Continuing Care Model
Winter 2005
Volume 5, Number 6
Background
The idea of a continuing care model for addiction treatment is an emerging concept put forth within the last five years. While many treatment experts are working on such models, very little is published at this point in time. However, this is the direction that the addiction field is moving in. This model offers a better fit for addiction, which is a chronic illness, and offers a better paradigm for measuring the success of addiction treatment.
Alcohol and other drug use begins with an individual’s conscious choice, but addiction is not simply "a lot of alcohol and other drug use." Recent scientific research provides overwhelming evidence that not only do alcohol and other drugs interfere with normal brain functioning by creating powerful feelings of pleasure, but they also have long-term effects on brain metabolism and activity. At some point, changes occur in the brain that produce conditioned urges to repeat drug use, while simultaneously reducing awareness, caution and judgment. It is not yet known how drugs can produce these powerful effects, but it is clear that these are predictable, physiological consequences of substance use, and they explain why those addicted to alcohol and other drugs suffer from a compulsive craving for, and use of, these substances and cannot quit by themselves. Treatment is necessary to end this compulsive behavior.
The word "treatment" may be a misnomer as applied to addiction because it implies a one-time strategy to eliminate the adverse effects of a physiological condition. Like other chronic and potentially fatal conditions such as heart disease or diabetes, treatment of addiction actually refers to an extended process of diagnosis, treatment of acute symptoms, identification and management of circumstances that initially may have promoted the alcohol and/or drug use, and development of life-long strategies to minimize the likelihood of ongoing use and its attendant consequences. In this context, treatment is best viewed as a continuum of different types and intensities of services over a long period of time. A phrase commonly used in the current treatment field is "recovery management," referring to the structured process of accessing and completing the range of services on the road to health and self-sufficiency.
Figure 1 illustrates a reasonable model of contemporary treatment with three stages. Each stage is designed to accomplish a different goal. Accountable, effective performance in the later stages of treatment is contingent upon effective performance in the earlier stages of care.
Treatment is a continuing process. An addict cannot do well in continuing care if he or she has not learned what he or she needs to know and developed the necessary skills in detoxification and rehabilitation.
The duration of these stages should not be determined by time constraints but, rather, by performance milestones—meeting the objectives of the early stages of care should qualify the patient for the next stages. Various parts of the addiction treatment system focus on different skills and developmental issues.
At some point during the rehabilitation phase of treatment—and research has not yet determined when this is—patients are ready to reduce the intensity of the care they are receiving and to take on more self-management of their problem. However, self-management needs help from a network of others, so most rehabilitation programs encourage active affiliation with AA or other mutual help network or help from a personal therapist. Here, there is realization that no fixed amount or duration of care can reliably cure addiction. As with many other illnesses, addiction is a recurring problem that will need life change and supported self-management to prevent its return.
Continuing care traditionally has been AA or NA or personal therapy, and these remain sound ways to maintain the improvements brought about through rehabilitation for about 30 percent of those who complete rehabilitation. Continuing care usually entails meetings or contacts at a frequency of once per week to once per month; there is no recommended duration for this type of care . For example, AA meets at many sites and at virtually all times in all cities just to provide the kind of support that may be necessary. Unfortunately AA and similar programs are not effective for a majority of persons with continuing care needs, so new alternatives may be needed for those who want an alternative. Increased use of telephone and Internet communication has been used to support and monitor patients who have attained stability, have begun a new lifestyle and who will need some level of assistance and monitoring to sustain that lifestyle and to prevent relapse.
Drug Dependence, A Chronic Mental Illness
Implications for Treatment, Insurance and Outcomes Evaluation
Study and Results: Studies estimate that drug dependence in the United States costs approximately $67 billion annually in crime, lost work productivity, foster care and other social problems. Furthermore, 40 percent to 60 percent of patients treated for addiction return to active substance abuse within a year following treatment discharge. Current addiction strategies generally treat dependence as a curable, acute illness when, in fact, dependence may require a long-term recovery strategy and be viewed as a chronic illness. The authors completed a literature review to compare drug dependence with three chronic illnesses: type 2 diabetes mellitus, hypertension and asthma. The article discusses characteristics of chronic illnesses and reviews recent studies in the medical treatment of drug dependence and treatment response. Overall, the study indicates that addiction shares many characteristics of other chronic illnesses. Furthermore, the most effective treatments have been long-term medication or treatment programs. The authors state that addiction should be insured, treated and evaluated like other chronic illnesses.
