Department of Alcohol & Drug Services

1. Applying the Principles of Chronic Illness Care To Drug Addiction Treatment Sustained Recovery Management Department of Alcohol & Drug Services

2. The Chronic Care Model 1. Community 2. Health System Resources & Policies Health Care Organization 4. DeliverySystem Design 3. Self-Management Support 5. Decision Support 6. ClinicalInformationSystems Prepared, Proactive Practice Team Informed, Activated Patient Productive Interactions Improved Outcomes Wagner, EH. Effective Clinical Practice 1998;1:2-4.

3. Community Health System Organization of Health Care Leadership concerned about the bottom line and favor more frequent, shorter visits. No organized QI functional oversight Resources and Policies No links with or only passive referrals to community agencies or resources Self-Management Support No systematic approach; didactic in orientation ClinicalInformationSystems Don’t know pts or what they need DeliverySystem Design Reliance on short visits Decision Support No agreement on good care; traditional referrals Frustrating Problem-Centered Interactions Uninformed, Passive Patient Unprepared Practice Team Crummy (suboptimal) Functional and Clinical Outcomes Wagner, EH. Effective Clinical Practice 1998;1:2-4.

4. Our Evolving System of Care • 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 • Standardized language and forms • Created a continuum of care • Individualized client-driven treatment versus program-driven • Focus on meeting client where they are at

5. How We Apply the Chronic Care Model 1. Community 2. Health System Health Care Organization Resources & Policies 4. DeliverySystem Design 6.ClinicalInformationSystems 3. Self-Management Support 5. Decision Support Prepared, Proactive Practice Team Informed, Involved Patient 2. Working collaboratively with other health providers and County Departments to develop integrated case managed care 1. The Innovative Partnership with the addiction treatment provider network, Drug Courts, Health & Hospital System 6. Research and development for planning delivery and evaluation of the care system, UniCare data base 3. Sustained recovery monitoring, patient education and self management support Productive Interactions Functional & Clinical Outcomes 4. A managed and coordinated system of care that reduces avoidable inpatient, hospital and jail admissions, continuous quality improvement systems 5. Application of nationally recognized evidence-based treatment practices

6. Self-Management Support Self-Management Support Empower and Prepare Patients to Manage 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

7. Delivery System Design Assure the Delivery of Effective, Efficient Clinical Care and Self-Management Support Assure the Delivery of Effective, Efficient Clinical Care and Self-Management Support Delivery 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

8. Decision Support Promote Clinical Care that is Consistent with Scientific Evidence and Patient Preferences Promote Clinical Care that is Consistent with Scientific Evidence and Patient Preferences Decision Support • 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

9. Clinical Information Systems Clinical Information Systems Organize Patient Data to 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

10. The Health System Create a Culture, Organization and Mechanisms that Promote Safe, High Quality Care Create a Culture, Organization and Mechanisms that Promote Safe, High Quality Care • 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

11. The Community Mobilize Community Resources to Meet Needs of Patients Mobilize Community Resources to Meet Needs of Patients • Partnerships with Mental Health, Social Services, Public Health, Justice Services, and Medical Services • The Learning Institute educational forums • Development of a Social Medicine program

12. Community Awareness & Education • Treatment Works! month • Recovery awareness campaigns • Community education (Learning Institute) • Internship programs • Solutions for Wellness program (from the UMDNJ)

13. Our Future . . . Utilize the Chronic Care model (CCM) to design an approach that will: • 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

14. 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.

15. The Current System of Care for Addiction as an Acute Illness Completion of care, discharged, passive referrals to self-help meetings, community support and case is closed. Detox Residential Outpatient Transitional housing The traditional continuum of care system stops short of providing continuing care services – an essential element in treating chronic conditions

16. Toward A System of Care for Addiction as a Chronic Illness As personal responsibility increases, treatment intensity decreases Treatment Intensity personal responsibility Treatment intensity Continuing Care Services (CCS): Frequency of contact determined at each post-treatment session Detox Residential Outpatient Brief Transitional Community intervention housing support From CCS risk assessment:   Education Brief intervention Brief counseling Readmission Via telephone E-counseling, or Face-to-face

17. 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

18. 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 Prepare client for sustained recovery monitoring Detox Residential Outpatient Transitional Brief Community housing Intervention support • 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 Identify within-session patient and therapist behaviors that predict subsequent dropout or relapse (ORS/SRS) What We’re Working On What 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 ???

19. A Shift from Acute Care to a more sustained recovery management model. Where we’ve placed the initial focus for a system redesign What the Hot Group has been working on

20. 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

21. 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.)

22. Toward A System of Care for Addiction as a Chronic Illness • Streamline the readmissions process for CCS clients • Additional level of care for CCS Continuing Care Services (CCS) Detox Residential OutpatientBrief Transitional Community intervention housing support CCS priority admissions over waitlist. Readmission back to “home clinic” as a pre-auth to bypass Gateway.

23. References American 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.

24. References McLellan, 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.