Performance Measurement in Addiction Treatment Programs

1
Performance Measurement in Addiction Treatment
Programs

• A series of briefings offered to state
  legislatures through a collaborative effort of
  the State Associations of Addiction Services,
  National Conference of State Legislatures, and
  the Treatment Research Institute. Funded by the
  Substance Abuse and Mental Health Services
  Association (SAMHSA) under the Partners for
  Recovery Initiative through a contract with Abt
  Associates Incorporated.
• 
  
  

2
Re-Considering Addiction Treatment
Have We Been Thinking Correctly?
3
Part I
Does Anything Work?

• FDA standards of effectiveness
• Do substance abuse treatments meet those
  standards?

4
An FDA Perspective
A Drug is Approved for An Indication 2
-Randomized Clinical Trials Often ask for
separate investigators Placebo Control
Movement to test vs approved medication
Treatment Research Institute
5
FDA-Level Evidence

• Therapies
• Cognitive Behavioral Therapy
• Motivational Enhancement Therapy
• Community Reinforcement and Family Training
• Behavioral Couples Therapy
• Multi Systemic Family Therapy
• 12-Step Facilitation
• Individual Drug Counseling

6
FDA-Level Evidence

• Medications
• Alcohol (Disulfiram, Naltrexone, Accamprosate)
• Opiates (Naltrexone, Methadone, Buprenorphine)
• Cocaine (Disulfiram, Topiramate)
• Marijuana (Rimanoban)
• Methamphetamine Nothing Yet

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Part II

• The Specialty Care System A Customer
  Perspective
• Patient Survey
• Care Provided
• Infrastructure

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The Alcohol Pyramid
In Spec Treatment 1,800,000
Abuse/Dependent 18,000,000
Harmful Users ??,000,000
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Addiction Specialty Care

• 13,200 specialty programs in US
• 31 treat less than 200 patients per year
• 65 private, not for profit
• 80 primarily government funded Private
  insurance lt12
• Sources NSSATS, 2002 DAunno, 2004

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Referral Sources

• Source 1990 2004
• Criminal Justice 38 59
• Employers/EAP 10 6
• Welfare/CPS 8 16
• Hosp/Phys 4 3

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Why Dont Patients Want Treatment?
Sources 4 Review Articles Rapp et al. JSAT
2005 Stanton JMFT 2004 Appel et al. AJDA
2004 Tsogia et al. JMH 2001
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Top Patient Reasons

• 1) No Problem/Can Handle 58
• 2) No Confidence in Trt 51
• 3) Bad Trt Experience 36
• 4) Abstinence-Only Goal 31

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WHY? Wont programs deliver quality care?
CANT
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Four Reasons

• a. The Infrastructure
• b. The Acute Care Model
• The Way it is Evaluated
• The State as the Only Market

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Program Infrastructure

• Phone Interviews With National Sample of 175
  Programs regarding personnel, management,
  information
• McL, Carise Kleber JSAT, 2003

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The Treatment System

• Modality 1975 1990 2005

Residential 64 39 9
Outpatient 27 59 79
Methadone 9 10 12
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Program Changes In 16 Months

• 12 had closed
• 13 had changed service operation RESULT 25
  FEWER PROGRAMS
• 31 of the rest had been taken over, usually by
  MH agencies RESULT STAFF CONFUSION

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STAFF TURNOVER!

• Counselor turnover 50 per year
• 50 of directors have been there Less Than 1
  year

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Who Are the Directors ?

• 17 No College Education
• 58 Had BA Degree 20 Had a MA or MSW
• 2 Physicians in 175 programs
• 28 NOT Working Full Time
• Most had been clinicians _at_ program

20
Information Systems

• Modest Computer Availability
• Mostly For Administrative Work
• 80 Had a Computer
• 50 had Web Access
• Still very little computer/software availability
  for CLINICAL STAFF

21
Other Staff

• 54 Had no physician 34 Had P/T
  physician 39 Had a Nurse (part of full time)
• lt 25 Had a SW or a Psychologist
• Major professional group - Counselors