What’s Important: Characteristics of chronic illnesses include diagnosis, heritability, role of personal responsibility and pathophysiology. In terms of addiction, diagnosis requires the distinction between use, abuse and dependence. Heritability appears to play a greater role in the risk of addiction than in other chronic diseases. An aspect of personal responsibility is important to the onset of addiction, but involuntary components such as genetic factors also play a role. The pathophysiology of addiction is marked by significant and persistent changes in the brain chemistry. Treatment for addiction is provided in a manner similar to treating acute care disorders. Evidence indicates that the best outcomes for addiction treatment have been seen in patients who receive long-term maintenance programs. Long-term treatment strategies of medication management and continued monitoring have shown lasting benefits for addiction patients.
Find This Study: McLellan, A. Thomas, Ph.D.; David C. Lewis, M.D.: Charles P. O’Brien, M.D. Ph.D.: Herbert D. Kleber, M.D. "Drug Dependence, A Chronic Medical Illness, Implications for Treatment, Insurance, and Outcomes Evaluation." Journal of the American Medical Association, 284 (2000): 1689-1695.
Is Addiction an Illness? Can it be Treated?
Study and Results: This study considers a number of questions to determine if addiction is an illness and if it can be treated. First, the author examines whether addiction is an illness by applying the same standards and methods used in the study of etiology, diagnosis and course of other diseases. In addition, the study reviews whether there are effective treatments for addiction, including medicinal treatments. The author also discusses research on the "active ingredients" in addiction treatment processes. Finally, the author explores an evaluation of the effectiveness of addiction treatments using measurement criteria typical of other chronic illnesses. The study concludes that drug and alcohol dependence are treatable medical illnesses. Further, evidence suggests that addiction is best considered as a chronic relapsing condition/illness. The best treatments for addiction are those that are ongoing; are able to address the multiple problems that present risks for relapse; and are well integrated into society, allowing for monitoring.
What’s Important: The study concludes that drug dependence can be reliably and validly diagnosed and is linked to genetic transmission. In addition, the author states that, from both a patient’s and society’s perspective a truly "effective" treatment will provide lasting reduction in substance abuse and also will improve personal and social functioning. Studies have consistently shown the patients who comply with the recommended regimen of education, counseling and medication have the most favorable outcomes during and following treatment. Unfortunately, many who start treatment drop out before completion. The components of effective treatment include staying longer in treatment, reinforcement, individual counselor, specialized services, inclusion of medications, and participation in AA or NA. Effectiveness is measured differently for other chronic illnesses, such as diabetes, hypertension, and asthma. High relapse rates following cessation of medications for other chronic illnesses are evidence of effectiveness of medications. On the other hand, relapse to drugs and/or alcohol following cessation of addiction treatments is considered treatment failure. Drug dependence is not evaluated under the same assumptions as other chronic illnesses, leading to different evaluation measurement standards.
Find this Study: McClellan, A.T. "Is Addiction an Illness? Can it be Treated?" Journal of Substance Abuse Treatment 23 (2002) (3S): 67-94.
Establishing the Feasibility of Performance Measures for Alcohol and Other Drugs
Study and Results: A multi-disciplinary group of providers, researchers, managed care representatives and public policy representatives, referred to as the Washington Circle, evaluated three performance measures—identification, initiation and engagement—for alcohol and other drug (AOD) services. Identification refers to the percent of adult enrollees with AOD diagnoses. Initiation refers to the percent of adults with an inpatient AOD admission or an index outpatient visit. Engagement refers to the percent of AOD-diagnosed adults who receive two additional AOD services within 30 days of diagnosis. The authors claim that performance measures for AOD services has lagged behind those of other chronic illnesses, but that these measures need to be established to set standards of accountability that will ultimately lead to improved quality of care for people with AOD disorders. The Washington Circle proposed seven core performance measures; the three measures selected for the paper were chosen because they can be calculated using administrative data. As a result of the study, the authors conclude that using administrative databases to compare managed care organizations’ performance is feasible, meaningful and informative. They also state that these three services represent a base that is absolutely necessary for providing sufficient services to patients with AOD disorders.
What’s Important: One main goal of the Washington Circle was to develop and pilot-test a core set of performance measures for AOD services for public and private sector managed care organizations. The measures were developed based on certain assumptions about AOD disorders and their treatment and on a particular conceptual model. The model states that the chronic, relapsing nature of AOD disorders requires a system of accountability beyond discrete treatment. Evidence shows that early recognition, managed recovery following an episode, and organization of services to treat post-treatment sobriety play an important role in the ultimate outcome of recovery. The circle proposed seven core performance measures that fit into four domains, representing the continuum of AOD services—prevention/education, recognition, treatment and maintenance.
