Overview

Topeka, Kansas

Promoting Sustained Recovery Through Promoting Sustained Recovery Through

Post-Treatment Recovery SupportsPost-Treatment Recovery Supports Promoting Sustained Recovery Through Promoting Sustained Recovery Through

Post-Treatment Recovery SupportsPost-Treatment Recovery Supports

November 16, 2011 Ijeoma Achara, PsyD

Achara Consulting Inc.

Achara Consulting

November 16, 2011

Overview

• The role of recovery-support services (RSS)

• The need for post-treatment RSS

• Connecting RSS to the changing healthcare environment

• Models and approaches to developing post-treatment RSS

• Strategies for successful implementation

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November 16, 2011

What are Recovery Support Services?

• Non-clinical services that assist individuals and families to recover from alcohol or drug problems

• Social support, allied service providers, and human services contributing to an improved quality of life

• Flexibly staged prior to, during, and after treatment(Kaplan, SAMHSA, 2008)

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November 16, 2011

Examples of Recovery Support Services?• Transportation • Employment services and job training • Outreach• Pre-treatment engagement services • Housing assistance and services • Child care• Family/marriage education • Peer support services• Recovery education and coaching • Life skills training and supports • Spiritual and faith-based support• Care coordination and assertive linkages to community resources • Parent education and child development; • Continuing care and post-treatment supports (recovery check-ups)

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November 16, 2011

4 Overlapping Stages of RSSContinuum of Recovery

Pre-Recovery Engagement

Recovery Initiation & Stabilization

Recovery Maintenance

Enhancement of Quality of Life in

Long-term Recovery

(William White)

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November 16, 2011

Systemic Challenges at Each Stage of Recovery

Pre-Recovery Engagement•Unmet Need•Low Pre-Treatment Initiation Rates

Recovery Initiation and Stabilization•Limited Engagement and Retention•Inadequate Service Dose

Recovery Maintenance•Lack of Continuing Care•Recovery Outcomes•Revolving Door

Enhancement of Quality of Life

Why Recovery Support Services?

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November 16, 2011

Evolving Trends and Future Directions

•SAMHSA’s strategic Priorities

•Redirection of Block Grants

•Healthcare Reform

•Service integration with primary care

Why Recovery Support Services?

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November 16, 2011

What’s the Connection?

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November 16, 2011

ROSC/RM BH-PC Integration

Chronic Care Approach Chronic Care Approach

Sustained healing relationships, post-tx montioring, support and early re-intervention

Ongoing relationship with care provider

Individualized approaches with a focus on dose, scope and quality

Individualized, stepped care

Attraction via assertive outreach/engagement

Enhanced access via open scheduling, enhanced hours, new mechanisms for communication, universal screening

Holistic Services Whole person orientation

Community Health and wellness Public health approach focused on population health outcomes

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November 16, 2011

ROSC/RM BH-PC Integration

Strengths Based Approaches Solution focused approaches

Peer Support (navigating systems, linkage to community resources, coaching, recovery planning, problem solving, etc).

Wellness Programs

Collaborative service relationships Collaborative care and shared decision making

Expanded composition of service teams Shift from individual practitioner model to team-based approach

Expanded locus of service delivery, services delivered in natural environments

e.g. Person Centered health homes

Choice, Self direction Activated patients (Patient education and self management/ self-care

Recovery Support Services Care Management, “Enabling Services”

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November 16, 2011

Emerging Healthcare Models

Medical Homes

Hospitals

Medical Homes

Food Mart

Specialty Clinics

Food Mart

Specialty Clinics

Medical Homes

Hospitals

Clinic

Clinic

Accountable Care Organization

Health Plan

Slide Acknowledgement: National Council on Community Behavioral Health

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November 16, 2011

The Value of Specialty Addiction Treatment

The Value of specialty addiction providers will depend on their ability to:

• Be accessible• Be efficient • Have the capacity for electronic health records• Produce Outcomes

• Engaged clients and natural support network• Help clients self manage their wellness and recovery• Greatly reduce need for disruptive/high cost services

Effectively promote sustained recovery

Slide Acknowledgement: MTM Services, David Lloyd, Presented at National Council 2011 Conference

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November 16, 2011

Post Treatment RSSWhat’s going well now?

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Approaches to Post-Treatment RSSMulti-media (face to face, technology based, mail)• Home visits• Peer Support groups• Linkage to mutual aid societies• Recovery check-ups• Peer leadership councils• Recovery centers• Contingency Management• Clinic based individual and group sessions• Mail• Internet-based RSS• Assertive Linkages to natural supports• Telephone-based RSS• Recovery Community Organizations• Embedded within primary care settings

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November 16, 2011

What’s the Difference?

Implementing a Practice versus Developing a Culture

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November 16, 2011

3 Approaches to Integrating RSS

Adding peer and community

based recovery supports to the

existing treatment system.

Practice and Administrative alignment in

selected parts of the

system/organization – e.g. pilot

projects/programs.

Cultural, values based change drives practice, community, policy and

fiscal changes in all parts and levels of the system. Everything is

viewed through the lens of and aligned with

recovery oriented care.

