Access, Engagement, and Retention Recovery Oriented Systems of Care OETAS Fall 2009

Access, Access, Engagement, and Engagement, and RetentionRetention

Recovery Oriented Systems of CareOETAS Fall 2009

Need for EngagementNeed for Engagement

Early intervention into chronic Early intervention into chronic diseases can shorten the duration diseases can shorten the duration and intensity of the disorderand intensity of the disorder

Neurological impairments Neurological impairments compromise choice-making compromise choice-making abilities during addictive addiction abilities during addictive addiction and early recovery, increasing and early recovery, increasing relapse risksrelapse risks


The primary responsibility for The primary responsibility for initiating motivation for recovery initiating motivation for recovery and sustaining motivation during and sustaining motivation during the earliest stages of recovery lies the earliest stages of recovery lies with the treatment staff, not the with the treatment staff, not the clientclient

Hope is the keyHope is the key

Need for EngagementNeed for Engagement Client motivation ebbs and flows Client motivation ebbs and flows

and must be actively managedand must be actively managed

Transformational change -Transformational change -recovery that is unplanned, recovery that is unplanned, sudden, positive and permanent – sudden, positive and permanent – is possible among clients with is possible among clients with even the poorest prognoseseven the poorest prognoses


Engagement strategies must be Engagement strategies must be refined for historically refined for historically marginalized populationsmarginalized populations

Factors Influencing Factors Influencing Engagement and RetentionEngagement and Retention

Over 40% of drop outs prior to Over 40% of drop outs prior to admission can be re-engaged by admission can be re-engaged by a follow-up phone call procedurea follow-up phone call procedure

Individual characteristics of Individual characteristics of treatment dropouts are less treatment dropouts are less significant than program significant than program differencesdifferences


The single best predictor of The single best predictor of retention and dropout is the retention and dropout is the quality of therapeutic relationship quality of therapeutic relationship between counselor and clientbetween counselor and client

A strong therapeutic relationship A strong therapeutic relationship can overcome low motivation for can overcome low motivation for treatment and recoverytreatment and recovery


Positive therapeutic alliance is more Positive therapeutic alliance is more important to long term recovery important to long term recovery outcome for clients with low motivation outcome for clients with low motivation than for highly motivated clientsthan for highly motivated clients

Culture, gender, and age specific Culture, gender, and age specific programs are associated with higher programs are associated with higher completion rates, as is family completion rates, as is family involvement in treatmentinvolvement in treatment

Contributors to Client Contributors to Client DropoutDropout

Lengthy and repeated assessment Lengthy and repeated assessment processesprocesses

multiple appointments before multiple appointments before treatment beginstreatment begins

failure to give clients the treatment failure to give clients the treatment they requestedthey requested

inadequate methadone dosesinadequate methadone doses mixing clients at differing stages of mixing clients at differing stages of

readiness for changereadiness for change

Nature of Clinical Nature of Clinical RelationshipRelationship

Collaboration/ partnership/ consultant Collaboration/ partnership/ consultant rolerole

Focus is to enhance client self-Focus is to enhance client self-efficacy, improve problem solving efficacy, improve problem solving skills, empower client as the expert in skills, empower client as the expert in how self-management strategies can how self-management strategies can be refined to fit his or her lifestyle be refined to fit his or her lifestyle


Burden of disease management Burden of disease management shifts to client and his or her shifts to client and his or her familyfamily

Professional acts as ongoing Professional acts as ongoing consultant, along with peers who consultant, along with peers who have achieved self-management have achieved self-management successsuccess


Clients who are more active in Clients who are more active in their treatment rate their their treatment rate their experience more positively, experience more positively, remain in treatment longer, and remain in treatment longer, and achieve better post-treatment achieve better post-treatment outcomesoutcomes

Connecticut Department of Connecticut Department of Mental Health and Addiction Mental Health and Addiction Services Services

Practice Guidelines for Practice Guidelines for Recovery-Oriented Behavioral Recovery-Oriented Behavioral Health CareHealth Care

1.1. Care is offered where people are - Care is offered where people are - designed around the needs, designed around the needs, characteristics and preferences of characteristics and preferences of the people receiving servicesthe people receiving services

2.2. A “no wrong door” approach A “no wrong door” approach

3.3. Clinical services are also Clinical services are also responsive to pressing social, responsive to pressing social, housing, employment and spiritual housing, employment and spiritual needsneeds

4.4. Interventions incorporate Interventions incorporate motivational enhancement motivational enhancement strategies - meeting each client strategies - meeting each client where he or she iswhere he or she is

5.5. Address barriers to care before Address barriers to care before concluding that a person is non-concluding that a person is non-compliant or unmotivatedcompliant or unmotivated

66. “Zero reject” policy. “Zero reject” policy

7.7. “Open case” policy “Open case” policy

8.8. Reimbursement for pre-Reimbursement for pre-treatment and recovery treatment and recovery management supportsmanagement supports

