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Motivational Incentives: Utility in Health Care Settings

Motivational Incentives: Utility in Health Care Settings. Maxine Stitzer, Ph.D. Johns Hopkins Univ SOM Christiana Care Health Systems Conference Addressing Substance Use in Hospitals April 9, 2013. Presentation Outline. Define Motivational Incentives

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Motivational Incentives: Utility in Health Care Settings

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  1. Motivational Incentives: Utility in Health Care Settings Maxine Stitzer, Ph.D. Johns Hopkins Univ SOM Christiana Care Health Systems Conference Addressing Substance Use in Hospitals April 9, 2013

  2. Presentation Outline • Define Motivational Incentives • Review utility in substance abuse treatment • Service access and entry • Repeated service access • Abstinence from abused substances • Discuss application in health care settings

  3. Motivational Incentives =Contingency Management • What are they? • Positive reinforcement for desired behaviors • Can be social (attention; praise) or tangible items • What’s the goal? • Counter ambivalence and barriers to service access • Guide people to better health and well-being by encouraging healthful and pro-social behaviors • Individual benefits and societal costs may be reduced

  4. Motivational Incentives positive reinforcement to promote desirable behavior change

  5. Reward programs Acknowledges patients for achieving a major goal or completing significant progress • Rewards usually given to the “best” and most motivated patients • They don’t change the behavior of those struggling the most with drug use and treatment compliance

  6. Reinforcement programs Reinforcement programs on the other hand, use incentives to… • Break down goals into very small steps • Reinforce each step along the way • Make it easy to learn & earn • Give reinforcements early and often • Include the most troubled and difficult to reach most troubled & difficult to reach patients

  7. Reward goals Completing treatment Get a job Complete GED 30 days abstinent Reinforcement goals Attend treatment session Submit a job application Sign up for GED One negative urine Reward vs Reinforcement

  8. Why pay people to do what they should be doing anyway? Because they aren’t doing it!Incentives are a practical fix to atherapeutic conundrum They change the therapeutic dynamic for difficult patients toward acknowledging and celebrating success rather than blaming or dwelling on failure

  9. Incentives in Substance Abuse Treatment: Efficacy Review • Service access and entry • Repeated service access • Drug use cessation and relapse prevention

  10. Service Access and EntryExamples from Substance Abuse Treatment

  11. Vouchers for Free Methadone Treatment (Sorensen et al., 2005) • Opioid abusers (N = 126) receiving care in a hospital • Randomly assigned to 4 conditions • Usual care referral • Case management for 6 months • Voucher for 6-months free methadone Tx • Combined voucher and case management

  12. Vouchers for Free Methadone Treatment (Sorensen et al., 2006) Six-Month Outcomes Percent Receiving Services

  13. Care Continuity: Detox to OP Chutuape et al. 2001 • Participants (N = 196) from a 3-day detox invited to enroll at an outpatient Tx program • Randomly assigned to: • Usual care control • $13 incentive • Van ride + incentive

  14. Care Continuity: Detox to OP Chutuape et al. 2001 * Percent Contacting Treatment

  15. Care Continuity: Residential to OP(Aquavita et al., JSAT, 2013) • Tested 3 methods of transition from 28-day residential to outpatient aftercare treatment (N = 260) • Usual care • Client incentive • Residential in-reach

  16. Care Continuity Interventions • Usual care • Select program; fax referral; make appt (optional) • Client Incentive • $25 to show up; $75 more for continued attendance • Residential in-reach • In-person meeting with OP counselor; sign contract; next day appt

  17. Residential-To-Outpatient Transition Rates 84%* 74%*

  18. Incentives for Treatment Entry Follow-Through(Corrigan et al., 2005) • Substance users with traumatic brain injury (N = 195) with intake completed at an OP treatment program • Outcome = return to sign an individual service plan (ISP) within 30 days • Randomly assigned via phone delivered intervention • Attention control • Motivational interview • Barrier reduction- pay for taxi, bus, parking, etc • Incentives- $20 gift certificate upon ISP completion

  19. Traumatic Brain Injured Sample Percent Signing ISP

  20. Services Access Getting People to the Door • Financial incentives can motivate people to take advantage of substance abuse treatment services • vouchers for free treatment • money or gift cards for showing/returning • “barrier reduction” incentives addressing transportation • Personal contact may also add value • Case management • Counselor “warm hand-offs”

  21. Attendance Incentives:Encouraging People to Stay

  22. Attendance Incentives in an HIV Drop-In Center(Petry et al., 2001) Prize draws escalate with weeks of consecutive attendance during a 14 week intervention (n = 43) Average Attendance per Session Baseline CM intervention 0.7 7 (range 0-3) (range 2-12)

  23. Attendance: Group Therapy for Methadone Patients(Sigmon & Stitzer, 2005) • Patients were assigned to attend orientation (N = 44) or cocaine (N = 58) groups 2X per week for 12 wks • Prize draws could be earned on an escalating schedule for attendance; max earnings = $170

  24. Cocaine Group Attendance in Methadone Maintenance Transition Clients Consistent Clients Percent Sessions Attended

  25. Attendance in OP Treatment(Petry et al., 2012) • Participants (N = 215) were cocaine abusers urine negative at entry to outpatient psychosocial counseling treatment • Randomly assigned • Usual care • Escalating prize draws over 12 weeks; max earnings = $250

