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ROSC for Clinicians: Recovery Management Checkups (RMC). Michael Dennis, Ph.D. & Christy K Scott, Ph.D. Chestnut Health Systems, Normal & Chicago, IL

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Rosc for clinicians recovery management checkups rmc l.jpg

ROSC for Clinicians: Recovery Management Checkups (RMC)

Michael Dennis, Ph.D. &

Christy K Scott, Ph.D.

Chestnut Health Systems,

Normal & Chicago, IL

Presentation Mid-Atlantic Regional Dissemination Workshop: Cutting edge treatment. A CTN Regional Dissemination Conference, Baltimore, MD, on June 3-4, 2010. This presentation was supported by funds and data from NIDA R37-DA11323. The opinions are those of the authors do not reflect official positions of the government. We would like to thank Belinda Willlis , Rodney Funk, and Lilia Hristova, Lisa Nicholson, for their assistance in preparing this presentation. Please address comments or questions to the author at [email protected] or 309-451-7801


Evolution of the general acute care model l.jpg
Evolution of the General Acute Care Model

  • During the early 1900’s, infectious diseases accounted for 60% of the deaths while only 20% resulted from chronic conditions.

  • This high incidence of infectious versus chronic conditions drove the ways in which various systems of care developed in this country.

  • Specifically, systems of care were organized around an episodic relationship in which a person seeks treatment, receives an assessment and treatment, and leaves the appointment or is discharged and assumed cured

  • This pattern produced expectations by patients, service providers, and policy makers that patients receive treatment followed by rapid positive outcomes or results.


Implications of an acute care model for addiction treatment and research l.jpg
Implications of an Acute Care Model for Addiction Treatment and Research

  • Substance abuse treatment has historically been organized around single episodes of care with the expectation that when patients finished the treatment they would be “cured.”

  • Indirect focus on changing the social recovery environment (with TCs being a major exception)

  • Passive referrals to address co-occurring problems

  • Minimal or no post-discharge monitoring or check-ups

  • Evaluation of outcomes over relatively short periods of time (6-12 months) with the expectation that improvements should continue after treatment.


Conflicts with the current paradigm l.jpg
Conflicts with the Current Paradigm

  • An emerging body of evidence from treatment epidemiology studies (e.g., DARP, TOPS, DATOS, UCLA, PENN, PETSA) suggests that the typical pathway to recovery often involves multiple episodes of care over many years.

  • Among people admitted to publicly funded treatment reported in TEDS, for instance, 60% of the people had been been in treatment before (including 23% 1x, 13% 2xs, 7% 3xs, 17% 4 or more).

  • Focus is expanding beyond matching at intake to matching along a continuum of care based on the response to treatment and the need for monitoring and continuing care is evident


Conflicts with the current paradigm continued l.jpg
Conflicts with the Current Paradigm (continued)

  • Evaluation of outcomes are increasingly looking at longer periods of time (2 to 5 years or more) and across multiple episodes of care.

  • In a recent study looking at the pathways to recovery Dennis, Scott et al found the median time from first use to a year of abstinence was 27 years,

  • And, the median time from first treatment to a year of abstinence was 9 years with 3 to 4 treatment episodes (Dennis, Scott, et al, 2005).


Managing chronic conditions l.jpg
Managing Chronic Conditions

  • In the U.S., chronic conditions currently account for 70 to 80% of the deaths (Matarazzo, 1982; Sexton, 1979) and for 70% of all health care expenditures (Institute of Medicine, 2001).

  • Over 10 years ago, the Institute of Medicine (IOM; 1993) report noted that ongoing management of chronic conditions can control the severity and progression of a number of chronic conditions.

  • Recently, the addictions field has started to embrace the idea that addiction often resembles other chronic conditions and that the typical acute care models of treatment may be outdated (McLellan et al., 2000; 2005; Weisner et al., 2004).

  • The purpose of this presentation is to review a Recovery Management Model developed recently to manage addiction over time and to improve patient outcomes.


