Acute Care Model for a Chronic Disease Recovery Oriented Systems of Care OETAS Fall 2009

Acute Care Model Acute Care Model for a Chronic for a Chronic DiseaseDisease

Recovery Oriented Systems of CareRecovery Oriented Systems of Care

OETAS Fall 2009OETAS Fall 2009

Past Models of AddictionPast Models of Addiction

All pathology focusedAll pathology focused Moral Model, Public Health Model, Moral Model, Public Health Model,

Disease ModelDisease Model

Past Models of AddictionPast Models of Addiction

All based on acute All based on acute

models of caremodels of care

Acute Care Model of Acute Care Model of TreatmentTreatment

Services are delivered in a uniform series of Services are delivered in a uniform series of encapsulated activitiesencapsulated activities screening,screening, admission,admission, a single point-in-time assessment,a single point-in-time assessment, a short course of minimally individualized a short course of minimally individualized

treatment,treatment, Discharge and brief “aftercare”,Discharge and brief “aftercare”,

followed by termination of the service relationship.followed by termination of the service relationship.

Acute Care ModelAcute Care Model

Focused on Focused on symptom eliminationsymptom elimination for a single primary for a single primary problemproblem

A professional A professional expert directsexpert directs and dominates decision- and dominates decision-making throughout this process.making throughout this process.

Services transpire over a Services transpire over a short period of time.short period of time. pre-arranged, time-limited insurance payment designed pre-arranged, time-limited insurance payment designed

specifically for addiction disorders and “carved out” from specifically for addiction disorders and “carved out” from general medical insurancegeneral medical insurance

Acute Care ModelAcute Care Model

At discharge, At discharge, “cure has occurred:”“cure has occurred:” long-term long-term recovery is then viewed as self-sustainable without recovery is then viewed as self-sustainable without on-going professional assistance.on-going professional assistance.

Evaluation of success occurs Evaluation of success occurs at a at a single point-in-single point-in-time follow-up, time follow-up, typically just months after treatment.typically just months after treatment.

Post-treatment Post-treatment relapserelapse is viewed as the is viewed as the failure failure (non-compliance) of the individual,(non-compliance) of the individual, rather than rather than potential flaws in the design of the treatment protocol. potential flaws in the design of the treatment protocol.

(Hubbard, Flynn, Craddock, & Fletcher, 2001); (Watkins, Pincus, Tanielian, & Lloyd, (Hubbard, Flynn, Craddock, & Fletcher, 2001); (Watkins, Pincus, Tanielian, & Lloyd, 2003) 2003)

Evidence from Pathology Evidence from Pathology

Acute Care ModelsAcute Care Models1.1. Low Treatment ComplianceLow Treatment Compliance

50% of outpatients drop out of 50% of outpatients drop out of treatment within one monthtreatment within one month

40% of court-ordered patients do 40% of court-ordered patients do not complete treatmentnot complete treatment

(Hubbard, Marsden, Rachal, Harwood, Cavanaugh, & Ginzburg, 1989)(Hubbard, Marsden, Rachal, Harwood, Cavanaugh, & Ginzburg, 1989)

Evidence from Pathology Evidence from Pathology

Acute Care ModelsAcute Care Models2.2. Relapse Rates are HighRelapse Rates are High

• About 60% use drugs within six About 60% use drugs within six months following treatment months following treatment dischargedischarge

• About 45% apply for residential About 45% apply for residential treatment within 12 monthstreatment within 12 months

Conclusion of Pathology Conclusion of Pathology Acute Care Model:Acute Care Model:

Public expectations have not Public expectations have not been metbeen met

Treatment is not very effective; orTreatment is not very effective; or We have the wrong model for the We have the wrong model for the

illnessillness

Chronic Disease Chronic Disease CharacteristicsCharacteristics

Influenced by genetic inheritance and Influenced by genetic inheritance and other personal, family, and environmental other personal, family, and environmental risk factorsrisk factors

Can be identified and diagnosed using Can be identified and diagnosed using well validated screening questionnaires well validated screening questionnaires and diagnostic checklistsand diagnostic checklists

Chronic DiseasesChronic Diseases behaviors begin as voluntary choices but behaviors begin as voluntary choices but

become deeply ingrained patterns of become deeply ingrained patterns of behavior that are further exacerbated by behavior that are further exacerbated by neurobiological changes in the brain that neurobiological changes in the brain that weaken volitional control over these weaken volitional control over these contributing behaviorscontributing behaviors

