Mark D. Godley Susan H. Godley Michael L. Dennis Chestnut Health Systems Bloomington, IL

1. Aftercare, Continuing Care, or Any Care at All: What is and What Could be Happening After Discharge Mark D. Godley Susan H. Godley Michael L. Dennis Chestnut Health Systems Bloomington, IL Presented at the 2006 Adolescent Treatment Issues Conference of the Florida Alcohol and Drug Abuse Association, February 28, 2006

2. 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

3. 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

4. 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

5. 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)

6. 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

7. Linkage to Continuing Care within 90 days Following Residential Treatment for Adolescents 2000 Source: 2000 Statewide DARTs

8. 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

9. First Use Entered CC Time to Enter Continuing Care and First Use after Residential Treatment 100% 90% 80% 70% 60% Percent of Adolescents 50% 40% 30% 20% 10% 0% 0 10 20 30 40 50 60 70 80 90 Days after Residential (capped at 90) Source: DARTS 2000 and Godley et al 2002

10. Linkage to Continuing Care: CSAT Grantees 100% 90% 80% 70% 60% Percent of Clients Linked 50% 40% 30% 20% 10% 0% 0 10 20 30 40 50 60 70 80 90 Days from Residential Discharge Source: CSAT ART Grantees

11. Discharged: transfer within agency Discharged:Referred to other agency Unplanned Discharge Who Links to Continuing Care? 100% 90% 80% 70% 60% Percent of Clients Linked 50% 40% 30% 20% 10% 0% 0 10 20 30 40 50 60 70 80 90 Days from Residential Discharge Source: CSAT ART Grantees Wilcoxon (Gehen) statistic (df=2)=79.83, p < .001.

12. 100% 10 90% 9 85% 80% 8 70% 7 60% 6 4.5 50% 5 42% 40% 4 30% 3 20% 2 10% 1 0 0% 0 Attended One or More Meetings Median No. Meetings Attended Adults Adolescents Significant chi-square for enrollment and Mann-Whitney U for meeting attendance, p<.05. Do adolescents attend 12 step meetings after residential discharge? * *

13. What continuing care services should counselors provide?

14. Actual UCC Outpatient Continuing Care Criteria 100% 100% 20% 20% 10% 10% 30% 30% 40% 40% 50% 50% 60% 60% 70% 70% 80% 80% 90% 90% 0% 0% Weekly Tx Weekly 12 step meetings Relapse prevention Communication skills training Problem solving training Regular urine tests Meet with parents 1-2x month Weekly telephone contact Contact w/ probation/school Referrals to other services Follow up on referrals Discuss probation/school compliance Adherence: Meets 7+ Criteria Expected UCC Expected

15. 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

16. 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

17. 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)

18. 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

19. 100% 12 90% 10 80% 70% 8 60% 50% 6 40% 4 30% 20% 2 10% 0% 0 Continuing Care Enrollment and Sessions Attended 94% 10 54% 2 Percent Enrolled Median Number of Sessions ACC UCC

20. Sustained Abstinence Early Abstinence General Continuing Care Adherence Relative to UCC, ACC will increase General Continuing Care Adherence (GCCA) GCCA (whether due to UCC or ACC) will be associated with higher rates of early abstinence Early Abstinence will be associated with higher rates of long term abstinence. Assertive Continuing Care (ACC)Change Model Assertive Continuing Care

21. ACC * p<.05 General Continuing Care Adherence (GCCA) 100% 20% 30% 10% 40% 50% 60% 70% 80% 90% 0% Weekly Tx Weekly 12 step meetings Relapse prevention* Communication skills training* Problem solving training* Regular urine tests Meet with parents 1-2x month* Weekly telephone contact* Contact w/probation/school Referrals to other services* Follow up on referrals* Discuss probation/school compliance* Adherence: Meets 7+ criteria* UCC

22. 55% 55% 43% High (7-12/12) GCCA * p<.05 High CC Adherence Improved Early (0-3 mon.) Abstinence 100% 90% 80% 70% 60% 50% 38% 36% 40% 30% 24% 20% 10% 0% Any AOD (OR=2.16*) Alcohol (OR=1.94*) Marijuana (OR=1.98*) Low (0-6/12) GCCA Source: Godley et al 2002, forthcoming

23. 73% 69% 59% Early (0-3 mon.) Abstainer * p<.05 Early (0-3 mon.) Abstinence Improved Sustained (4-9 mon.) Abstinence 100% 90% 80% 70% 60% 50% 40% 30% 22% 22% 19% 20% 10% 0% Any AOD (OR=11.16*) Alcohol (OR=5.47*) Marijuana (OR=11.15*) Early(0-3 mon.) Relapse Source: Godley et al 2002, forthcoming

24. Can ACC help those who do not attend Usual Continuing Care? Significant difference between groups during Continuing Care Phase, p < .05.

25. 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?

26. 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

27. Contingency Management Enhanced Assertive Continuing Care (ACC) Usual Continuing Care (UCC) UCC Contingency Management UCC ACC UCC ACC Contingency Management Funding for this study provided by National Institute on Alcoholism and Alcohol Abuse (2 RO1 AA10368)

28. For More Information To Download this presentation, go to: www.chestnut.org/LI/Posters/index.html Mark D. Godley, Ph.D. Chestnut Health Systems 720 W. Chestnut St. Bloomington, IL 61704 309.827.6026 ext.3401 mgodley@chestnut.org