Common features of early re intervention models l.jpg
Common Features of Early Re-Intervention Models

  • proactively tracking patients and providing regular “checkups,”

  • screening patients for early evidence of problems,

  • motivating people to make or maintain changes,

  • negotiating access to additional formal care and potential barriers to it, and

  • emphasizing early formal re-intervention when problems do arise.

The core assumption of these approaches is that earlier detection and re-intervention will improve long-term outcomes.


Slide8 l.jpg

Understanding Addiction as a Chronic Condition

Substance Use Careers Last for Decades

1.0

Median duration of 27 years

(IQR: 18 to 30+)

.9

.8

Cumulative Survival

.7

Years from first use to 1+ years abstinence

.6

.5

.4

.3

.2

.1

Source: Dennis, Scott et al (2005).

0.0

0

5

10

15

20

25

30


Slide9 l.jpg

Understanding the Response to Treatment

Treatment Careers Last for Years

1.0

Median duration of 9 years

(IQR: 3 to 20) and 3 to 4 episodes of care

.9

.8

Cumulative Survival

.7

Years from first Tx to 1+ years abstinence

.6

.5

.4

.3

.2

.1

Source: Dennis, Scott et al (2005).

0.0

0

5

10

15

20

25


Understanding the cycles of relapse treatment incarceration and recovery l.jpg

Treatment is not the only, but the mostly likely path to “enter” recovery

Incarcerated

(60% stable)

3%

2%

16%

15%

9%

18%

17%

4%

5%

27%

Understanding the Cycles of Relapse, Treatment, Incarceration and Recovery

  • 33% moved per quarter

  • 82% moved 1+ times

  • 62% multiple times.

In the

In Recovery

Community

(76% stable)

Using

(71% stable)

33%

8%

  • Focus of RMC:

  • Shortening time using in community until entering treatment

  • Increasing likelihood of entering recovery

In Treatment

(35% stable)

Source: Scott et al 2005, Dennis & Scott, 2007


What predicted the transition from using to treatment l.jpg

Less Likely with “enter” recovery

Frequency of Use

Treatment Resistance

More Likely with

Problem orientation

Desire for help

Prior weeks of treatment

Amount of self help

Self help “engagement”

Need to be proactive

Need to address barriers

What predicted the transition from using to treatment?

Need to be convince problems are solvable

  • Recovery Management Checkups (RMC) by 2 to 3 times

Need to keep engaged in treatment

Need to engage in self help


A subset of these factors also predict the transition from treatment to recovery l.jpg

Less Likely with “enter” recovery

Frequency of Use

Treatment Resistance

More Likely with

Amount of self help

Self help “engagement”

A subset of these factors also predict the transition from treatment to recovery?

Importance of linkage to recovery community

In its current form RMC primarily relies on treatment to cause this linkage and engagement

Importance of “degree of engagement”


Managing addiction recovery requires l.jpg
Managing Addiction & Recovery Requires “enter” recovery

  • Tracking

  • Assessing

  • Linking

  • Engaging

  • Retaining.

Which we call the TALER Model

(Scott & Dennis, 2003, in press)


Some challenges for managing addiction recovery l.jpg
Some challenges for Managing “enter” recoveryAddiction & Recovery

  • Substance-abusing lifestyles often lead to unstable living arrangements, alienation from friends and family members, and a high rate of social isolation

  • High rates of multi-morbidity (e.g., health problems, psychiatric illness, criminal justice involvement, unemployment, homelessness)

  • Friends, Family and System of care more likely to view relapsing as a moral failing or choice

  • Low rates of insurance, personal resources and social support


Tracking model l.jpg

Key “enter” recovery

Tracking Model

No

(Scott 2004)

Yes


Tracking model continued l.jpg

Key “enter” recovery

Tracking Model (continued)

Yes

(Scott 2004)


Tracking model continued17 l.jpg

Key “enter” recovery

Tracking Model (continued)

No

(Scott 2004)


Some other key facets of tracking l.jpg
Some Other Key Facets of Tracking “enter” recovery

  • Weekly monitoring and staff meetings

  • Recycling contact information

  • Anticipating institutional barriers and design issues particular to a target population

  • Split incentives

  • Customer services


Tracking track record l.jpg
Tracking Track Record “enter” recovery

  • Reliably achieves over 90% regardless of study, level of care, age, race, primary substance, mental health, homelessness, or geography in over 30,000 interviews

  • Typically average 94-97% 3 to 9 years later, with 85-95% within 2 weeks of target date

  • Average cost is generally under $300/wave, less than most research studies (typically $500-1,000 per wave) with follow rates more like 70-85%.

