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					            Santa Clara County Department of Alcohol & Drug Services

        Bringing Continuing Care to the Continuum of Care
Concept Paper
Historically, addiction treatments have been delivered and evaluated under an acute-care format
(1). Fixed amounts or durations of treatment have been provided and their effects evaluated 6 –
12 months after completion of care. The general goals of treatment generally include; sustained
reductions/elimination of illicit substance use, improved personal health and improved social
function, all of which are commonly referred to as ―recovery‖(2). In contrast, treatments for
chronic illnesses such as diabetes, hypertension and asthma have been provided for
indeterminate periods and their effects evaluated during the course of those treatments. Here the
expectations are for most of the same results, but only during the course of continuing care and
monitoring (3). The many similarities between addiction and mainstream chronic illnesses stand
in contrast to the differences in the ways addiction is traditionally conceptualized, treated and
evaluated.

The alcohol and other drug (AOD) problems arena is on the brink of shifting from long-standing
pathology and intervention paradigms to a solution-focused recovery paradigm (4). The former
rested on the assumption that investigations into the etiology and patterns of AOD problems and
studies of the professional treatment of these problems would reveal the ultimate solution to
these problems. The recovery paradigm posits that solutions to severe AOD problems have a
long history and are currently manifested in the lives of millions of individuals and families and
that the scientific study of these lived solutions could elucidate principles and practices that
could further enhance recovery initiation and maintenance efforts (5, 6, 7).

The shift toward a recovery paradigm is evident in a number of quarters: the international growth
of addiction recovery mutual aid societies, a new recovery advocacy movement, and calls to shift
the design of addiction treatment from a model of acute biopsychosocial stabilization to a model
of sustained recovery management (8, 9, 10).

Based on the growing evidence of the chronic nature of addiction, the Department of Alcohol &
Drug Services (DADS) of Santa Clara County is augmenting its current system of care to
incorporate more of an Addiction Services Continuum. This would include service expansion in
the area of continuous recovery monitoring that offers recovery management checkups at
designated intervals post-treatment. Continuous recovery monitoring would require a review and
re-tooling of the outcomes methods used by the DADS Research Division and would also require
a data collection plan to be used by the provider network during treatment.

Substance addiction is a chronic condition. Because of the relapsing nature of all chronic
disorders, some form of continuing care is usually recommended following completion of an
initial phase of treatment (11). Despite the potential benefits of continuing care, many substance
abusing individuals either do not attend any continuing care or stop attending after a relatively
small number of sessions. McKay, et al (12) has demonstrated that telephone-based continuing




                                                               Chronic Care Implementation Committee
care is a viable therapeutic tool in the monitoring and treatment of a number of disorders,
including depression, obsessive-compulsive disorder, congestive heart failure and chronic
pulmonary disease. With addictions, it seems that for most substance-dependent patients who
complete an initial stabilization phase of outpatient treatment, telephone-based monitoring and
brief counseling appears to be as effective a form of step-down continuing care as more intensive
face-to-face counseling.

Continuing care protocols that are more flexible and less burdensome than traditional face-to-
face counseling sessions are more attractive to patients and can promote better adherence and
improved disease management over time.

IMPLEMENTATION AND LOGISTICS NOTES

For stabilized patients completing a primary treatment episode, implement the post-treatment checkup
process in order to enhance sustained recovery management.

The client’s primary counselor will initiate post-treatment checkups during the near completion of
treatment and thereafter on a regular basis. After treatment completion, the frequency of post-treatment
checkups is determined after each individual session and in accordance with the risk level assessment
findings. Ultimately, with sustained recovery management, post-treatment checkups will be on an as
needed basis. The client can initiate post treatment checkups at any time.

The post treatment checkup uses a risk assessment instrument to determine relapse risk. The post
treatment checkup tool contains an algorithm for immediate results that the counselor can use to
determine a disposition. Post treatment is not counseling, but more of a means to discover where the
client is at in his/her continued recovery.

In order to integrate more of the chronic care principles into addictions treatment, DADS will re-
engineering the system of care from its current state (figure A) to what is more in alignment with the
chronic care model (figure B). The system’s current continuum of care system is limited in continuing
care. And, there are insufficient levels of care within the existing continuum for returning clients
needing only short-term ―booster‖ sessions.