Find this Study: Garnick, D., et al. "Establishing the feasibility of performance measures for alcohol and other drugs." Journal of Substance Abuse Treatment 45 (2002): 124-131.
Reconsidering the evaluation of addiction treatment from retrospective follow-up to concurrent recovery monitoring
Study and Results: This study reviews evaluation techniques of chronic illnesses in comparison with addiction and discusses a more in-depth model called the "Concurrent Recovery Monitoring" (CRM) model to more effectively evaluate addiction recovery. The authors highlight that addiction is similar to chronic illnesses such as diabetes, hypertension and asthma in a variety of ways; but differences arise, however, in the way addiction is conceptualized, treated and evaluated. The study outlines reasonable outcome expectations for addiction treatment, changes in addiction treatment concepts and delivery and reviews recent evaluation approaches in comparison to the CRM model. The proposed CRM model focuses on evaluation measures to assess recovery progress and make decisions about continuing care. The authors feel the CRM model will be beneficial for researchers and policymakers because it offers more accurate and efficient evaluation of addiction treatment. For clinicians, the CRM model offers more clinically relevant patient information in a timely manner. The authors also identify reduced administrative costs, increased accountability, and greater comparability to other evaluation forms as additional advantages. The article recommends that the CRM model be implemented and reimbursed as part of the standard outpatient treatment of addiction.
What’s Important: Expected outcomes that from addiction treatment include a reduction in substance abuse, improved personal health and social function, and reduction in threats to the public. All these characteristics are similar to other chronic illnesses, but the treatment and evaluation is different in that it is not provided over an indefinite period of time and the effects are not continually assessed. Recent approaches to treatment recovery have included post-treatment follow-up, performance monitoring, or patient-focused evaluation. The CRM model combines aspects of each of these evaluation methods to create a model that offers traditional post-treatment evaluation and efficient and repeated measurement procedures such as those used in managing chronic medical conditions.
Find This Study: McLellan, A. Thomas, et al. "Reconsidering the evaluation of addiction treatment from retrospective follow-up to concurrent recovery monitoring." Horizons Review (July 2004).
A. Thomas McLellan, Ph.D. is a professor of Psychiatry at the University of Pennsylvania and founder and executive director of Treatment Research Institute. He is best known for his leading role in creation of the Addiction Severity Index and the Treatment Services Review, two of the most widely used instruments in the field of substance abuse.
Assuming addiction is a chronic illness, is the common model of addiction treatment a good fit?
No. Under the common treatment model for chronic diseases-hypertension, diabetes, asthma-patients go to specialty care through referral by a primary care doctor only after problems cannot be controlled. In addition, specialty care doesn't discharge patients without follow-up to a primary care doctor for continued management. The job of specialty care is to get the patient's condition to where it can be managed with minimal involvement of the primary care doctor and with new, acquired knowledge, behaviors and attitudes for self-management.
Although addiction is chronic, most treatments are funded, insured and evaluated on an acute care model. In addictions, less than 4 percent of admissions to primary care come from any part of the medical establishment; essentially, no patients are referred to primary care for management. Other areas of chronic care have disease management systems in place. Health care delivery organizations have telephone, Internet and email management systems for patients and their families that are designed to encourage self-management, provide new information, and encourage medication adherence and adherence to behavioral change strategies. In addictions, the poor fit between the treatment model and disease model is not due to resistance from the field. It's due to the way addiction has been conceptualized, financed, insured and evaluated, which hasn't followed the health care model.
What does continuing care consist of?
Nobody imagines diabetic patients will be cured. They may be in danger of losing fingers from lost circulation; acute care strategies ensure fingers aren't lost. The next phase is to teach appropriate monitoring, diet, stress reduction, exercise regiments and medication adherence. In the third phase, continuing care, the patient understands what needs to be done; a continuing care plan is worked out and conducted by telephone, Internet, or office/home visits, when appropriate.
The same thing applies in addiction. When patients come in, they may be in withdrawal, may not have slept for weeks, and may have terrible financial, legal, family and health problems. First, correct the emergent problems and stabilize things. Next, offer rehabilitation so the patient understands and accepts there is a problem, has embraced change strategies, and possibly has begun taking medications. Finally, continuing care is called for when the patient is ready to self-manage. Self-management means staying away from temptation-people, places and things; changing life, stress, and other factors; and avoiding another expensive, dangerous emergency event. That is continuing care. AA is the only program readily that is available and widely used. Data show approximately 25 percent of people develop active involvement with AA. That's great, and doesn't cost anything. But 75 percent of people need another form of continuing care, and it's time that the kind of disease management practices being used in other chronic diseases be used in addiction. Treatment of addiction, done right, where addiction is managed for long periods of time, will reduce costs-legal, employment, welfare-associated with this health care problem.