  • Scott has been able to teach others to replicate this success in over a dozen different independent studies


Assessing l.jpg
Assessing “enter” recovery

  • ERI experiments 1 and 2 used the Global Appraisal of Individual Needs (GAIN; Dennis et al 2003)

  • In ERI 1 we used annual on-site saliva testing and a lab based urine tests

  • Several problem were identified including:

    • Saliva and urine not agreeing, turned out to be related to delays in shipping and addressed with freezing

    • Urine and self report not agreeing (aka false negative & positive)

    • Rate of false negatives growing over time


Assessing continued l.jpg
Assessing (Continued) “enter” recovery

  • In ERI 2 we switched to quarterly on-site urine cup, gave the results to the participant BEFORE asking detailed recency of use questions, and probed any inconsistencies.

  • One step cup and laboratory tests agreed 99% of time in subsamples that were frozen before shipping

  • False negative rates were low and shrinking over time

  • Experiment 2 was more likely to identify people in need of treatment (30% vs. 44%, d=.30, p<.05).


Slide22 l.jpg

ERI 2 “enter” recovery

Comparison of False Negative Rates

by Substance at 24 months

20%

Introducing the new protocol in ERI 2 dropped the 24 month FN rate to 3%

18%

ERI 1

16%

At 24 months FN were at 19% for any drug

14%

12%

10%

8%

6%

4%

2%

0%

Opiates

Marijuana

Cocaine

Any Drug Tested


Slide23 l.jpg

Rates of False Negatives Also “enter” recovery

Dropping Over Time in ERI 2

* False Negative defined as the percent with positive urine & no past

month use reported


Assessment definition of need for rmc l.jpg
Assessment: Definition of Need for RMC “enter” recovery

Any of the following…

  • Had 13 or more of 90 days of use

  • Had 1 or more of 90 days of getting drunk or being high for most of the day

  • Had 1 or more of 90 days where AOD use caused not to meet responsibilities

  • Any past month symptom of abuse or dependence

  • Self reported a need to return to treatment

Did not attempt with people already in treatment, incarcerated, or living out side of the Chicago area.

The revised urine protocol in ERI 2 helped to increase the percent identified in “need” from an average of 30% per quarter to 42% per quarter


Linkage meeting l.jpg
Linkage Meeting “enter” recovery

  • Linkage Manager (LM) uses motivational interviewing to:

    • provided feedback to patients regarding their current substance use and related problems,

    • discussed implications of managing addiction as a chronic condition, and

    • discussed treatment barriers.

    • assessed and discussed level of motivation for treatment

    • schedules treatment intake appointment and develops plan to keeping it

  • Starting in ERI-2, LM also offered alternatives to treatment (e.g., 12 step, mega church or other recovery group, behavior change plans)


Slide26 l.jpg

  • RMC Treatment Follow-up Plan “enter” recovery

    My Linkage Manager, _________________, is available:

  • To help me get into a program

  • To me by telephone.

  • I have an appt. for treatment ______________,

  • Some things I want to talk to the treatment program staff about are:

  • ___________________________________

  • ___________________________________

  • ___________________________________

  • My Linkage Manager will meet me at the treatment program and will be available to:

  • Support me through the first stages of treatment

  • Discuss my progress

  • Monitor my length of stay

    I agree that I will not leave treatment without contacting my Linkage Manager

  • We hope that Linkage Assistance and Engagement Support will be helpful to you.

