Michael Boyle1 , David Loveland and Susan George
(1)
Fayette Companies, 600 Fayette Street, Peoria, IL 61603, USA
Michael Boyle
Email: mboyle@fayettecompanies.org
Abstract
This chapter will provide an overview of how a large behavioral health provider has implemented the principles of recovery management for treating individuals with a substance use disorder over the past 10 years. The story begins with the launching of the Behavioral Health Recovery Management (BHRM) project in 1999 and the subsequent funding of the grant project from the Illinois Division of Alcohol and Substance Abuse. We will briefly review the differences between recovery management and the broader disease management model. The BHRM project was the catalyst and incubator for implementing many of the principles outlined in this book. We will review the trials launched, successes achieved, barriers encountered, mistakes made, and lessons learned while incorporating the principles of recovery management within the existing, publicly funded addiction and mental health treatment system in Illinois. We will highlight the challenges involved in translating recovery principles into the existing medical or professional model of treatment. In particular, we will discuss the philosophical challenges involved in altering the views and values of staff, limitations with the Federal and State funding streams, and structural barriers associated with publicly funded organizations. The chapter will close with a discussion of how to translate the lessons learned to other organizations, future applications of the BHRM principles in an emerging concept of integrative care, and expanding the model to include emerging technologies.
Keywords
Addiction recovery managementPrinciples of recovery managementBehavioral health recovery managementAcute care modelEvidence-based treatment
Introduction
The goal of this chapter is to provide the reader with an overview of one organization’s ongoing process of implementing the principles of recovery management. The chapter begins with an overview of the Behavioral Health Recovery Management (BHRM) project and how it was used as a platform to implement the principles of recovery management at Fayette Companies. We review the successes and barriers encountered in the process of moving toward this model of care within a large, urban, not-for-profit behavioral health organization. The chapter also includes an example of the implementation process using recovery coach services, which were a product of the BHRM project. The chapter concludes with a discussion of lessons learned and future directions of the recovery management model in the not-for-profit behavioral health-care field.
BHRM Project
The first author, Michael Boyle with assistance from a local state representative, wrote legislation in the spring of 1999 mandating our organization to develop a disease management approach to serious mental illness and addiction. The legislation passed the Illinois House and Senate and was signed into law by the Governor. During this process, the Secretary of the Illinois Department of Human Services stated that he had become intrigued with the concept and pledged $1,000,000 over a 3-year period to support development of the project.
M.B. became the Project Director and recruited Bill White [1] from Chestnut Health Systems to be Associate Director for addictions and David Loveland, the second author of this chapter, to be Associate Director for mental health. Pat Corrigan [2–4], Director of the Center for Psychiatric Rehabilitation at the University of Chicago subsequently joined the project.
The project began with a mission to resolve the paradox between the theoretical formulation of serious mental illness and addiction, which views these diseases as chronic conditions, similar to diabetes or hypertension, and the applied behavioral health treatment system, which treats these diseases with an acute care model [5]. Addiction, for example, is described as a chronic, relapsing disease; however, most addiction treatment interventions are delivered in acute, discrete episodes of care [6, 7].
Researchers in the medical field developed a chronic disease model to address conditions, such as diabetes or hypertension, for which there is no cure, but can be treated and managed over an individual’s lifespan [8]. The model is often referred to as disease management because of its focus on helping individuals learn how to manage their chronic medical conditions over time through the integration of effective medical care, ongoing support, and self efficacy.
The chronic care model, as articulated by Wagner et al. [9], served as the framework for developing a behavioral health treatment model for chronic conditions of mental illness or addiction. Bill White proposed the term “recovery management” rather than disease management for the BHRM project to emphasize the realistic possibility of recovery from either addiction or serious mental illness (or both). This model of care included consumers as partners in the process and utilized community resources while focusing on a long-term orientation to recovery. When initially challenged that disease management was a known treatment process while no one has heard of recovery management, Bill replied “they will in 3 years.” With this inspiration, the BHRM project was launched.
The BHRM team outlined an action plan for the project along with the initial principles of recovery management. An agreement was reached on an overarching purpose: to change the world of addiction and mental health treatment. One of the significant differences between disease management and recovery management was the inclusion of the community as a significant resource for recovery support. Charles Rapp [10], in his work on a strength-based approach for the treatment of serious mental illnesses, characterized the community as “an oasis of resources” that could be used to help individuals achieve their goals in life. This view of the community was adopted as a major BHRM principle.
The first task of the project was to outline the essential principles of recovery management. We established 11 guiding principles of recovery management over the course of 4 years. These principles include the following:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
A description of these principles can be accessed on the project web site at http://www.bhrm.org.
The next task was the dissemination of the recovery management principles and concepts through peer-reviewed journals and trade journals [5, 11–15]. The third task was promoting the application of evidence-based treatment approaches, which is a key component of the disease management model. A notable problem in the dissemination of evidence-based behavioral health practices is the significant lag in time between the development of effective practices within research settings and the eventual application of these interventions in applied settings [16]. This lag in time can exceed 17 years, on average, from development to application [17]. In contrast, new medications and medical technologies are rapidly adopted in both primary and specialty medical treatments. One explanation is that private corporations with a profit motive develop most medications and technologies in medical care. Significant resources are spent in marketing and sales staff to convince practitioners to use new medications and medical instruments. In contrast, research in behavioral health lacks “detailers” who go into clinical settings to promote and train on new clinical technologies.