22
Kerwin et al. 2006
Regulations for license certification All 50
states and Washington, D.C. Both substance abuse
and mental health counselors
23
Degree Required?
Substance Mental Abuse Health No
Degree required 13 0 lt BA min 77
2 Masters min 10 98
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The Acute Care Model

• The Acute Care Model
• Treatment Models for Other Illnesses

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A Nice Simple Rehab Model
Substance Abusing Patient
Medications, Therapies, JCAHO, CARF, WC Ev. Based
Prac.
Treatment
NTOMS Sample of 250 Programs
Non- Substance Abusing Patient
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ASSUMPTIONS

• Some fixed amount or duration of treatment will
  resolve the problem
• Clinical efforts put toward correctly placing
  patients and getting them to complete treatment
• Evaluation of effectiveness should occur
  following completion
• Poor outcome means failure

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How Do Other Treatments Work? Chronic Illness
Continuing Care
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A Continuing Care Model
Primary Care
Specialty Care
Primary Continuing Care
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In Chronic Illnesses.
1 The effects of treatment do not last very
long after care stops 2 Patients who are out
of treatment/contact are at elevated risk for
relapse
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So, For Treatment.
1 One goal is to retain patients at an
appropriate level of care and monitoring 2
Another goal is to prepare patients to do well in
the next level of care 3 - The effects of
treatment are evaluated during treatment not
post-discharge
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But Addiction Isnt Like Other Diseases .Is
it?
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A Comparison With Three Chronic Medical Illnesses

• Hypertension
• Diabetes
• Asthma

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Why These?

• No Doubt They Are Illnesses
• All Chronic Conditions
• Influenced by Genetic, Metabolic and
  Behavioral Factors
• No Cures - But Effective Treatments Are
  Available

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Heritability Estimates Twin Studies
Eye Color 1.00
ASTHMA (adult only) .35 - .70 DIABETES (insulin
dep) .70 - .95 (males) HYPERTENSION .25 - .50
(males)
ALCOHOL (dependence) .55 - .65 (males) OPIATE
(dependence) .35 - .50 (males)
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HYPERTENSION
Adherence to medication regime lt
60 Adherence to diet and exercise lt 30
Retreated in 12 months 50 - 60 (by
Physician, ER, or Hospital)
Treatment Research Institute
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DIABETES (Adult Onset)
Adherence to medication regime lt
50 Adherence to diet and exercise lt 30
Retreated in 12 months 30 - 50 (by
Physician, ER, or Hospital)
Treatment Research Institute
37
ASTHMA
Adherence to medication lt 30
Retreated in 12 months 60 - 80 (by
Physician, ER, or Hospital)
Treatment Research Institute
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RELAPSE
Predictive Factors - All 3 Illnesses
1 - Lack of Adherence to diet, medications, or
behavior change 2 - Low Socioeconomic status 3
- Low Family Supports 4 - Psychiatric
Co-Morbidity
Sources Natl Ctr Health Stats Harrison, 13th
Ed. 30 studies
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The Way it is Evaluated
I

• Implications of How We Evaluate
• Differences in Outcome Expectations

40
If many or most cases of addiction are really
chronic then 1) We may be evaluating the
effectiveness of addiction treatments in the
wrong way.
41

• Studies show few differences between
• Brief and Intensive Treatments
• Inpatient and Outpatient Treatments
• Conceptually Different Treatments
• Matched and Mismatched Trt.
• Gender or Culturally Oriented Trt.

42
Outcome In Hypertension
Pre - During - Post
Treatment Research Institute
43
Outcome In Addiction
Pre - Post
Treatment Research Institute
44
Maybe this is why
45

• Studies show few differences between
• Brief and Intensive Treatments
• Inpatient and Outpatient Treatments
• Conceptually Different Treatments
• Matched and Mismatched Trt.
• Gender or Culturally Oriented Trt.

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What Can be Done in Programs?

