Aftercare, Continuing Care, or Any Care at All: What is and What Could be Happening After Discharge

Mark D. GodleySusan H. Godley

Michael L. DennisChestnut Health Systems

Bloomington, IL

Presented at the 2006 Adolescent Treatment Issues Conference of the

Florida Alcohol and Drug Abuse Association, February 28, 2006

Acknowledgements

This work was supported by grants from NIAAA, CSAT, and the Illinois Department of Alcoholism & Substance Abuse

We are grateful to the dedicated staff of Chestnut Health Systems—a wonderful example of a clinical research partnership

Special thanks to all the clients and their families who have sought help from Chestnut Health Systems and participated in our studies

General Information: Youth Srvcs since

1985 Eval. Research on CC

since 1989 based on input from tx staff

CC research is our major research focus

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Goals of Presentation

• Develop a common understanding of • Continuing care• Prevalence of Continuing Care • Continuing Care Barriers/Facilitators

• Learn results of provider survey on elements of effective continuing care

• Learn what distinguishes assertive approaches to continuing care from usual continuing care

• Learn some of the main results from the Assertive Continuing Care study

Continuing Care—Defined

The provision of a treatment plan and organizational structure that will ensure that a patient receives whatever kind of care he or she needs at the time. The treatment program thus is flexible and tailored to the shifting needs of the patient and his or her level of readiness to change. (p. 361, ASAM Placement Criteria-2nd edition; Mee-Lee et al., 2001)

General Models of Continuing Care Step up or lateral transfer, e.g., OP -> Res

Relapse/poor response to treatment Step down transfer, e.g., Res ->OP

Successfully completed index treatment Decrease frequency/intensity

Tx progress results in decreased OP freq and/or intensity

Attend 12 step meetings Advice frequently given upon tx discharge

Non AOD Tx referrals E.g., family counseling; psych medication monitoring

Source: 2000 Statewide DARTs

2000

Linkage to Continuing Care within 90 days Following Residential Treatment for

Adolescents

64%

15%

3%

16%2%

No Linkage OP IOP Residential Other

Why do so many clients fail to link to continuing care?

May never get a referral – why? Referral advice to see another provider

(medical model) is “hit or miss” at best Even transferring to another counselor

within agency can be a problem. Low Motivation/Treatment Fatigue- clients

ready to be finished Financial disincentives

Time to Enter Continuing Care and First Use after Residential Treatment

Source: DARTS 2000 and Godley et al 2002

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0 10 20 30 40 50 60 70 80 90

Days after Residential (capped at 90)

Per

cen

t o

f A

do

lesc

ents

Entered

CC

First Use

Linkage to Continuing Care: CSAT Grantees

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0 10 20 30 40 50 60 70 80 90

Days from Residential Discharge

Source: CSAT ART Grantees

Per

cent

of C

lient

s Li

nked

Who Links to Continuing Care?

Source: CSAT ART Grantees Wilcoxon (Gehen) statistic (df=2)=79.83, p < .001.

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0 10 20 30 40 50 60 70 80 90

Days from Residential Discharge

Per

cent

of C

lient

s Li

nked

Discharged: transferwithin agency

Discharged: Referred toother agency

Unplanned Discharge

Do adolescents attend 12 step meetings after residential discharge?

85%

42%

4.5

00%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Attended One or More Meetings Median No. Meetings Attended0

1

2

3

4

5

6

7

8

9

10

Adults AdolescentsSignificant chi-square for enrollment and Mann-Whitney U for meeting attendance, p<.05.

*

*

What continuing care services should counselors provide?

Outpatient Continuing Care Criteria

0% 10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Expected

0% 10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Expected UCC

Weekly Tx Weekly 12 step meetings

Regular urine tests

Contact w/ probation/school

Follow up on referrals

Relapse prevention

Communication skills training

Problem solving training

Meet with parents 1-2x month

Weekly telephone contact

Referrals to other services

Discuss probation/school compliance

Adherence: Meets 7+ Criteria

Actual UCC

What Makes Assertive Approaches … Assertive?

Shifts linkage/retention responsibility from the adolescent/parent to the clinician

All admitted adolescents are eligible - not just graduates or “as planned” discharges

Understands the “clock is ticking” from the date of discharge and initiates continuing care within first-second week out of treatment

No confrontation, sessions are positive and reinforce progress toward goals

What Makes Assertive Approaches …Assertive?