The BHRM project identified and contracted with researchers and clinicians to write guidelines that were posted on the project’s web site. The authors were asked to write materials that could be utilized by clinical staff and supervisors, including
· A brief review of the research establishing the effectiveness of the practice.
· An overview of how the components and how the approach is utilized.
· A section that identifies manuals, books, videos, CDs, and other resources that can be used to learn and implement the practice.
Implementing BHRM Principles at Fayette Companies
Fayette became the beta site for piloting the BHRM principles. Using Fayette as a pilot site was a natural choice considering that the primary architect of the BHRM, M.B., was and still is the president of the organization and could provide internal leadership. Moreover, the organization had already launched several initiatives around the same time period that reflected and informed the BHRM principles. These overlapping initiatives included
· The integration of mental health and addiction treatment services for those with co-occurring conditions
· Integrating behavioral health and primary care services for all clients
· Training staff on evidence-based practices, such as Motivational Interviewing and the Community Reinforcement Approach.
Despite the advantages of piloting recovery management principles at Fayette, the BHRM team encountered multiple barriers in the process of implementing evidenced-based practices. The first challenge was to create an infrastructure to support evidence-based practices. Initially, we assumed that the first step in the implementation process was to train staff on evidence-based practices. Most counselors at HSC, including those with advanced degrees, had received minimal or no training on evidence-based practices. It became clear, however, that Fayette lacked the capacity to support these interventions. For example, the organization had sponsored multiple trainings by national experts on various evidence-based practices to a large portion of clinicians at HSC. Nonetheless, it became apparent that providing training was insufficient without follow-up. Notable barriers identified, included
· Supervisors would support some but not all aspects of an evidence-based practice (i.e., poor fidelity to the model).
· Staff would continue to use outdated modes of service delivery, such as confrontational techniques, along with aspects of motivational interviewing or strength-based case management.
· Counselors received minimal structured supervision. Most counselors received hallway supervision (i.e., random communications based on crisis rather than proactive training) or weekly meetings that focused on process issues (e.g., reviewing cases for billing or paperwork, but not for outcomes) rather than improving the skills of the clinicians.
These barriers highlighted the differences between academic settings and not-for-profit behavioral health operations in the implementation of EBPs. We were able to translate the technologies associated with the EBPs, but not the oversight, feedback and ongoing supervision that support the development of these interventions within academic environments. In other words, EBPs don’t exist in a vacuum; they require an environment that supports and nurtures data collection, fidelity, quality improvement procedures, and an outcome-based vision of treatment. While some researchers have noted that community-based organizations lack the resources to conduct the quality training and supervision utilized in research [18], it became apparent that this was exactly what was needed to change clinical behaviors.
We shifted resources from expensive trainings to developing an organizational structure to support EBPs based on the results of the initial round of training. Fayette Companies created the position of Vice President of Clinical Services to oversee the development of an organizational infrastructure and subsequent guidelines for implementing and sustaining EBPs. The third author of this chapter, Susan George (S.G.), was hired into the position in 2006.
S.G. initiated a supervision-training protocol that was adopted across the agency. The process involved multiple steps, including
· Establishing a monthly meeting for all supervisors and program directors (this included over 30 employees) to develop action plans, providing training, and disseminate practices.
· Establishing requirements for training for all supervisors that would be subsequently applied to all counselors.
· Initiating the training with a basic skill set for all supervisors and counselors, i.e., active listening, as well as identifying ineffective techniques that can undermine active listening, such as arguing, confronting, or dictating treatment solutions without understanding the client’s stage of change or personal goals.
· Developing competency standards for supervisors, followed by counselors, which included an internal certification program.
· Requiring all supervisors to audiotape individual sessions with clients and submitting the tapes to S.G. for review and feedback.
· Training supervisors to audiotape counselors to evaluate their performance and to provide constructive, informative feedback (as well as learning how to rate the fidelity of the counselor’s performance).
Changing Organizational and Administrative Structures
Each staff-level change required a parallel change at the administrative-level of the organization. For example, the administration had to commit time and resources to modifying the supervision structure. Moreover, many changes were required within the electronic medical records to support the changes in clinical approaches. The process was and still is time consuming; therefore, administrators had to adopt a long-term view that required dedication and vigilance against drifting away from the process of change.
Integrating Treatment for Addiction, Mental Health, and Physical Conditions
An important principle of the recovery management model is using a holistic view of individuals. The concept implies that we treat individuals not diseases or diagnostic categories. The principle is intuitive, but again, creates a challenge in the behavioral health field that was structured to treat specific, nonoverlapping diseases. Individuals who need behavioral health services are more likely to have co-occurring conditions, particularly medical complications related to extensive alcohol or drug use or neglect as a result of an ongoing SMI [19–25]. As an example, 25% of women entering our residential programs test positive for Hepatitis C. Yet, only four out of ten women who test positive are aware that they have the virus.