• Serving the Customer
• Helping the Counselor

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Demands on Counselor

• Do Comprehensive Assessement
• Develop Individual Treatment Plan
• Provide Services to Meet Needs of Patient
• Be Culturally and Gender Sensitive

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Computer Assisted System for Patient Assessment
and ReferralCASPAR

• Start with Computer Assisted ASI
• Reduced training administration time
• Generates, state forms, JCAHO narrative and
  treatment plan
• Add Free or Low Cost Service Referral
• From United Ways First Call for Help
• Easy match of services to problems

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Problem-Services Linkage

• Alcohol
• Drugs
• Medical
• Employment
• Family
• Psychiatric
• Legal

From United Way
GED training Resume Development Job
Finding Mentoring Sessions Training Loans
Treatment Research Institute
50
Problem-Services Linkage

• Alcohol
• Drugs
• Medical
• Employment
• Family
• Psychiatric
• Legal

From United Way
Domestic Violence Parenting Skills Specialized
Babysitting Safe Housing Legal Aid
Treatment Research Institute
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Results of CASPAR Training

• Counselors now get ASI
• Now seen as part of engagement
• They love United Way services
• Most counselors use it for most patients
• Many counselors use it themselves
• Patients who get more services stay longer

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Mean Number of Services Received
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Percent Retained at 30 Days
54
Percent Retained at 60 Days
55
Average Percent Positive
trend
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The State as the Only Market

• Regulating Treatment Process
• Vs
• Purchasing Results

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Addiction Specialty Care

• 13,200 programs in US
• 65 private, not for profit
• 80 primarily government funded Private
  insurance lt12
• 31 treat less than 200 patients per year
• Sources NSSATS, 2002 DAunno, 2004

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State of Delaware
Performance Contracting
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Delaware Situation 2002

• 11 Outpatient Providers
• Limited Budget
• No success with outcome evaluation
• Providers wont/cant use EBPs

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Delawares Performance Based Contracting

• 2002 Budget 90 of 2001 Budget
• Opportunity to Make 106
• One Criterion Active Participation
• Audit for accuracy and access

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Delawares ResultsYears 1 2

• One program lost contract
• Two new providers entered, did well
• Mental Health and Employment Programs
• Programs worked together
• First, common sense business practices
• Second, incentives for teams or counselors
• 5 programs learned MI and MET

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Utilization
63
Attending
64
Philadelphia
Contracting for Public Health
Value Eliminating Detox-Only
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Detox-Only Episodes

• 40 70 of all Addiction Treatment Episodes are
  Detox-Only
• Cost 1,750 - 2,400 per episode
• Re-Detox only tracked by 7 states
• Average 40 (23 78 range)
• 28 admitted 3 times/yr

2000 Inspector Gen Report
66
Detox-Only Inpatient Detoxification 1-year
Follow-UpDavison et al., J. Add. Dis. 25, 2006
Treatment Research Institute
67
Inpatient DetoxificationShort Term Results

• 92 completed
• All prescribed Opt. Care Naltrex.
• 20 left AMA
• 73 Attended 1 or more sessions 65
• 25 Still Attending at 60 Days 22
• 5 Opiate free at 90 days 3

John Davison et al., J. Add Dis. 25(4), 2006
68
Inpatient Detoxification1-Year Results

• 92 Completed Detoxification
• 23 Readmitted for Detox 21
• 21 Admitted to ER 19
• 5 Died 5

John Davison et al., J. Add Dis. 25(4), 2006
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Contracting for Continuity

• State is the market for D-O
• State could make market for continuity
• 85 Detox-only reimbursement
• 115 Detox5 sessions of OPT
• 100 Detox 5 days Residential

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CONCLUSIONS

• Specialty care system is in trouble
• Customers Do Not Want the Product
• Ruled by Gov, Not Market Forces
• System Change is Necessary
• Public Health Value thru Patient Value
• Treatment Programs MUST Change
• Meet Customer Needs Offer New Options

Purchasers CAN
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CONCLUSIONS

• Specialty care system is in trouble
• Customers Do Not Want the Product
• Ruled by Gov, Not Market Forces
• System Change is Necessary
• Public Health Value thru Patient Value
• Treatment Programs MUST Change
• Meet Customer Needs Offer New Options

Purchasers CAN
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