ADDITIVE SELECTIVE TRANSFORMATIONAL

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November 16, 2011

Setting the Stage

• Aligning Concepts: Changing how we think

• Aligning Practice: Changing how we use language and practices at all levels; implementing values based change

• Aligning Context: Changing regulatory environment, policies and procedures, community support

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November 16, 2011

• Attraction and Assertive Outreach• Global Assessment vs. Categorical Assessment• Recovery Planning• Expanded Service Team• Collaborative Service Relationships• Appropriate Service Dose, Scope and Quality• Expanded Locus of Service Delivery• Assertive Linkage to communities of Recovery and

Natural Support• Post-Treatment, Monitoring, Support and Early Re-

Intervention

Conceptual Alignment: Recovery Management Approach

Setting the Stage

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November 16, 2011

Addiction/Chronic IllnessAddiction/Chronic IllnessCompliance Compliance

Rate (%)Rate (%)Relapse Rate Relapse Rate

(%)(%)

AlcoholAlcohol 30-5030-50 5050

OpioidOpioid 30-5030-50 4040

CocaineCocaine 30-5030-50 4545

NicotineNicotine 30-5030-50 7070

Insulin Dependent DiabetesInsulin Dependent Diabetes

MedicationMedication <50<50 30-5030-50

Diet and Foot CareDiet and Foot Care <50<50 30-5030-50

HypertensionHypertension


DietDiet <30<30 50-6050-60

AsthmaAsthma


Slide Acknowledgment: William White. Data Source: O’Brien CP, McLellan AT. Myths about the Treatment of Addiction (1996). The Lancet, Volume 347(8996), 237-240.

Conceptual Alignment: Chronic Care PhilosophySetting the Stage

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November 16, 2011

Conceptual Alignment: Timing of Recovery Stability• Stability of alcoholism recovery is not reached until 4 to 5

years of sustained remission• Relapse in alcoholism recovery is rare after 7 years• Stability of recovery from other substances may take

longer• People are particularly vulnerable during the first 90 days

following treatment• Recovery is more sustainable with time in recovery

Setting the Stage

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November 16, 2011

Conceptual Alignment: Core Principles of Post-Tx RSS• Post-Tx RSS do not require longer Tx episodes but an

extended period of check-ups and support• Create easy mechanisms for early re-intervention• Responsibility for continued contact lies with professionals • Support needs to be saturated within periods of greater

vulnerability (e.g. the first 90 days after tx)• Focus on convenience• Provide ongoing assistance in building recovery and

problem solving obstacles to recovery

Setting the Stage

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November 16, 2011

Setting the Stage

• Flexible and individualized plan• Use assertive linkages, not passive referrals• Use multi-media approaches• Emphasize continuity of contact in primary service

relationship• Embed Post-Tx RSS in the person’s natural environment• Facilitate delivery by counselors, recovery coaches, and

trained volunteers

Conceptual Alignment: Core Principles of Post-Tx RSS

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November 16, 2011

Characteristics of Effective Peers• Credibility with other peers• Creative with limited resources• Knowledge of individual/family addiction and recovery • Knowledge of the local community and recovery support

resources • Knowledgeable about multiple pathways of recovery • Capable of initiating and sustaining healthy, respectful

(non- exploitive) recovery support relationships • Able to work collaboratively with others• Has good self-care rituals and the ability to ask for and

utilize supervisory guidance

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November 16, 2011

Implementation of Post-Tx RSS

• Set Expectation• Explore past experiences with post-tx RSS• Identify and assemble recovery support team/ “recovery circle”• Conduct a recovery capital assessment• Increase your and client’s awareness of community-based resources• Review menu of post-tx RSS options• Support individual and family in developing a Continuing Care Plan• Clearly identify roles of all members of team• Clearly identify various contexts for Post-tx RSS• Assertively connect people to relevant resources in the community• Monitor and evaluate person’s initial and ongoing responses to

resources/strategies

Individual Level

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November 16, 2011


• Make the processes transparent and participatory• Identify a guiding group or point person/s• Create a sense of urgency – Why?• Establish a shared vision for post-tx RSS. What will your menu of services

include?• Identify the resources available to you currently or in the future

(counselors, recovery coaches, community partners, volunteers, peer leadership councils, recovery community organizations, etc)

• Determine who will provide which types of support• Identify a few priorities “what’s the low hanging fruit?”• Determine how incentives may be used to support these priorities• Implement your prioritized strategies• Study the results (focus groups, outcome data, staff observations, etc)• Make the necessary changes

Learn from implementation science: Staff need training, feedback and coaching (Miller, 2004)

Organizational Level

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November 16, 2011


• To what extent…

• Has your organization shifted from an acute to a chronic care approach to tx?

• Are peers integrated as a part of your service teams?• Do you have a mobilized cadre of volunteers to support a

culture of continuing care?• Do you have a recovery-oriented work environment?

Organizational Level: Factors to Consider

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November 16, 2011

Spotlight on Telephone-based RSS

• Benefits• Orientation Session• Timing of Calls• Wording of Questions

• You didn’t drink, did you?’ • Have you drank any alcohol in the past seven days?’ • How many days in the past seven did you drink any alcohol? (Carise)

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November 16, 2011

Step by Step Telephone Session Overview

• Acknowledge client and focus of call • Review Progress Assessment Worksheet • Provide feedback• Review client’s progress/goals• Identify future high-risk situations• Discuss focus for remainder of call • Problem-solving• Set goals• Schedule next phone call

The Arkansas Continuing Care Program Telephone Monitoring and Adaptive Counseling - Clinician Manual (2008). The manual was adapted with permission from the work of James R. McKay, Ph.D. by the Mid-

America ATTC

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November 16, 2011

Case Study

How might things look different?

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November 16, 2011

Post Treatment RSS in Primary Care

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November 16, 2011

Let’s Go For It!!!

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November 16, 2011

Contact InformationContact Information

Ijeoma Achara, PsyDAchara Consulting Inc. [email protected]

Overview

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