The Comprehensive, Continuous, Integrated Systems of Care approach developed by Minkoff [26] was chosen as a guideline to integrate behavioral health services for individuals with both mental illness and substance use disorders. A multidisciplinary quality improvement committee of addiction and mental health professionals was organized to oversee planning and implementing changes in policies and procedures at the program level. In addition, clinical staff were trained to address both conditions. Some of the changes included
· Implementing a single access point for all services using an integrated assessment for substance abuse, mental health disorders, and physical health disorders.
· Developing a policy that an individual receiving services anywhere in the organization had priority for all services provided.
· Providing easy access to psychiatric assessments and medications for persons receiving addiction treatment.
· Assisting all clients in completing medication scholarships for those who don’t have access to insurance or resources to purchase medications.
· Requiring mental health counselors to participate in ongoing treatment planning sessions with their clients while they are enrolled in a residential addiction treatment program.
· Providing specialized groups for persons with co-occurring conditions at the mental health outpatient facility with effective addiction treatment interventions.
Counselors are also required to connect all clients with a medical care provider. Most clients are referred to the local Federally Qualified Health Center (FQHC). FQHCs receive enhanced Medicaid and Medicare rates for persons without insurance, which allows these centers to serve our primary population. The FQHC in Peoria also assumed operations of a primary care clinic within the Fayette mental health facility. The satellite clinic allows integration of primary care and psychiatry and utilizes a shared medical record. The clinic provides medical services to many of our clients who have co-occurring conditions. In the Winter of 2009, Fayette and the FQHC will open a crisis center to divert persons with behavioral health problems from unnecessary use of hospital emergency departments or arrest as a result of a police encounter (for nonviolent offenses that could be diverted from arrest or booking).
We also developed a set of guidelines for establishing a relationship with an existing or new primary care provider [27]. The guidelines include sample referral forms and letters for physicians that can be used integrate medical care and ongoing recovery management from an addiction (or mental illness). Primary care providers can play a supportive role in implementing the BHRM principle of ongoing monitoring and support.
Addressing Culture
Another challenge was addressing the institutional norms that existed within all programs across the agency, such as the beliefs and values of counselors which had been passed down from generation to generation of behavioral health-care providers. This process can be compared to societies where the elders pass down stories and wisdom to the youth of the tribe around the campfires. These beliefs and values exist, even if they are not documented.
We introduced a series of “fire starter” meetings with staff to see if we could uncover some of these latent values that could undermine the recovery management model. Staff members from different service areas were brought together to discuss a list of statements that were meant to evoke passion and start fires in the discussions. Examples included are as follows:
· “Medications can be an effective strategy in the treatment of both substance use and mental health disorders”
· “It is more important to convey caring and concern than to avoid being manipulated or conned – even at the cost of “enabling” ”
· “All persons should be retained in service and treated with great respect in spite of nonadherence with treatment plan recommendations, including not taking prescribed psychiatric medications or a return to use of the drug of choice.”
Discussion among staff in these facilitated groups assisted people in examining their beliefs by hearing opposing views and real-life stories. For example, a person who believed an individual could not be in recovery if taking methadone was able to hear from a staff member working in a methadone program about clients who, for years, are employed, supporting a family, and not using illegal drugs. The need to address staff beliefs and values is a continual challenge.
During implementation of BHRM, the organization has needed to address the following cultural and philosophical issues (Table 13.1).
Table 13.1
Contrasting professional-driven and recovery management practices
|
Practice |
Professional-driven model of care vs. recovery management model of care |
|
|
Path to recovery
|
One path to recovery, as designed by the professional staff, for all persons |
Multiple paths to recovery and all can be valued based on the needs and motivation of individuals |
|
Clinical practice
|
Clinical approaches based on firmly held folklore, eclectic mix, or personal experiences |
The application of evidence-based treatments based on manual-driven protocols and measures of fidelity |
|
Dealing with relapse
|
Zero tolerance for any alcohol or drug use are mandatory |
Harm reduction approach and the use of multiple, stepped interventions to keep individuals engaged |
|
Treatment philosophy
|
Use of the professional expert or paternalistic approach |
A collaborative and strengths-based model |
|
Treatment plans
|
Development of staff-driven treatment plans |
Working with persons to develop their personally owned recovery plans |
|
Focus of treatment
|
Utilization of an office-based “they come to us” treatments |
Working with persons in the community and working with the community to support recovery |
|
Family involvement
|
Isolating individuals in residential treatment to focus on his or her addiction, minimal family involvement |
Emphasize ongoing connections with the community and involvement of family and friends as a crucial treatment component |
Reimbursement and Regulatory Challenges
Another significant issue to consider when implementing principles of recovery management is the identification of viable funding sources. There are many regulatory and financing challenges to implementing BHRM that vary significantly from State to State. Further, most of these funding mechanisms for behavioral health are based on an acute care model and office-based services. For example,
· Treatment reimbursement may be restricted to services that occur after an individual has been classified as eligible (i.e., meets target population) following a full assessment process. Services needed to engage individuals in the community may not be reimbursed under an office-based model that assumes that all individuals who need services are capable and ready to enter the program.