Are marked by patterns of onset that may be Are marked by patterns of onset that may be sudden or gradualsudden or gradual

Chronic DiseasesChronic Diseases

Have a prolonged or permanent course that Have a prolonged or permanent course that varies from person to person in intensity (mild varies from person to person in intensity (mild to severe) and pattern (from constant to to severe) and pattern (from constant to recurrent)recurrent)

Are accompanied by risks of profound Are accompanied by risks of profound pathophysiology, disability, and premature pathophysiology, disability, and premature deathdeath

Chronic DiseasesChronic Diseases Have effective treatments, self-management protocols, Have effective treatments, self-management protocols,

peer support frameworks, and similar remission rates, peer support frameworks, and similar remission rates, but no known definitive curebut no known definitive cure

Often generate psychological responses that include Often generate psychological responses that include hopelessness, low self esteem, anxiety, and depressionhopelessness, low self esteem, anxiety, and depression

Generate excessive demands for adaptation by families Generate excessive demands for adaptation by families and intimate social networksand intimate social networks

McLellan (2003). What's Wrong with Addiction Treatment?McLellan (2003). What's Wrong with Addiction Treatment?

Outcome in Addiction Outcome in Addiction TreatmentTreatment

0

1

2

3

4

5

6

7

8

Pre During During Post

(O'Brien & McLellan, 1996)(O'Brien & McLellan, 1996)

Addiction/Chronic IllnessAddiction/Chronic IllnessCompliance Rate Relapse RateCompliance Rate Relapse Rate

Addiction Alcohol Opioid Cocaine Nicotine

30-50%30-50%30-50%30-50%

50%40%45%70%

Insulin Dependent Diabetes Medication Diet and Foot Care

<50%<50%

30-50%30-50%

Hypertension Medication Diet

<30%<30%

50-60%50-60%

Asthma Medication <30% 60-80%

(Zarkin, et al, 2005)(Zarkin, et al, 2005)

Cost/ Benefit Ratio of Cost/ Benefit Ratio of Acute Care Model vs. Acute Care Model vs. Chronic Care Model for Chronic Care Model for Heroin UsersHeroin Users

$0.00

$5.00

$10.00

$15.00

$20.00

$25.00

$30.00

$35.00

$40.00

Acute Chronic

Value of$ Spent

$4.86

$37.72

DisconnectDisconnect

If we (the practitioners of addiction If we (the practitioners of addiction treatment) really believed addiction was a treatment) really believed addiction was a chronic disorder, we would not:chronic disorder, we would not:

view prior treatment as a predictor of view prior treatment as a predictor of poor prognosis (and grounds for denial of poor prognosis (and grounds for denial of treatment admission);treatment admission);


convey the expectation convey the expectation that all clients should that all clients should achieve complete and achieve complete and enduring sobriety enduring sobriety following a single, brief following a single, brief episode of treatment;episode of treatment;


punitively discharge clients for punitively discharge clients for becoming symptomatic;becoming symptomatic;

relegate post-treatment continuing relegate post-treatment continuing care services to an afterthought;care services to an afterthought;


terminate the service relationship terminate the service relationship following brief intervention; orfollowing brief intervention; or

treat serious and persistent AOD treat serious and persistent AOD problems in serial episodes of self-problems in serial episodes of self-contained, unlinked interventions.contained, unlinked interventions.

Treatment Renewal Treatment Renewal MovementMovement

Addiction is best Addiction is best understood as a understood as a chronic illnesschronic illness

Addiction requires Addiction requires continuing care over a continuing care over a continuum of care for continuum of care for lifelife


Chronic vs. Acute ModelChronic vs. Acute Model Continuum of Care vs. Unit or Continuum of Care vs. Unit or

EpisodeEpisode Performance Measurement vs. Performance Measurement vs.

OutcomesOutcomes Medication Assisted TreatmentsMedication Assisted Treatments

NIDA (1999)NIDA (1999)


Addiction treatment Addiction treatment should adhere to proven should adhere to proven practices and principlespractices and principles

Treatment is very Treatment is very effective when these effective when these ideas/principles are ideas/principles are followedfollowed

Documents

Acute Care Model for a Chronic Disease Recovery Oriented Systems of Care OETAS Fall 2009