  • 1 800 990-5670

  • (IT’S FREE)


Slide27 l.jpg

  • RMC Alternative Recovery Plan “enter” recovery

    My Linkage Manager, _________________, is available

  • To help me get into a treatment program.

  • Discuss options other than treatment to address substance abuse

  • To me by telephone.

  • Things I will do to improve my current situation and how often I will do them:

  • How often?

  •  Attend 12 step/self help meetings _______________

  •  Attend church/ faith based programs ____________

  •  Meet with Recovery Coach _____________________

  •  Support programs (housing) ___________________

  •  Call my Linkage Manager ______________________

    We hope that Linkage Assistance will be helpful to you.

    1 800 990-5670

  • (IT’S FREE)


Slide28 l.jpg

Linkage Meeting Flowchart “enter” recovery

Client transferred to LM

  • LM greets client

  • Introduces self

  • Shakes client hand

  • Engages in brief casual conversation

  • LM provides personalized feedback to client using the Linkage Assistance Worksheet(LAW)

  • Review substance use and related problems

  • Review barriers to treatment

  • Engage in change talk with the client

  • Determine level of motivation (using Ruler)

  • 0-2 Little Motivation

  • Express empathy

  • Roll with resistance

  • Explore ways to increase motivation

  • Keep treatment an option

  • 3-7 Moderate Motivation

  • Explore ambivalence

  • Elicit motivational statements

  • Roll with resistance

  • Explore treatment as an option

  • 8-10 Highly Motivated

  • Explore any ambivalence

  • Support self-efficacy

  • Talk about treatment

LM discuss treatment with client


Slide29 l.jpg

LM discuss treatment with client “enter” recovery

Linkage Meeting Flowchart

Client agrees to go to treatment

  • Negotiate same day access

  • Discuss barriers

  • Problem solve to address barriers

Client agrees to go the treatment same day

 clt signs M90 release

Client agrees to treatment later in week

 clt signs M90 release

Implement

Same day access to treatment protocol

Implement

Not same day access to treatment protocol

  • LM

  • Compensates client for interview

  • Thanks them for time

  • Gives clt copy of REC plan

  • Gives clt copy of M90 release

  • Gives clt schedule card

  • LM business card w/ toll free #

  • Completes LM Log

  • Escorts clt out of the building

  • LM

  • Compensates client

  • Gives clt schedule card

  • Gives clt copy of REC plan

  • Gives clt copy of M90 rel.

  • Completes LM log


Slide30 l.jpg

Linkage Meeting Flowchart “enter” recovery

LM discuss treatment with client

Client refuses treatment

Discuss alternative options to treatment

  • Discuss other options

  • Self help groups

  • Church/Faith activities

  • YMCA

Client refuses all services

LM and client

 Complete REC plan

 Give clt copy of REC plan

 Link clt to alternative

 Keep option open to call

  • LM provide client with

  • Copy of REC plan

  • Gives LM card with toll free #

  • Keep option open to call

  • LM

  • Compensates client for interview

  • Gives clt schedule card

  • Thanks clt for time

  • Escorts clt out of the building


Engagement l.jpg
Engagement “enter” recovery

  • In advanced we had negotiated an accelerate readmission process that allows the agency to accept our assessment and get someone in within 1-2 days

  • On an individual level the Linkage Manager (LM) also..

    • Scheduled appointments for treatment and next quarterly checkup.

    • Transported patients to treatment intake and stayed through the intake process.


Retention l.jpg
Retention “enter” recovery

  • LM visited the treatment programs weekly to check in with clients currently there and contacted all at least weekly to proactively identify any unmet needs or concerns

  • Treatment agency staff agree to contact LM before discharging a client

  • LM attempts to act as an omnibudsman and keep client in treatment

  • If client leaves, LM tries to shift to an alternative plan


Slide33 l.jpg

Engagement and Retention Flowchart “enter” recovery

Client admitted to inpatient txt

LM and HC staff walk clt to unit

Txt day 1

Face to face with clt Schedule Day 4 meeting

Reinforce motivation Give clt congrats card

  • Client at-risk to leave Txt

  • Client has behavior issues at Txt agency

  • Client wants to leave txt

Txt day 4

Face to face meeting Schedule Day 8 meeting

Reinforce motivation Hand clt Thank you card

Txt agency staff call LM

  • Pre-mature discharge Intervention

  • Immediately schedule meeting with client, LM and HC tx. staff.