· Posttreatment monitoring and support services may not be reimbursed by a State’s funding mechanism, particularly for clients who have completed a formal phase of treatment.
A couple options may be used to address these administrative issues. First, providers can collaborate with state agencies to make changes to licensing, certification, and funding rules to facilitate change in delivery systems that may enhance effectiveness. The Substance Abuse and Mental Health Services Administration’s Strengthening Treatment Access and Recovery – State Initiative (STAR_SI) and the Robert Wood Johnson Foundation’s Advancing Recovery provided funding to states to implement provider–state partnerships. For example, Fayette and the Illinois Division of Alcohol and Substance Abuse worked together through a STAR-SI collaborative to identify funding options for preenrollment services to help engage individuals in treatment.
The second option is for a provider to request an exemption to current rules from their state authorities. Fayette initially used this approach by requesting exemptions to allow billing of recovery support services for 9 months following active treatment without requiring periodic treatment plans updates and to allow use of a personal recovery plan rather than a professionally developed discharge plan. This exception significantly facilitated the development and implementation of recovery coaching (reviewed next).
The Recovery Coach Model
All the changes that occurred within our organization that have been reviewed in this chapter set the stage for implementing recovery management interventions. The recovery coach program is one of our longest standing innovations resulting from these changes and provides an example of how we translated the theory of recovery management to a real-world application. The recovery coach model is based on the BHRM principles (noted in this chapter and Bill White’s review of recovery management [1]) and the concept of recovery capital [28]. The model is implemented through a community-based case management program developed in addiction treatment research. All three concepts are reviewed next.
Recovery Capital
Research with general samples of substance users has shown that as many as 50% of all individuals who have achieved full or partial recovery from their SUD, did so without the help of a professional-based intervention [29–33]. Individuals who require professional interventions to overcome their SUD:
· Experience more alcohol and drug related problems
· Have a more intensive pattern of drug or alcohol use
· Have limited or no social support
· Are in lower paying jobs or unemployed
· Have higher rates of mental illness
· Their SUD had an earlier onset than those who are able to achieve recovery without a formal intervention [28, 31, 32, 34]
· Cloud and Granfield [35] used the term “recovery capital” to refer to resources that support peoples’ recovery from an SUD. The authors found that people who achieved recovery without treatment had substantial recovery capital, such as a strong social support network of sober friends and family members, well-paying jobs, education, and a range of coping skills [28, 35]. The authors postulated that people who require formal addiction treatment services have less recovery capital and that the goal of treatment should be to increase these recovery-supporting assets.
We used the recovery capital concept as well as White’s [36] elements of recovery management as a framework for constructing an intervention for those who are less likely to achieve recovery on their own. Specifically, we postulated that
· Capacity for recovery from a substance use disorder exists on a continuum of skills.
· The goal of addiction treatment is to teach individuals how to achieve their own recovery.
· Full recovery is not essential at completion of treatment as long as individuals leave with the capacity to eventually achieve recovery without additional treatment interventions.
· All individuals are capable of achieving sufficient recovery capital if given the skills or access to the resources.
· Addiction treatment is one of multiple resources used to help individuals achieve a sustainable recovery from alcohol and other drugs.
Research on Case Management
A community-based case management model was selected as the vehicle for delivering recovery coach services. Case management interventions have received extensive attention in addiction treatment research [37]. Individuals assigned to a case management condition (with or without standard addiction treatment services) were more likely to engage and remain in treatment, report lower rates of drug and alcohol use, be linked to needed ancillary services, and report better outcomes in other problem areas, such as employment, housing, and involvement in the criminal justice system compared to individuals who received only standard addiction treatment services [38, 39, 40, 41, 42, 43].
The research of Siegal and colleagues [44, 42, 45] was particularly informative of the potential for case management in addiction treatment. The researchers combined case management services with a standard continuum of addiction treatment services for veterans with a SUD. Individuals who received the enhanced condition, which included a strengths-based case management component, stayed in treatment longer, and had lower reported drug and alcohol use [41]; had better outcomes on multiple indicators of criminality [45]; and, for those who wanted to work, had better employment outcomes compared to a randomized group of individuals who received the same addiction treatment services without the case management component [44]. The authors also found that approximately a third of the individuals assigned to the enhanced treatment condition dropped out of the addiction treatment services, but stayed engaged with the case management component [42]. This subgroup within the enhanced condition had similar outcomes to those individuals that remained engaged in treatment. Siegal et al.’s research as well as others highlighted the potential of using a community-based model that could simultaneously augment treatment or function as the primary intervention for individuals with a SUD. Case management is useful because:
· It provides a direct link to the community.
· Can be used to engage individuals entering any point of the addiction treatment continuum, such as at detoxification or at assessment for services [32].
· Can be coordinated with office- or residential-based programs.
· Case managers can use a harms-reduction approach to relapse, even when the office-based or residential programs may not [38].
· Case management services are fairly low cost compared to office-based program.
· Effective case management models:
· Are community based (office-based models are less effective; [46, 47]).
· Maintain small caseloads of below 25 individuals [48, 37].
· Train case managers in evidence-based techniques, including motivational interviewing and behavioral-skills training [38, 49, 48].