How does the way that addiction treatment is commonly evaluated, months after it has ended, make treatment appear to be ineffective?
Why don't we have 28-day insulin programs and evaluate insulin effectiveness after it's over? You would never evaluate an intervention after its effects have worn off. In addictions, one of the paradoxes is that research shows expensive, residential, highly intensive forms of treatment rarely do better than brief, short, inexpensive, less invasive treatments for addiction. That's because they're evaluated after the treatment's over. No matter what treatment is provided, all have 50 percent relapse rates. You would find no difference between expensive and inexpensive diabetes treatments either, if you stopped them. Research may have systematically underestimated the true effectiveness of addiction treatment because of the evaluation paradigm.
Is continuing care in addiction treatment cost effective?
Expensive treatments consume limited state dollars. Detox care costs around $800 per day and residential care costs at least $100 per day, both with relapse rates of 50 percent to 60 percent. Although costs are capped, you haven't saved anything, because people use emergency room services or psychiatric emergency centers when they don't have access to other care. If continuing care in outpatient settings yields the appropriate measures of treatment effectiveness-patients reduce or eliminate substance use, (re)initiate productive social activities (work, family, parenting), and eliminate socially negative activities (crime, drunk driving, use of welfare, inappropriate use of medical services)-there is a great social value for a very small investment in continuing care. Conversely, it's not a wise to spend public funds on recurrent, short-term, expensive treatments.
Do any states have promising practices in place?
One of the best is Delaware, where the state decided it's valuable to minimize social costs and maximize function outcomes-to have patients in the public treatment system retained and managed for long periods of time. The state only wants to pay providers that show strategies that retain patients into active involvement in outpatient care. First, the state incentivized programs to retain-not discharge-and actively involve patients in rehabilitation. The second phase pays more for programs that show that clients who are retained are working, not using drugs, not committing crimes and not being arrested; all are quantifiable outcomes with financial consequences. Massachusetts has moved toward performance-based contracting. Iowa is attempting to align administrative, regulatory and financing practices to facilitate good clinical practices. Many states are examining their data collection and data reporting requirements.
Treatment Research Institute (TRI) just hired Dr. Mady Chalk from CSAT and started a Center for Evidence-based Policy, explicitly to help states create and support policies that foster better clinical effectiveness in treatment programs. We want to publicize the advances some states are making, encourage states to disseminate their best practices through manuals and lessons, and help other states implement what successful states have done.
Concurrent Recovery Monitoring
Concurrent recovery monitoring (CRM) is an approach to treatment designed to keep individuals involved in recovery over a sustained period of time. The first major test of CRM is being conducted in Delaware, with an eye to linking pay with performance. Working with Treatment Research Institute (TRI), Delaware’s Division of Substance Abuse and Mental Health (DSAMH) has already begun to track one CRM measure and plans to implement several more in the months ahead. Concurrent recovery monitoring is one part of a statewide effort to improve addiction services. The plan, notes Jack Kemp, DSAMH director, is to "reward people for engaging clients in treatment and keeping them there."
Delaware is approaching CRM in a measured way. Thanks to the state’s relatively small size, DSAMH has been able to implement CRM statewide. At the same time, the state began by introducing only one performance measure—attendance. In Reconsidering the Evaluation of Addiction Treatment, a paper describing a prospective CRM system, scientists from TRI and the University of Pennsylvania advocate beginning with attendance because it is easy to track and a "clinically appropriate target for improvement." Providers of addiction recovery services have a required set of functions that clients must participate in to remain active; DSAMH now asks that attendance at these events be tracked and regularly reported to clinicians and the state agency.
Attendance reporting already has shwon positive results. "It improved access," says Mr. Kemp, "because we spent a lot of time talking about how to get people in and how to make it easy for them to get an appointment. We also see that people are staying in treatment longer."
Simply tracking attendance is not a concurrent recovery monitoring system as it appears in the scientific research. A. Thomas McLellan, James McKay, Robert Forman, John Cacciola and Jack Kemp—the authors of the Evaluation of Addiction Treatment paper mentioned above—recommend additional items to be tracked and reported regularly. Measures such as 1) reduction of alcohol and drug use, 2) increases in physical health, 3) improvements in social function and 4) reductions in threats to public health and safety are recommended. Currently, DSAMH and its providers are working to select three or four outcome measures to track, one of which will be reduction or elimination of drug use. Questions tracking employment, recidivism in the criminal justice system, and housing and lifestyle arrangements also could be among the measures introduced in the coming months.
