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
Achara Consulting
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)
Achara Consulting
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)
Achara Consulting
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)
Achara Consulting
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?
Achara Consulting
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?
Achara Consulting
November 16, 2011
What’s the Connection?
Achara Consulting
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
Achara Consulting
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”
Achara Consulting
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
Achara Consulting
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
Achara Consulting
November 16, 2011
Post Treatment RSSWhat’s going well now?
Achara Consulting
November 16, 2011
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
Achara Consulting
November 16, 2011
What’s the Difference?
Implementing a Practice versus Developing a Culture
Achara Consulting
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
Achara Consulting
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
Achara Consulting
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
Achara Consulting
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
MedicationMedication <30<30 50-6050-60
DietDiet <30<30 50-6050-60
AsthmaAsthma
MedicationMedication <30<30 60-8060-80
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
Achara Consulting
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
Achara Consulting
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
Achara Consulting
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
Achara Consulting
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
Achara Consulting
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
Achara Consulting
November 16, 2011
Implementation of Post-Tx RSS
• 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
Achara Consulting
November 16, 2011
Implementation of Post-Tx RSS
• 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
Achara Consulting
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)
Achara Consulting
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
Achara Consulting
November 16, 2011
Case Study
How might things look different?
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November 16, 2011
Post Treatment RSS in Primary Care
Achara Consulting
November 16, 2011
Let’s Go For It!!!
Achara Consulting
November 16, 2011
Contact InformationContact Information
Ijeoma Achara, PsyDAchara Consulting Inc. [email protected]