Recovery Coach Program at Fayette
Translating both White’s [36] and Cloud and Granfield’s [35] concepts into a model of case management, the goal of treatment is to improve peoples’ resources and tools so that they can sustain their recovery after the formal treatment program has been completed [50]. An essential function of a case manager in the addiction treatment field, therefore, is to help people build their recovery capital.
The recovery coach model was constructed as a pilot test of the BHRM principles [51] and based on the established protocols for case management in addiction treatment. The integration of these elements included
· A community-based case management program that coordinated services with the continuum of addiction treatment services offered at Fayette, including detoxification, residential treatment, intensive outpatient, outpatient, and medication-assisted programs.
· Case managers who were also in recovery from a SUD, i.e., peers who were trained as case managers.
· A strength-based model of service delivery.
· A continuum of care based on the treatment needs and goals of consumers.
The recovery coach program was initiated in Fall 2004 with two female recovery coaches serving women leaving residential treatment (we made the assumption that recovery coaches would be more effective if they were matched on gender).
A training manual was developed that outlined the principles of the recovery coach model as well as the skills needed to be a recovery coach [52]. The training protocol included effective practices of case managers and evidence-based practices in addiction treatment. Specifically, we adapted training protocols from Motivational Interviewing [53], the Community Reinforcement Approach (CRA;[54]), and the assertive continuing care model for adolescents [55].
The second author (D.L.) provided most of the training and supervision of recovery coaches. The training protocol included weekly supervision and individual training sessions with consumers. An interactive training format was used and involved working with recovery coaches and consumers in the learning sessions.
The recovery coaches were initially assigned to a supervisor within the existing addiction treatment programs at HSC, while receiving weekly clinical training from D.L. This split management model proved to be ineffective, particularly when it became clear that the recovery coaches were receiving conflicting messages on how to work with clients. The approach was modified to have D.L. train and supervise the recovery coaches. This modification in training and supervision reduced the risk of recovery coaches drifting toward the institutional, office-based treatment model within these programs. Further, we implemented a clinical team structure similar to the one developed by Bond and colleagues [56, 57] for their supported employment program. Bond and colleagues [56] designed a community-based model that promoted fidelity of supported employment though a cohesive team unit, while simultaneously promoting continuity by assigning employment specialists to work with specific mental health teams. Employment specialists work and train as a team under one supervisor but also meet weekly with mental health teams to receive referrals and integrate treatment planning.
Recovery coaches are trained and supervised as a team but are also assigned to specific programs at Fayette. Coaches meet weekly with counselors to receive referrals or coordinate services with clients. All clients who live or plan to reside in the Tri-County area of Peoria are eligible for recovery coach services. Counselors refer clients who show an interest in receiving recovery coach services. Specific elements of the program include
· Voluntary services:Recovery coach services are always voluntary and based on the clients’ willingness to meet with coaches, regardless of their needs, involvement in the criminal justice system, or recommendations of counselors.
· Time-unlimited service:Recovery coach services are time-unlimited, although most clients require <3 months of recovery coach services.
· Community based: Recovery coach services are provided in the community, but coaches will meet with clients on site at a residential facility to establish an engaging relationship, develop an initial personal recovery plan or provide support.
· Open-ended policy:Clients have the option of working with recovery coaches after they complete or if they withdraw from treatment.
· Harms-reduction approach: Recovery coaches continue working with clients who have relapsed or returned to active use of alcohol or other drugs. One goal of recovery coaching is to encourage individuals to stay engaged in treatment or consider returning to treatment after a relapse, if needed. A recovery coach can also assist a person in working through a brief relapse without returning to treatment.
· The Vegas Rule (confidentiality of information):What is said with recovery coaches remains with recovery coaches, regardless of the clients’ involvement in treatment or the criminal justice system. Recovery coaches encourage clients to maintain open communication with their counselors or probation officers about their addiction but won’t share information without the clients’ approval, including relapse.
Research on the Recovery Coach Model
As of June 30, 2009, 503 women (398) and men (105) have been enrolled in the recovery coach program. Table 13.2 provides a summary of the individuals who have been engaged in the program. Individuals are considered enrolled if they received at least three contacts from a recovery coach (a combination of phone and face-to-face contacts). Approximately 30% of men and women who are referred to a recovery coach decline the service or cannot be reached after the referral has been made. More men and women accept referrals in the residential programs, whereas nearly half decline the offer in the outpatient programs or cannot be reached. Individuals with more need are also more likely to accept a referral.
