Continuing Care Strategies for Long Term Recovery Richard Spence, PhD, ACSW Addiction Technology Transfer Center School of Social Work University of Texas at Austin
Three Concepts That will Change the Landscape of Services for Substance Use Disorders 1. SUD as a Chronic Health Disorder Similar to other Chronic Health Conditions 2. Recovery Support Services 3. ROSC Costs & svcs outside of traditional treatmt Systems and paradigm change
Each of these three concepts represent TRENDS that will figure largely in your immediate future if you stay in this field. Each of these trends involve competencies and services outside the boundaries of treatment as usual. We need to look for more options to extend the continuum of care for those we serve
RECOVERY Each of the three trends revolve around the underlying concept of Recovery from a Complex Chronic Disorder. What is Recovery? Recovery from substance dependence is a voluntarily maintained lifestyle characterized by sobriety, personal health, and citizenship. Betty Ford Foundation Recovery from alcohol and drug problems is a process of change through which an individual achieves abstinence and improved health, wellness and quality of life. SAMHSA
When does Recovery Begin? A. At the beginning of Treatment? B. After becoming fully engaged in the treatment process? (Simpson Model) C. When deciding to enter treatment? (Sobel) D. None of the above. (natural recovery) E. Any of the above. (many paths to recovery)
What Model of Care Do We Have? ACUTE CARE MODEL? CHRONIC CARE MODEL?
SUD Patient --- ACUTE MODEL Acute Temporary Deficits of Information, Insight Readiness, Social Support, Coping, Other Skills & Tools.
SUD Treatment --- ACUTE MODEL Inject EDUCATION, TRAINING, INSIGHT, SKILLS, AND EVIDENCE BASED PRACTICES
In a Chronic Care Model, How Long should recovery effort continue? A. Until the End of Treatment? B. Life-long, and involves stages Early Recovery -- Acquiring readiness, skills, and support Middle Recovery -- sharpening skills and achieving balance Late Recovery -- continued growth and maintenance
Recovery is a life-long effort. That for many, can also include one or more lapses. T T T T The lapses may require re-entry into Treatment in order to resume the pathway to recovery. In the Healthcare World, this is a very familiar picture of a chronic health condition similar to hypertension, diabetes, and athsma.
WHAT IS MISSING FROM THIS PICTURE? T T T T What is needed in addition to traditional SUD treatment?
If we really believe in addiction as a lifelong chronic condition, how does that change our work in maintaining recovery? T T T T For you as a Person in Recovery For you as a Treatment Provider For you as a Policy Maker For all of us who want to enhance the recovery environment for those we serve
Implications of a Chronic Care Model (a beginning list) RECOVERY PLANNING Following up with patients after treatment Re-engagement without delay when needed Evaluation based on During-Treatment outcomes Adaptive treatment Self-directed care Aftercare and a continuum of service options
AFTERCARE Continuing Care or Step-down to less intensive After an Episode of Care, the Usual Aftercare by treatment programs Voluntary effort by programs (unpaid) Alumni groups Nothing, ad hoc contacts by patients as needed
Research on Aftercare Recent Review by James McKay on research studies of continuing care in the last 20 years. Twenty controlled studies on the effectiveness of CC have been published since the late 1980s. Ten studies of Primary Alcohol patients. Ten with combined alcohol and drug problems. 60% studied graduates from residential pgms, 25% graduates from outpatient, and 15% had mixed graduates. McKay, J. R (2009) Continuing care research: what we ve learned and where we re going Journal of Substance Abuse Treatment 36(2): 131-145.
Research Findings Predictors of Effective Continuing Care: 1. Continue for at least one year 2. Assertive and Direct attempts to bring services to the client 3. Monitoring and feedback of patient status 4. Convenient for the patient 5. Adaptive to needs of the patient and include recovery support services 6. Facilitate Participation in support groups
EXAMPLE Telephone based aftercare Program By James McKay
Telephone Aftercare --- Recovery Monitoring (RM) --- Participant Eligibility Completed Treatment At least 3 contact persons (on Locator Form) Initial Procedure First Contact is face to face during treatment (Motivational Enhancement for enrollment in RM) Consent forms for contacts Agreement about a plan for contacts
The RM program 5 to 10 minute calls for up to a year and a half. WEEKLY for the first 8 weeks EVERY Other Week for the next 11 months ONCE A Month for the final 6 months
Each Call Assessment Current Substance Use Status Other Risk Factors craving, low self efficacy, depression Stress, Drinking environment Protective Factors Attendance at AA Health & recreation Pro-social activities or school Feedback, (and Appointments if needed)
Telephone Monitoring + Counseling (e.g. CARE, Betty Ford, McKay) Recovery Monitoring procedure is the same to include Feedback Additional 5 10 minutes. Review recent situations, analyze progress on targets, identify revised targets, plan next steps. Appointment for face-to face treatment if needed. (Cognitive Behavioral Methods)
Patients remaining abstinent over a 24 months after graduation McKay, 2005
Patients remaining abstinent by Degree of Addiction Severity McKay, 2005
Telephone Continuing Care Therapy for Adults Softcover manual, 88 pp with CD-ROM Author: James McKay Author: Deborah H.A. Van Horn Author: Rebecca Morrison Item: 2837 ISBN-10: 1592857450 ISBN-13: 9781592857456 Publisher: Hazelden Published Year: 2010 Online Price: $39.95 Each
CARE Session Outline 1. Acknowledge client for the call, and orient to the task at hand 2. Review Progress Assessment items 3. Provide feedback on assessment 4. Review progress/goals from last call 5. Identify upcoming high-risk situations 6. Select target for remainder of call 7. Brief problem-solving regarding target concern(s) 8. Set goal(s) for interval before next call 9. Schedule next phone call
MAXIMIZING ADHERENCE It is the Counselor s responsibility to try to reach the client, determine the reason for the missed appointment, and reengage the client. Make active efforts to re-engage a missing client for up to two months after a missed session, including phone calls to the client, to the client s emergency contact, and letters to the client. Suggested efforts if a client who has missed a session: Additional phone calls at various times of day as well as alternative communication strategies such as text messaging, instant messaging, Face Book, and MySpace. Use the client s Health Study Locator form. The idea is to balance active, caring efforts to contact a missing client with not harassing a client who does not wish to be found.
TMAC Progress Assessment RISK FACTORS Each Item is Scored as 2, 1, or 0 1.Substance Use 2.Potential High Risk Situations 3.People, Places, Things 4.Mood 5.Confidence 6.Cravings Total Risk Score of 5 or more is of particular concern PROTECTIVE FACTORS Each Item is Scored as 0, 1, or 2 7. Coping Skills 8. Sober Activities 9. Personal Goals 10. Positive Experiences 11. Support Groups Total Risk Score of 5 or lower is of particular concern
Other Recovery Resources Recovery Community to include AA Recovery Coaches Web Sober Sports and Recreation Alumni Groups Other
Recovery Support Resources Linkages with other Community Agencies for medical needs, psychiatric care, emergency housing, transportation, child care, vocational training, job placement, parent training, pastoral counseling, family counseling, etc.
Readiness to change How important is it for your program to try to make this change happen? --- from 1 to 10 Pros Cons, Obstacles, Worries, Benefits What are some of the good things about the acute care model? What are some of the not so good things? How Confident are you that if your program decided to make a change, it could be achieved? --- from 1 to 10 How Ready is your program to make a commitment to intiate this change? What Stage of Change? Pre-Contemplation, Contemplation, Preparation, Action