  • Discuss client issues and concerns to come to a resolution

Txt day 8

Face to face meeting Reinforce motivation

Introduce relapse plan and chronic disease model

Schedule Day 14 mtgHand clt Thank you card

Client decides to stay in txt

Client leaves treatment

Or

Is asked to leave

Txt day 14

Face to face meeting

Revisit relapse plan and chronic disease model

Thank you, Good job card

LM continues with protocol


Rmc protocol adherence rate by experiment l.jpg

Quality assurance and transportation assistance reduced the variance

Generally averaged as well

or better

ImprovedScreening

Improved Tx Engagement

RMC Protocol Adherence Rate by Experiment

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%

Treatment

Need

(30 vs. 44%)

d=0.31*

Follow-up

Interview

(93 vs. 96%)

d=0.18

Showed to

Assessment

(30 vs. 42%)

d=0.26*

Showed to Treatment

(25 vs. 30%)

d=0.18*

Agreed to Assessment

(44 vs. 45%)

d=0.02

Linkage Attendance

(75 vs. 99%) d=1.45*

Treatment Engagement

(39 vs. 58%)

d=0.43*

ERI-1 ERI-2

<-Average->

Range of rates by quarter * P(H: RMC1=RMC2)<.05


Slide35 l.jpg

Results variance

H1: return to treatment at a higher rate -

% Readmitted (Months 4-24)

(d=+0.21)*

(d=+0.41)*

*p<.05


Slide36 l.jpg

Results variance

H2: receive more total days of treatment –

Mean Days of Treatment Received (of 630)

(d=+0.27)*

(d=+0.23)*

*p<.05


Slide37 l.jpg

Results variance

H3: experience more days of abstinence –

Percent of Days of Abstinence (of 630)

(d=+0.04)

(d=+0.29)*

*p<.05


Slide38 l.jpg

Results variance

H4: less successive quarters of unmet need for treatment

% of quarters with unmet treatment need (of 7)

(d=-0.19)*

(d=-0.32)*

*p<.05


Slide39 l.jpg

Results variance

H5: be less likely to need treatment at the end of year two

% with unmet need for treatment (month 24)

(d=-0.21)*

(d=-0.24)*

*p<.05


Results from eri experiment 2 after 4 years l.jpg
Results from ERI Experiment 2 after 4 years variance

Relative to the control group, RMC helped to

  • Reduce the time from relapse to readmission by 71% months (45 vs 13 months)

  • Increase the percent reentering treatment by 37% (51% vs. 70%)

  • Increase the days of treatment by 41% (112 vs.79 days)

  • Reduce the successive quarters of being in “Need” of treatment by 21% (50 vs.38% of 14 quarters)

  • Reduce the number of substance problems x months by 29% r (126 vs. 89 of 720 problem x months)

  • Increase the days of abstinence by 9% (1026 vs. 932 of 1350 days)


Cost of rmc l.jpg
Cost of RMC variance

  • Relative to outcome monitoring only, adding RMC to Following up increased costs per quarter by 81% ($177 vs.. $321 per quarter)

  • The cost of RMC can also be thought of in several other ways including:

    • $843 per person found in “need” of treatment

    • $3,011per person entering and staying in treatment at least 14 days


Some limitations of rmc l.jpg
Some Limitations of RMC variance

  • Biggest effects are the first few times we bring them back to treatment, after that it can become a revolving door

  • Treatment systems are not set up to handle people coming back to treatment for the 4th to 15th time.