Table 13.2
Demographics of RC clients
|
Total |
Female |
Male |
|
|
Number opened |
503 |
398 |
105 |
|
Ethnicity |
|||
|
Minority (95% African American) (%) |
32 |
26 |
53 |
|
White (%) |
68 |
74 |
47 |
|
Legal involvement (%) |
53 |
50 |
66 |
|
Martial status |
|||
|
Single (%) |
58 |
58 |
60 |
|
Married (%) |
13 |
13 |
12 |
|
Divorced/separated (%) |
24 |
26 |
17 |
|
Widowed (%) |
2 |
3 |
0 |
|
Unknown (%) |
3 |
1 |
10 |
|
Child welfare involvement (women only) |
23 |
23 |
n/a |
|
Has a co-occurring mental illness |
|||
|
Yes (%) |
42 |
50 |
11 |
|
No (%) |
58 |
50 |
89 |
|
Education level |
|||
|
Some college (%) |
27 |
33 |
12 |
|
HS/GED (%) |
41 |
41 |
41 |
|
Less than HS (%) |
27 |
25 |
34 |
|
Unknown (%) |
5 |
3 |
12 |
Table 13.2 provides information comparing treatment continuation of 84 women who received RC services compared to 84 women who completed the same residential program during the same time period but did not receive RC services (Discharged between July 30, 2005 and February 24, 2009). Women in the matched group were included if they lived in the local area and were referred to one of the organization’s intensive outpatient program after leaving the residential program. We reviewed 90 days of treatment records for all women after discharge from the residential program. All women were referred to HSC’s outpatient programs (women who did not complete the residential program, moved out of the county or were not referred to outpatient services were excluded from these analyses). The groups were similar in age and race (diagnostic information was not compared) (Table 13.3).
Table 13.3
Treatment continuation for women receiving RC services
|
Connected with IOP |
Average no. of IOP – groups |
Average no. of groups for those who connected |
|
|
Recovery coach (n = 84) |
78 (93%)* |
22 (SD = 13)* |
24 (SD = 12)* |
|
No recovery coach (n = 84) |
61 (73%) |
13 (SD = 14) |
18 (SD = 13) |
* Significant at 0.05
Women who received RC services were significantly more likely to engage in outpatient services after leaving the residential program and stay longer in treatment compared to women who did not connect with a recovery coach. Of course, it is also possible that women who voluntarily agreed to work with a recovery coach were more motivated to stay engaged in treatment. The results are encouraging but require research using a randomized design (i.e., eliminate the possible confound of motivation for treatment) to further evaluate the effectiveness of the model.
Preliminary results indicate that recovery coaches have been successful at helping women obtain employment, improve their housing, and acquire essential resources in the community.
The initial success of the recovery coach program led to several expansions through grant projects. The first adaptation of the model occurred through a US Department of Justice grant to expand treatment services for a drug court program. The grant project allowed us to provide recovery coach services to men involved in the criminal justice system. We recently developed an outreach program with two recovery coaches – one male and one female – who are receiving referrals directly from the County’s probation program. The outreach program was a product of our ongoing research with the drug court program.
We acquired a grant in 2009 through the Illinois Department of Healthcare and Family Services to develop a 24-h crisis center that can divert individuals from either an emergency room or jail. The program will focus on individuals who are in crisis due to a psychiatric condition or substance use disorder and can be treated in an outpatient setting. Recovery coaches will help engage individuals who are diverted to the program as well as assist in triaging them to treatment or other needed resources in the community.
A third grant project will use the recovery coach model with adolescents enrolled in a US Department of Labor’s Youth Build Vocational Training Program (2009). One recovery coach will work with young adults who have an SUD and are enrolled in the vocational and educational program. The grant project was awarded to a workforce program in Peoria and is slated to begin in January 2010.
Challenges and Modifications of the Recovery Coach Model
The recovery coach program continues to evolve at Fayette. Limited research at HSC provides initial support for the model, although more research is needed to thoroughly evaluate the intervention. Below is list of challenges and barriers that have been encountered over the course of 5 years of the recovery coach program.
Adapting a Consumer-Driven Model to a Professional-Driven Treatment Program
Combining a consumer-driven model with an established, professional-driven addiction treatment system was the first challenge encountered in the implementation process. Many of the counselors working in the Fayette programs in 2004 tended to use a hierarchical, i.e., paternalistic, model of care that viewed the clinician as the expert and the client as the patient needing care and guidance. Recovery coaches, on the other hand, are trained to use a collaborative model that views the consumer as the expert of their own recovery and the coach as a consultant. These divergent philosophies of care led to conflicting strategies, such as
· Counselors wanted recovery coaches to become community extensions of the treatment plan as developed by the clinical team; whereas recovery coaches tended to provide services based on the goals of clients.
· Counselors wanted recovery coaches to monitor and report back client activities in the community, whereas recovery coaches allow clients to control the flow of information that is delivered back to the counselors.
· Counselors would discontinue treatment to clients who continued to relapse, whereas recovery coaches continued to work with clients, regardless of their relapse.
· Counselors would discourage clients from acquiring a job or returning to the community before achieving particular treatment plan objectives, whereas coaches would encourage clients to acquire a job or other activities the clients wanted.
· Counselors would discourage clients from accessing family and friends in the early stages of residential treatment, whereas recovery coaches would facilitate these connections upon clients’ request.
These philosophical or ideological conflicts will likely be amplified if the two interventions are provided by independent agencies.
As noted previously, the solution at Fayette was to change the treatment approaches of counselors and the overall institutional culture to make it consistent with the philosophy and approach of the recovery coach program and recovery management model.