                                                        Completion of care, discharge, referral to self-help meetings
                                                                                  when appropriate and case closed



  Gateway       Detox                   Residential                     OP                         THUs
  authorization
  for treatment

                                               Figure A




                                                               Chronic Care Implementation Committee
                                                                                       Continuous Recovery Monitoring.
                                                        Post-tx checkup intervals: Weekly - 2x/month – monthly – as needed
                                                                                                          and indefinitely.



 No Gateway         Detox                 Residential                         OP          Brief                THUs
 readmissions                                                                         Intervention
 process for returning
 clients of Con’t Care.                                                                Telephone-based Post-
 Use post-authorization.
                                                                                           Tx Checkups
                                                                                              Education only
                                                                                              Brief intervention (1-2 sessions)
                                                                                              Brief counseling (2-3 sessions)
                                                                                              Expedited readmission
                                                       Figure B

Finally, the illustration below (figure C) shows how the next step of evolution for system of care where
as the client assumes more responsibility for their recovery health, the less intense is the treatment.


             A Conceptual Model: DADS Addiction Services Continuum
                                               Stage of change
                                               Increased readiness to change
                                                                                                Post Treatment
                                               Completion of treatment goals
                                                                                              Checkups is offered
         As personal                           Personal responsibility
        responsibility                                                                          indefinitely and
          increases,                                                                               represents
          treatment                                                                           continuous recovery
           intensity                                       Treatment Intensity                    monitoring
          decreases
                                                           Post Treatmentt Check-up: Intervals:
                                                           Weekly - 2x/month – monthly – as needed

                                                                                                    From the Post Tx
         Detox              Residential   Outpatient         Transitional     Community             Checkup
                                                             housing          support               assessment:
                                                                                                     Education
                                                                                   Via telephone     Brief intervention
                                                                                                     Brief counseling
                                                                                                     Readmission


                                                       Figure C




                                                                        Chronic Care Implementation Committee
REFERENCES

  1. McLellan, A.T., and McKay, J.R. (2005). Reconsidering the evaluation of addiction treatment:
      from retrospective follow-up to concurrent recovery monitoring. Society for the Study of
      Addiction, 100, 447-458.
  2. McLellan, A.T., Carise, D., & Kleber, H.D.. (2003). Can the national addiction treatment
      infrastructure support the public’s demand for quality care? Journal of Substance Abuse
      Treatment, 25, 117-121.
  3. W. White, Recovery: Its history and renaissance as an organizing construct, Alcoholism
      Treatment Quarterly 23 (1) (2005), pp. 3–15.
  4. K. Humphreys, Circles of recovery: Self-help organizations for addictions, Cambridge
      University Press, Cambridge (2004).
  5. W. White, Addiction recovery mutual aid groups: An enduring international phenomenon,
      Addiction 99 (2004), pp. 532–538.
  6. M. Flaherty, A unified vision for the prevention and management of substance use disorders:
      Building resiliency, wellness and recovery—A shift from an acute care to a sustained care
      recovery management model, Institute for Research, Education and Training in Addictions,
      Pittsburgh, PA (2006).
  7. J.R. McKay, Is there a case for extended interventions for alcohol and drug use disorders?,
      Addiction 100 (2005), pp. 1594–1610.
  8. A.T. McLellan, D.C. Lewis, C.P. O'Brien and H.D. Kleber, Drug dependence, a chronic medical
      illness: Implications for treatment, insurance, and outcomes evaluation, Journal of the American
      Medical Association 284 (2000), pp. 1689–1695.
  9. Dennis, M.L., Scott, K.C., & Funk, R. (2003). An experimental evaluation of recovery
      management checkups (RMC) for people with chronic substance abuse disorders. Evaluation
      and Program Planning, 26, 339-352.
  10. Donovan, DM. (1998). Continuing care: promoting the maintenance of change. In: Miller WR,
      Heather N, eds. Treating Addictive Behaviors: 2nd ed. New York, NY: Plenum; 1998:317-336.
  11. Institute of Medicine, Improving the quality of health care for mental and substance-use
      conditions, National Academy Press, Washington, DC (2006).
  12. McKay, J.R., Lynch, K.G., Shepard, D.S, & Pettinati, H.M. (2005). The effectiveness of
      telephone-based continuing care for alcohol and cocaine dependence. Arch Gen Psychiatry, 62,
      199-207.




                                                             Chronic Care Implementation Committee

				
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