Sessions are usually held in the community (home, school, after work, restaurant, park) or by phone

Clinician may drop by unannounced if missed sessions

Case Mgmt and transportation assistance to access needed services

Telephone calls between sessions to check “homework” progress and provide support

Assertive Continuing Care Enhancements

Sessions based on ACRA manual (Godley, Meyers et al., 2001) Individual sessions for adolescent,

parents, and together

Case Management based on ACC manual (Godley et al, 2001) to assist with other issues (e.g., accessing needed services, job finding, monitoring, support)

Assertive Continuing Care Experiment

Sample: 183 clients meeting DSM IV dependence on alcohol, marijuana or other drug; meets ASAM placement criteria, returning to target counties, not a ward of state.

Instruments: Global Appraisal of Individual Needs (GAIN);TLFB; BAC and Urine tests for Cannabis and Cocaine; Collateral

Interviews

Design: Random Assignment to UCC or ACC+UCC Active CC phase was 90 days after res. discharge

Follow-up: 92% of all participants received a follow up interview at 3, 6, and 9 months after residential treatment

Continuing Care Enrollment and Sessions Attended

94%

54%

10

2

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Percent Enrolled Median Number of Sessions0

2

4

6

8

10

12

ACC UCC

Assertive Continuing Care (ACC)Change Model

Assertive Continuin

g Care

General Continuin

g Care Adherence

Relative to UCC, ACC will increase General Continuing Care Adherence (GCCA)

Early Abstinence

GCCA (whether due to UCC or ACC) will be associated with higher rates of early abstinence

Sustained Abstinence

Early Abstinence will be associated with higher rates of long term abstinence.

General Continuing Care Adherence (GCCA)

0% 10%

20%

30%

40%

50%

60%

70%

80%

Weekly Tx Weekly 12 step meetings

Regular urine tests

Contact w/probation/school

Follow up on referrals*

ACC * p<.05

90%

100%

Relapse prevention*

Communication skills training*

Problem solving training*

Meet with parents 1-2x month*

Weekly telephone contact*

Referrals to other services*

Discuss probation/school compliance*

Adherence: Meets 7+ criteria*

UCC

High CC Adherence Improved Early (0-3 mon.) Abstinence

Source: Godley et al 2002, forthcoming

24%

36% 38%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Any AOD (OR=2.16*) Alcohol (OR=1.94*) Marijuana (OR=1.98*)

Low (0-6/12) GCCA

43%

55% 55%

High (7-12/12) GCCA * p<.05

Early (0-3 mon.) Abstinence Improved Sustained (4-9 mon.) Abstinence

Source: Godley et al 2002, forthcoming

19% 22% 22%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Any AOD (OR=11.16*) Alcohol (OR=5.47*) Marijuana (OR=11.15*)

Early(0-3 mon.) Relapse

69%

59%

73%

Early (0-3 mon.) Abstainer * p<.05

Can ACC help those who do not attend Usual Continuing Care?

11%

35%

11%

21%

0%

10%

20%

30%

40%

50%

60%

70%

80%

Per

cent

Rem

aini

ng A

bsti

nent

Continuing Care Phase Total Follow-up Period

UCC (n=36)ACC (n=48)

Significant difference between groups during Continuing Care Phase, p < .05.

Recommendations for Post-residential Continuing Care

Consent to participate in CC should be obtained within the first week of residential treatment

Linkage after residential discharge should be accomplished in the first week following discharge

Using an assertive approach, nearly all clients can be linked to CC—regardless of discharge type.

Maybe half of the “As Planned” discharges do not need the extra effort required of assertive approaches….but which half?

Recommendations for Post-residential Continuing Care

Strive for high adherence to CC criteria (7+criteria) with every client

For the most resistant clients consider motivational approaches such as contingency management to increase attendance, prosocial activities, and abstinence

Facilitate linkage to needed services (medical, psychiatric, school, legal/probation, 12-step, etc)

Develop local and community-wide recovery support activities to improve clients’ recovery environment

Contingency Management Enhanced Assertive Continuing Care (ACC)

Usual Continuing

Care (UCC)

UCC

ACC

UCC

ACC

Contingency Management

UCC

Contingency Management

Funding for this study provided by National Institute on Alcoholism and Alcohol Abuse (2 RO1 AA10368)

For More Information

To Download this presentation, go to:www.chestnut.org/LI/Posters/index.html

Mark D. Godley, Ph.D.Chestnut Health Systems720 W. Chestnut St.Bloomington, IL 61704309.827.6026 ext.3401mgodley@chestnut.org