Maintaining Fidelity of the Recovery Coach Program
Maintaining the fidelity and mission of recovery coaching is another ongoing challenge of the program. Recovery coaching is designed to help individuals’ access resources (internal coping skills and external resources) that will help individuals achieve recovery, based on the principles of recovery capital. The overall mission of the recovery coach program was articulated to treatment staff, but we neglected to outline services that were not considered within the framework of the model. For instance, the majority of our treatment population lives at or below the poverty level. Most of our clients need assistance with housing, transportation, clothing, childcare, food, and other necessities of basic living; however, many of these needs are not related directly to abstaining from alcohol and other drugs. Counselors often confused recovery coaching with services to address poverty. For example, recovery coaches were frequently viewed as cab drivers who could provide clients with transportation services, regardless of how these trips were related, if at all, to the overall goal of recovery. Moreover, many of the clients struggled to differentiate their own goals for recovery from other objectives. To maintain fidelity of the recovery coach model, our recovery coaches have been trained to
· Provide transportation services to clients who have a clear, recovery-based objective; otherwise, clients are encouraged or trained to ride the bus or acquire other forms of transportation (e.g., purchasing a bicycle).
· Engage family and friends in the treatment planning process to help clients address both recovery- and non-recovery-based activities.
· Coordinate services with counselors and assign responsibility for achieving specific objectives.
· Provide in-service training to counselors about the goal of recovery coaching.
· Provide pamphlets to counselors, clients, and family members on the services provided and not provided by recovery coaches.
Next Steps in Fayette Companies’ Transformation
We continue to encounter practices and institutional policies that require modifications as we integrate principles of recovery management. Three additional challenges encountered in the process of transformation are (1) sustaining a viable workforce, (2) modifying residential treatment for individuals with a SUD, and (3) providing alternative treatment interventions for individuals in the early stages of a substance use illness (i.e., those who require brief interventions in nonconventional settings). The following discussions highlight three recent developments in the recovery management process to address these challenges.
Development and Utilization of New Technologies
The addiction treatment field is extremely labor intensive with salary and benefit costs comprising an average of 76% of total costs. Overall, salaries are low resulting in both high turnover and challenges in recruiting highly qualified counselors [58]. Dave Gustafson determined early in his work as Director of NIATx that the addiction treatment field was not sustainable due to the factors discussed above. He organized an international group of experts in various technology fields, such as genetics, bio-informatics, and nanotechnology, to identify or develop technological interventions that could overcome the deficiencies in the behavioral health workforce. This think-tank of experts identified numerous technological innovations that were already available and could be used to augment addiction treatment interventions. Gustafson and colleagues used the information from this think-tank to launch the Innovations for Recovery project (http://www.innovationsforrecovery.org) within the Department of Industrial Engineering at the University of Wisconsin.
Fayette has partnered with Dr. Gustafson and his staff to develop and implement technological innovations for addiction treatment services. A product of this partnership was the acquisition of a 5-year National Institute of Alcoholism and Alcohol Abuse (NIAAA) grant to develop and evaluate the use of smart phones to provide recovery support for persons with an alcohol use disorder. Persons leaving residential treatment programs at Fayette will be randomly assigned to the study beginning in November 2009. The web-connected smart phones will have a variety of recovery support features ranging from 24 h immediate access to a counselor if in a high risk or crisis situation to reminders of upcoming rewarding social and recreational activities based on individual interests. The phones will have a variety of recovery support features, such as a GPS function that can provide individuals with a warning when they near high-risk relapse zones (e.g., a previously frequented local bar), relapse prevention reminders, and easy access to social support networks.
Restructuring Residential Treatment
Residential addiction treatment presented a unique set of barriers in the process of implementing principles of recovery management. Most short- and long-term residential treatment programs, as designed, create a safe treatment milieu for clients. The inpatient environment can be used effectively as both respite and treatment for individuals who are living in chaotic situations and are unable to abstain from alcohol or other drugs. Unfortunately, the sterile sanctuary of residential care can also lead to isolation from the community, which poses a direct conflict to the principles of recovery management. The longer an individual resides in a residential treatment setting, the more difficult it becomes for them to integrate back in to the community where they will eventually live (this is an unavoidable outcome associated with any institutional program). In fact, it is common that we hear clients say that “I can doresidential but I cannot make it in the outside.” When the BHRM project began in 1999, our residential programs had “black-out” periods where people could not make phone calls or have visitors during their first few weeks of treatment. The folklore rational was that people would become lonesome or be influenced by individuals in their social system resulting in their leaving treatment. We eliminated the black-out policies in our three residential programs, which led to a significant decrease in early withdrawals (i.e., AMAs) from treatment. More recently, we altered the admission policy so that clients could keep their cell phones and laptops in treatment (if they had them).
It became apparent that we had to redesign residential treatment. Some people need this level of care as to achieve a break in their addiction and to regain basic health through nutrition, rest, and lifestyle modification. Nonetheless, individuals who need residential treatment are, by default, the ones who need more recovery capital, i.e., access to community resources, such as housing, medical, or mental health care, employment, problem solving skills, and social support. The challenge for our agency was to create a residential treatment intervention that could effectively treat an individual’s severe addiction to alcohol or other drugs while simultaneously helping the person rebuild or develop a recovery support system in the community. Our goal was to help individuals increase their recovery capital before they leave residential treatment.
