Access, Engagement, and Retention

1. Access, Engagement, and Retention Recovery Oriented Systems of Care OETAS Fall 2009

2. Need for Engagement • Early intervention into chronic diseases can shorten the duration and intensity of the disorder • Neurological impairments compromise choice-making abilities during addictive addiction and early recovery, increasing relapse risks

3. Need for Engagement • The primary responsibility for initiating motivation for recovery and sustaining motivation during the earliest stages of recovery lies with the treatment staff, not the client • Hope is the key

4. Need for Engagement • Client motivation ebbs and flows and must be actively managed • Transformational change -recovery that is unplanned, sudden, positive and permanent – is possible among clients with even the poorest prognoses

5. Need for Engagement • Engagement strategies must be refined for historically marginalized populations

6. Factors Influencing Engagement and Retention • Over 40% of drop outs prior to admission can be re-engaged by a follow-up phone call procedure • Individual characteristics of treatment dropouts are less significant than program differences

7. Factors Influencing Engagement and Retention • The single best predictor of retention and dropout is the quality of therapeutic relationship between counselor and client • A strong therapeutic relationship can overcome low motivation for treatment and recovery

8. Factors Influencing Engagement and Retention • Positive therapeutic alliance is more important to long term recovery outcome for clients with low motivation than for highly motivated clients • Culture, gender, and age specific programs are associated with higher completion rates, as is family involvement in treatment

9. Contributors to Client Dropout • Lengthy and repeated assessment processes • multiple appointments before treatment begins • failure to give clients the treatment they requested • inadequate methadone doses • mixing clients at differing stages of readiness for change

10. Nature of Clinical Relationship • Collaboration/ partnership/ consultant role • Focus is to enhance client self-efficacy, improve problem solving skills, empower client as the expert in how self-management strategies can be refined to fit his or her lifestyle

11. Nature of Clinical Relationship • Burden of disease management shifts to client and his or her family • Professional acts as ongoing consultant, along with peers who have achieved self-management success

12. Nature of Clinical Relationship • Clients who are more active in their treatment rate their experience more positively, remain in treatment longer, and achieve better post-treatment outcomes

13. Connecticut Department of Mental Health and Addiction Services Practice Guidelines for Recovery-Oriented Behavioral Health Care

14. Care is offered where people are - designed around the needs, characteristics and preferences of the people receiving services A “no wrong door” approach

15. Clinical services are also responsive to pressing social, housing, employment and spiritual needs • Interventions incorporate motivational enhancement strategies - meeting each client where he or she is

16. Address barriers to care before concluding that a person is non-compliant or unmotivated 6. “Zero reject” policy 7. “Open case” policy

17. Reimbursement for pre-treatment and recovery management supports 9. Outpatient counselors are paired with outreach workers to facilitate access

18. 10.Mental health professionals, addiction specialists, and people in recovery are placed in critical locales to assist in the early stages of engagement 11.The agency employs staff in recovery

19. 12.Housing and support options are available for those who are not ready for detoxification 13.The availability of sober housing is expanded

20. Evidence Based Practices Network for the Improvement of Addiction Treatment (NIATx) Workbook - Promising Practices

21. Reducing No-Shows • Get the client to first appointment quickly • Address barriers clients face in attending assessment appointment • Clearly explain to the client what he/she can expect at first appointment • Model communication with the client upon Motivational Interviewing techniques

22. Increasing Continuation • Scheduling • Connect the patient to a counselor and other support staff within 24 hours of admission. Build a therapeutic alliance immediately. • Make it as easy as possible for patients to remember appointments and continue in treatment.

23. Scheduling Issues • Treatment schedule is inconvenient • Patients forget appointment times • Patients have limited ability to choose treatment schedule • Sessions are scheduled too far apart for patients to maintain momentum

24. Scheduling Suggestions • Adjust staff schedules so that sessions are available at times most convenient for patients. • Make reminder calls to help patients keep track of their appointments, and provide patients with appointment cards that list the next four treatment sessions

25. Increasing Continuation:Orientation to Treatment • Provide a welcoming live or video orientation • Establish clear two-way expectations • Schedule, attendance, participation requirements, how to progress through phases of care • Assign a peer buddy

26. Increasing Continuation • On an ongoing basis, identify patients at risk of leaving and barriers to continuing in treatment. Resolve barriers to continuing in treatment. • Maintain counselor resiliency with staff collaboration and personal care/development.

27. Increasing Continuation • Tailor treatment to patient’s individual circumstances and needs; use individual client-driven treatment plans • Avoid fixed lengths of stay in any level of care, so that patient movement occurs as soon as they are ready

28. Increasing Continuation • Along with a variety of education and treatment activities, have fun. • Reinforces message that sobriety is more enjoyable than using drugs • Offer positive reinforcements for continuing in treatment. • Contingency management programs, incentives

29. References • The Role of Clinical Supervision in Recovery-Oriented Systems of Behavioral Healthcare.White, Schwartz &The Philadelphia Clinical Supervision Workgroup • Recovery Management and Recovery-Oriented Systems of Care: Scientific Rationale and Promising Practices.White, 2008. • Connecticut Department of Mental Health and Addiction Services Practice Guidelines for Recovery-Oriented Behavioral Health Care • Network for the Improvement of Addiction Treatment (NIATx) Workbook - Promising Practices