  26. Attendance in OP Treatment $250 in prize draws (Petry et al., 2012) Sessions attended

  27. Care Continuity Study: Client Incentive Increased OP Attendance First 30 Days *

  28. Incentives for Session Attendance Positive incentives have clearly been useful for increasing rates of attendance in substance abuse treatment settings

  29. Abstinence Incentives:Initiating and Sustaining Drug AbstinenceMajority of research has used drug abstinence during treatment as targetby reinforcing drug negativeurine tests

  30. Voucher Reinforcement for abstinence initiation and maintenance in cocaine abusers • Principle of alternative reinforcement: • Benefits of abstinence are long-term • Making abstinence today a more attractive option • Points earned for cocaine negative urine results • Escalating schedule of point earnings • Trade in points for goods • $1000 available over 3 months

  31. 5 4 # Draws 3 2 1 Weeks Drug Free Draws Escalate With Drug-Neg Test Results and Reset With Positive

  32. Voucher Incentives for Outpatient Drug-free Treatment of Cocaine Abusers Higgins et al. Am. J. Psychiatry, 1993 Cocaine negative urines

  33. Intermittent schedule/prize system • Draws from a fishbowl • Advantages: may be more fun and less expensive than vouchers; cost can be controlled via number and cost of prizes and percentage of winning chips

  34. Half the slips are winnersWin frequency inversely related to cost • largest chance of winning a small $1 prize • moderate chance of winning a large $20 prize • small chance of winning a jumbo $100 prize

  35. CTN MIEDAR Study(Stitzer, Petry, Peirce et al., 2005) Participants in OP drug-free Tx could earn up to $400 in prizes on average during 12-week study if they tested negative for cocaine, methamphetamine alcohol, opiates, and marijuana

  36. Control Incentive Incentives Improved Retention in Counseling Treatment 100 80 60 50% Percentage Retained 40 35% 20 RH = 1.6 CI=1.2,2.0 0 2 4 6 8 10 12 Study Week

  37. Percent of Submitted Samples Testing Stimulant and Alcohol Negative 100 80 60 Percentage negative samples 40 Abstinence Incentive Usual Care 20 0 1 3 5 7 9 11 13 15 17 19 21 23 Study Visit

  38. A b s t i n e n c e I n c e n t i v e U s u a l C a r e Methadone Maintenance Sample:Percent Stimulant Negative Urines 1 0 0 8 0 6 0 Percentage of stimulant negative urine samples 4 0 2 0 OR=1.98 (1.4-2.8) 0 1 3 5 7 9 1 1 1 3 1 5 1 7 1 9 2 1 2 3 S t u d y V i s i t

  39. Long-term effects on Cocaine Use in Methadone Maintenance Take-Homes Plus Vouchers (n = 26) Random Assignment Take-Homes Only (n = 26) Usual Care Control (N = 26) 0 4 8 0 4 8 12 16 20 24 28 32 36 40 44 48 52 Baseline Intervention Evaluation Period Study Weeks Silverman et al., JCCP, 2004

  40. Reducing Cocaine Use in Methadone Patients Silverman et al., 2004 58% 36% 15%

  41. Abstinence Incentives • Promotes initial abstinence when drug use is on-going • Promotes increased duration of drug-free treatment participation after drug use stops • i.e. works for relapse prevention • Positive impact on long-term outcomes • Longer during-treatment abstinence translates into better long-term outcome

  42. Cross-Substance Generality • Cocaine Opioids • Methamphetamine • AlcoholMarijuana • Nicotine (Tobacco smoking)

  43. Abstinence incentives as an add-on to counseling promote retention and drug-free participation This is the building block for long-term recovery

  44. Summary • Positive incentives in the form of vouchers or prize draws can be therapeutically helpful in several ways to promote: • services access and entry • continued involvement in services • abstinence and relapse prevention

  45. Potential Application in Health Care • Access specialty services • e.g. vaccinations; prenatal and pediatric care • Keep follow-up medical appointments • Address drug use as a barrier • Take prescribed medicines • Promote lifestyle change

  46. Immunization Rates Rate Percent Immunized Rates increased when WIC food vouchers were given to those who had their children immunized (Hoekstra et al., 1998)

  47. Receipt of HIV Test Results(Thornton R, Am. Econ Rev, 2008) Rural Malawi residents (N = 2812) offered free HIV testing All participated in a drawing where there could earn from $0 to $3 if they returned for HIV test results PERCENT INCENTIVES

  48. Pregnancy-Focused Incentive Schemes In Developing Nations Bangladesh Food, cash, baby gifts for pre and post-natal care and delivery in a health clinic Uganda Motorcyclists paid to transport pregnant women to maternity clinic Rwanda Health teams paid for baby deliveries, family planning and vaccinations

  49. Incentive Applications at Christiana Care • 100 mothers per year go through opioid detox • But may not have optimal outcomes due to fragmented care and lack of follow-through

  50. Can you do it here?Traditional barriers to implementation are coming down • Attitudes • Cost/financing • Training resources

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