We instituted several low-cost modifications that promoted access to recovery capital while men and women were in the residential program. These modifications included
· Constructing computer labs that clients could use to learn basic computer skills, study for a GED, improve typing, develop a resume, taking online course or to email friends and family members (emails reduced the cost of communication for clients compared to cell phone minutes or pay phones).
· A pilot program was developed that allowed residents to acquire and maintain employment in the community in the evenings and on weekends.
· A second pilot that evolved out of the first allowed women to continue to reside in one of the residential programs while they establish a savings account from their income, complete an initial phase of school, or acquire stable housing. Women could decrease their involvement in clinical groups while they increased their support in the community through work, school, and social outlets.
A major barrier to assisting people to start employment, a GED program or course at the local community college was the State of Illinois licensing requirement that persons in residential treatment receive a minimum of 25 h of treatment weekly. This requirement also limited the time counselors had available for individual and family counseling. The primary mode of treatment within a residential program is group therapy. Thus, we were faced with a conflict between wanting to change the service delivery system to a model that we believed would be more effective and the need to earn revenues to support operations.
The breakthrough came when the Manager of Clinical Records and State Reporting challenged the funding box we were living within. Residential services were paid on an all inclusion per diem rate. She calculated that we could unbundle the services, while earning the same dollars. This unbundled model includes billing a residential rate for recovery home services while billing a mix of individual, group, and case management services at their rates for each service. As a result, we can now decrease the number of group therapy hours while increasing services that can help individuals increase their recovery capital, such as family sessions, couples therapy, supported employment services, and recovery coaching (e.g.,access to medical care, housing, or education). Having more time for individual and family sessions will allow greater use of evidence-based practices such as the Community Reinforcement Approach [54] and Behavioral Couples Therapy [59]. An evaluation will be conducted to measure the impact of these changes on retention in treatment, employment, involvement in educational activities, and living conditions at discharge.
Outpatient Buprenorphine-Assisted Program
Clients with an addiction to opiates can now receive buprenorphine treatment combined with individualized outpatient services. The program was developed in response to the long waiting list of clients who had entered the detoxification program and were successfully stabilized on buprenorphine. Fayette adopted the use of buprenorphine for opiates in the medical detoxification program in 2004. The usual length of detoxification for opiates was 5–7 days. With buprenorphine, most individuals could be medically stabilized within 24 h. As a result, most individuals were no longer in need of inpatient care after 1 or 2 days. Unfortunately, there was often a waiting list for residential or intensive outpatient services; thus, individuals in detoxification had to wait for a treatment slot or leave the unit without being transferred to a treatment program. An outpatient buprenorphine service was implemented in 2007 to reduce the stay in the inpatient setting, allow a longer period of detoxification at home and provide ongoing outpatient services.
We initially established a 13-day in–outpatient detoxification program based on a NIDA study [60]. We combined the detoxification program with a four-night weekly IOP. A focus group was held with participants after a few weeks of implementation to see if the program was meeting their needs. Participants wanted two significant changes to the medication-assisted program. First, most did not want a short detoxification. Instead most clients wanted to continue the medication-assisted treatment. Second, nearly all participants wanted a reduction in group time during the week from four to two nights but an increase in individual counseling. The program immediately was modified to meet these requests and participation and retention has remained high. Several clients tapered to a low maintenance dose while others chose to finish the detoxification process. The key word is this process was and still is the consumer choice.
True-North Solutions Outpatient Program
Over 87% of those who may benefit from substance abuse treatment do not seek these services [61]. Perhaps one reason is that they don’t feel they need or want what is being offered. Addiction treatment consists mostly of residential and intensive outpatient interventions. Both models of treatment are very intrusive to an individual’s life. Some people may desire a more individual and private approach. Based on this assumption, Fayette developed an alternative addiction treatment intervention for people who desire an individualized model of care.
Individuals with a SUD who are willing to pay privately or have access to private insurance can now enroll in an alternative treatment program, True North Solutions. Clients in this program are provided with a menu of choices including individual and family-couples counseling, pharmacological treatments to augment therapy (e.g., naltrexone or buprenorphine), and psychiatric care. Counselors also provide the Community Reinforcement Approach Family Training (CRAFT; [62]) for concerned others who wish to assist their loved ones in entering addiction treatment. The services package has a lower cost than traditional private pay treatment programs. Based on experience, an episodic rate may be offered. It is hoped that the demonstration of this model may influence the public sector to reconsider their payment system.
Lessons Learned
Albert Einstein was correct when he noted that insanity is doing the same thing over and over again and expecting different results [63]. Repeatedly admitting someone to the residential or intensive outpatient services, providing the same treatment within these settings and thinking maybe this time will be successful is wasting health-care resources. The BHRM team was aware that change was needed. The challenge, of course, is transcending a behavioral health system that was built and funded on an acute care model. Below is listing of lessons learned in the process of transitioning from an acute care model to a recovery management model.
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The 10-year journey to implement Behavioral Health Recovery Management at Fayette Companies resulted in significant learning and changes that were never anticipated. We have many more miles to go.
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