Implementing the attendance tracking requirement led Delaware to construct its own concurrent recovery monitoring system. Although many decisions fit naturally, given the state’s capabilities, some key decisions are yet to be made. The reporting mechanism is one question of great significance in tracking health and welfare information. Providers thus far have reported attendance measurements to DSAMH on paper. This anachronism is based on necessity and, explains Mr. Kemp, future transmissions need not be transmitted electronically, either; "We don’t have the technology to do that," he notes. The frequency of data collection is another consideration that potentially could affect the program’s success. Attendance measurement is easily conducted at every visit. As more measures are added, however, providers could be overwhelmed by reporting requirements and paperwork. DSAMH and its providers currently are discussing how often to request information, from as regularly as every session to no less frequently than once a month.
With the experience gained in its trial run, Delaware is well-poised to begin a second round of CRM, this time using more detailed and potentially informative measures. So far, providers remain eager to participate, and the costs to the system have been few. "This is something the clinicians should be doing anyway, and it is directly related to the client stopping drug use," noted Mr. Kemp. Asked what obstacles might present themselves as other programs adopted CRM, Mr. Kemp pointed primarily to the high costs of gathering data in a system that has low technology adoption. To properly collect and use more measures across a larger system, better technology and systems would be needed. Added Mr. Kemp, "There’s a huge cost to that."
Addiction Treatment Continuing Care Model
The Institute for Research, Education and Training in Addiction’s (IRETA) executive director, Dr. Michael Flaherty, convened a group of prominent researchers, policymakers, and senior foundation staff, which soon grew to include payers, purchasers, funders and patients, to discuss the need for a common national vision on how to treat drug and alcohol problems. During the past two years, they have worked to develop a new model from which chemical dependency treatment can be integrated into prevention, intervention and the use of recovery support activities. Clinical research indicates that alcohol and drug abuse should be characterized as a medical illness that requires continuing care, and this model accomplishes that.
The current addiction treatment system typically is paid to provide treatment for shorter periods of time than that recommended by several scientific studies and the National Institute on Drug Abuse, and it is not encouraged to effectively link patients with recovery support services. The model addresses these problems and seeks to measure community resilience, wellness and recovery, in addition to treatment. The support services offered to those with diabetes and depression are similar, and they allow an individual more autonomy in managing his or her illness. The combination of treatment and recovery support services has been demonstrated to significantly increase a patient’s ability to achieve stable recovery and wellness.
This model has been piloted in some programs, and the results have been encouraging. Treatment access has been greatly improved—people are able to access treatment more quickly, which allows more patients to be admitted in a timely manner. In fact, the amount of time between first contact and first treatment session was reduced from an average of 14 days to 48 hours.* Redundant paperwork was reduced by approximately 40 percent, and program revenues were increased by more than 25 percent from the previous year, due to phasing out inefficient treatment processes and billing practices. Client retention was significantly increased, and the number of clients grew by at least 50 percent. Perhaps most revealing, according to one program, of clients who were referred from the county jail and completed treatment, 84 percent had ceased drug and alcohol use, 60 percent were employed, 92 percent had no probation or parole violation, and 100 percent were stably housed six months after discharge.
One of three centers at the Substance Abuse and Mental Health Services Administration, the Center for Substance Abuse Treatment (CSAT) is the federal authority on substance abuse treatment. CSAT supports several activities aimed to expand the availability of effective treatment and recovery services for alcohol and drug problems: http://csat.samhsa.gov/
The Chestnut Health Systems’ Lighthouse Institute provides applied research, training and consulting services and publications and manuals to help substance abuse practitioners and health and human service organizations improve service quality: www.chestnut.org/LI
Delaware’s Division of Substance Abuse and Mental Health initiated the Concurrent Recovery Monitoring system—which focuses on effectiveness during the treatment course, the principle that treatment is continual and a pay-for-performance provider contract system—to promote accountability and effectiveness in the state’s substance abuse treatment: http://www.dhss.delaware.gov/dhss/dsamh/
Institute for Research, Education and Training in Addictions (IRETA) provides current, science-based information related to addiction research, health policy, prevention, intervention and treatment, as well as interdisciplinary training to professionals in the addiction and human services fields: http://www.ireta.org/
An educational, scientific and informational organization, the National Association of State Alcohol and Drug Abuse Directors supports the development of and provides links to alcohol and other drug abuse prevention and treatment programs throughout the states: http://www.nasadad.org/
The Treatment Research Institute disseminates evidence-based applied research information and develops policy and practice recommendations for substance abuse treatment for families, communities and jurisdictions. Its countless resources help policymakers, practitioners and community members understand what works to treat substance abuse: http://www.tresearch.org/
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