continuous recovery monitoring (i.e. brief intervention, 1-2 episodes of OP treatment, etc.)

Detox Residential Outpatient Brief Transitional Community intervention housing support

Continuing Care Services (CCS)

Toward A System of Care for Addiction as a Chronic Illness

• Streamline the readmissions process for CCS clients

CCS priority admissions over waitlist. Readmission back to “home clinic” as a pre-auth to bypass Gateway.

•Additional level of care for CCS

ReferencesAmerican Society of Addiction Medicine. www.asam.org Dennis, M.L., Scott, C.K., & Funk, R. (2003). An Experimental Evaluation of recovery Management Checkups For People With Chronic Substance Abuse Disorders. Evaluation and Program Planning, 26, 339-352. Flaherty, Michael. (2006). A Shift From An Acute Care to a Sustained Care Recovery Management Model. Institute for Research, Education and Training in Addictions. Foote, A. & Erfurt, J.C. (1991). Effects of EAP Follow-Up On Prevention of relapse Among Substance Abuse Clients. Journal of Studies on Alcohol, 18, 143-161. McKay, J.R., Lynch, K.G., Shepard, D.S.,& Pettinati, H.M. (2005). The Effectiveness of Telephone Based Continuing Care For Alcohol and Cocaine Dependence: 24 Month Outcomes. Archives of Gen Psych, 62. 199-207.

ReferencesMcLellan, A.T., McKay, J.R., Forman, R., Cacciola, J., and Kemp, J. (2005). Reconsidering the Evaluation of Addiction Treatment: From Retrospective Follow-Up to Concurrent Recovery Monitoring. Addiction, 100(4), 447-458.  Miller, W.R., Westerberg, V.S., Harris, R.J., & Tonigan, J.S. (1996). What Predicts Relapse? Prospective Testing of Antecedent Models. Addiction, 91, S155-S172. Nestler EJ, Malenka RC. The addicted brain. Scientific American. March 2004. Neuroscience of Psychoactive Substance Use and Dependence. Geneva: World Health Organization; 2004. White, W. & Kurtz, E. (2006). Linking Addiction Treatment and Communities of Recovery: A Primer for Addiction Counselors and Recovery Coaches. Pittsburgh, PA: IRETA/NeATTC. White, W. & Kurtz, E. (2005). The Varieties of Recovery Experience. Chicago, IL: Great Lakes Addiction Technology Transfer Center.