9.9. Outpatient counselors are paired Outpatient counselors are paired with outreach workers to with outreach workers to facilitate accessfacilitate access

10.10.Mental health professionals, Mental health professionals, addiction specialists, and people addiction specialists, and people in recovery are placed in critical in recovery are placed in critical locales to assist in the early locales to assist in the early stages of engagementstages of engagement

1111.The agency employs staff in .The agency employs staff in recoveryrecovery

12.12.Housing and support options are Housing and support options are available for those who are not available for those who are not ready for detoxificationready for detoxification

13.13.The availability of sober housing The availability of sober housing is expandedis expanded

Evidence Based PracticesEvidence Based Practices

Network for the Improvement Network for the Improvement of Addiction Treatment of Addiction Treatment (NIATx) Workbook - Promising (NIATx) Workbook - Promising PracticesPractices

Get the client to first appointment Get the client to first appointment quicklyquickly

Address barriers clients face in Address barriers clients face in attending assessment appointmentattending assessment appointment

Clearly explain to the client what Clearly explain to the client what he/she can expect at first appointmenthe/she can expect at first appointment

Model communication with the client Model communication with the client upon Motivational Interviewing upon Motivational Interviewing techniquestechniques

Reducing No-ShowsReducing No-Shows

Increasing ContinuationIncreasing Continuation

SchedulingScheduling Connect the patient to a counselor and Connect the patient to a counselor and

other support staff within 24 hours of other support staff within 24 hours of admission. Build a therapeutic alliance admission. Build a therapeutic alliance immediately.immediately.

Make it as easy as possible for patients Make it as easy as possible for patients to remember appointments and continue to remember appointments and continue in treatment.in treatment.

Scheduling IssuesScheduling Issues

Treatment schedule is inconvenientTreatment schedule is inconvenient Patients forget appointment timesPatients forget appointment times Patients have limited ability to choose Patients have limited ability to choose

treatment scheduletreatment schedule Sessions are scheduled too far apart Sessions are scheduled too far apart

for patients to maintain momentumfor patients to maintain momentum

Scheduling SuggestionsScheduling Suggestions

Adjust staff schedules so that sessions Adjust staff schedules so that sessions are available at times most convenient for are available at times most convenient for patients.patients.

Make reminder calls to help patients keep Make reminder calls to help patients keep track of their appointments, and provide track of their appointments, and provide patients with appointment cards that list patients with appointment cards that list the next four treatment sessionsthe next four treatment sessions

Increasing Continuation:Increasing Continuation:Orientation to TreatmentOrientation to Treatment

Provide a welcoming live or video Provide a welcoming live or video orientationorientation

Establish clear two-way expectationsEstablish clear two-way expectations Schedule, attendance, participation Schedule, attendance, participation

requirements, how to progress through requirements, how to progress through phases of carephases of care

Assign a peer buddyAssign a peer buddy


On an ongoing basis, identify patients On an ongoing basis, identify patients at risk of leaving and barriers to at risk of leaving and barriers to continuing in treatment. Resolve continuing in treatment. Resolve barriers to continuing in treatment.barriers to continuing in treatment.

Maintain counselor resiliency with Maintain counselor resiliency with staff collaboration and personal staff collaboration and personal care/development.care/development.


Tailor treatment to patient’s Tailor treatment to patient’s individual circumstances and individual circumstances and needs; use individual client-driven needs; use individual client-driven treatment planstreatment plans Avoid fixed lengths of stay in any Avoid fixed lengths of stay in any

level of care, so that patient level of care, so that patient movement occurs as soon as they movement occurs as soon as they are readyare ready


Along with a variety of education Along with a variety of education and treatment activities, have fun.and treatment activities, have fun. Reinforces message that sobriety is Reinforces message that sobriety is

more enjoyable than using drugsmore enjoyable than using drugs

Offer positive reinforcements for Offer positive reinforcements for continuing in treatment.continuing in treatment. Contingency management programs, Contingency management programs,

incentivesincentives

The Role of Clinical Supervision in Recovery-Oriented Systems of Behavioral Healthcare. White, Schwartz &The Philadelphia Clinical Supervision Workgroup

Recovery Management and Recovery-Oriented Systems of Care: Scientific Rationale and Promising

Practices. White, 2008. Connecticut Department of Mental Health and Addiction Connecticut Department of Mental Health and Addiction

Services Practice Guidelines for Recovery-Oriented Services Practice Guidelines for Recovery-Oriented Behavioral Health CareBehavioral Health Care

Network for the Improvement of Addiction Treatment Network for the Improvement of Addiction Treatment (NIATx) Workbook - Promising Practices(NIATx) Workbook - Promising Practices

ReferencesReferences

Documents

Access, Engagement, and Retention Recovery Oriented Systems of Care OETAS Fall 2009