  • Given that over a third relapse in 90 days, a quarter may be too long of an initial period

  • Need better linkage to 12 step and other recovery support services

  • Costs could be very different if done by non-researchers and/or with less detailed assessment


Next steps l.jpg
Next Steps variance

  • Just submitting year 4 findings

  • Currently evaluating the cost, cost-effectiveness and benefit-cost of RMC

  • Just completed a 5 year follow-up wave for ERI to evaluate the impact of “removing” RMC and to evaluate 5 year HIV sero conversion

  • Just finished recruitment for a 3 year randomized trial of RMC with women coming out of cook county jailing using RMC plus new components targeting HIV risk behaviors and criminal activity

  • Examining the indirect effect of RMC on other outcomes

  • Planning a pilot study of RMC with adolescents


References and related work l.jpg
References and Related Work variance

  • American Psychiatric Association. (1994). American Psychiatric Association diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: American Psychiatric Association.

  • American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (DSM-IV-TR) (4th - text revision ed.). Washington, DC: American Psychiatric Association.

  • Epstein, J. F. (2002). Substance dependence, abuse and treatment: Findings from the 2000 National Household Survey on Drug Abuse (NHSDA Series A-16, DHHS Publication No. SMA 02-3642). Rockville, MD: Substance Abuse and Mental Health Services Administration, Office of Applied Studies. Retrieved from http://www.DrugAbuseStatistics.SAMHSA.gov.

  • GAIN Coordinating Center Data Set (2005). Bloomington, IL: Chestnut Health Systems. See www.chestnut.org/li/gain .

  • Kessler, R. C., Nelson, G. B., McGonagle, K. A., Edlund, M. J., Frank, R. G., & Leaf, P. J. (1996). The epidemiology of co-occurring mental disorders and substance use disorders in the national comorbidity survey: Implications for prevention and services utilization. Journal of Orthopsychiatry, 66, 17-31.

  • Dennis, M. L., Scott, C. K. (under review). Managing substance use disorders (SUD) as a chronic condition. NIDA Science and Perspectives.

  • Dennis, M. L., Scott, C. K., Funk, R., & Foss, M. A. (2005). The duration and correlates of addiction and treatment careers. Journal of Substance Abuse Treatment, 28, S51-S62.

  • Dennis, M. L., Scott, C. K., & Funk, R. (2003). An experimental evaluation of recovery management checkups (RMC) for people with chronic substance use disorders. Evaluation and Program Planning, 26(3), 339-352.

  • Office Applied Studies (2002). Analysis of the 2002 National Survey on Drug Use and Health (NSDUH) on line at http://webapp.icpsr.umich.edu/cocoon/ICPSR-SERIES/00064.xml .

  • Office Applied Studies (2002). Analysis of the 2002 Treatment Episode Data Set (TEDS) on line data at http://webapp.icpsr.umich.edu/cocoon/ICPSR-SERIES/00056.xml)

  • Scott, C.K, & Dennis, M.L. (2003). Recovery Management Checkups: An Early Re-Intervention Model. Chicago: Chestnut Health Systems. Available online at http://www.chestnut.org/LI/downloads/Scott_&_Dennis_2003_RMC_Manual-2_25_03.pdf .

  • Scott, C.K. Dennis, M.L. (in press). Recovery Management Checkups with adult chronic substance users. In Kelly, J.F., and White, W.L. (Eds), Addiction Recovery Management: Theory, Research, and Practice. New York, NY: Springer

  • Scott, C. K., & Dennis, M. L. (2009). Results from two randomized clinical trials evaluating the impact of quarterly recovery management checkups with adult chronic substance users. Addiction. 2009;104:959-971

  • Scott, C. K., Dennis, M. L., & Foss, M. A. (2005). Utilizing recovery management checkups to shorten the cycle of relapse, treatment re-entry, and recovery. Drug and Alcohol Dependence, 78, 325-338.

  • Scott, C. K., Foss, M. A., & Dennis, M. L. (2005). Pathways in the relapse, treatment, and recovery cycle over three years. Journal of Substance Abuse Treatment, 28, S61-S70.

  • World Health Organization (WHO). (1999). The International Statistical Classification of Diseases and Related Health Problems, tenth revision (ICD-10). Geneva, Switzerland: World Health Organization. Retrieved from www.who.int/whosis/icd10/index.html.


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