Performance Measurement in Addiction Treatment Programs

2. This is basically the charge of the current talk 1 � I have tried to put myself and the research literature I have reviewed into the position of a legislator faced with the difficult public health and public safety problems associated with addiction � BUT with competing demands for resources and reservations about what can really be expected from addiction treatment Will the public really get its money�s worth? What should we expect? How can we tell whether we are getting the best impact for the most reasonable (not necessarily the cheapest) expense? These are the issues addressed here.This is basically the charge of the current talk 1 � I have tried to put myself and the research literature I have reviewed into the position of a legislator faced with the difficult public health and public safety problems associated with addiction � BUT with competing demands for resources and reservations about what can really be expected from addiction treatment Will the public really get its money�s worth? What should we expect? How can we tell whether we are getting the best impact for the most reasonable (not necessarily the cheapest) expense? These are the issues addressed here.

3. FDA standards of effectiveness Do substance abuse treatments meet those standards? In these studies it is very important to keep in mind the phrase �Compared to What?� To maximize the accountability and performance of treatment it will be very important to keep reasonable comparisons in mind. As legislators you are obliged to ask what else could be done � what are the most cost effective options? In these studies it is very important to keep in mind the phrase �Compared to What?� To maximize the accountability and performance of treatment it will be very important to keep reasonable comparisons in mind. As legislators you are obliged to ask what else could be done � what are the most cost effective options?

4. An FDA Perspective

5. Therapies Cognitive Behavioral Therapy Motivational Enhancement Therapy Community Reinforcement and Family Training Behavioral Couples Therapy Multi Systemic Family Therapy 12-Step Facilitation Individual Drug Counseling

6. Medications Alcohol (Disulfiram, Naltrexone, Accamprosate) Opiates (Naltrexone, Methadone, Buprenorphine) Cocaine (Disulfiram, Topiramate) Marijuana (Rimanoban) Methamphetamine � Nothing Yet

7. The Specialty Care System A �Customer� Perspective Patient Survey Care Provided Infrastructure

8. The Alcohol Pyramid

9. 13,200 specialty programs in US 31% treat less than 200 patients per year 65% private, not for profit 80% primarily government funded Private insurance <12% Sources � NSSATS, 2002; D�Aunno, 2004

10. Referral Sources  Source 1990 2004 Criminal Justice 38% 59% Employers/EAP 10% 6% Welfare/CPS 8% 16% Hosp/Phys 4% 3%

12. Top Patient Reasons  1) No Problem/Can Handle 58% 2) No Confidence in Trt 51% 3) Bad Trt Experience 36% 4) Abstinence-Only Goal 31%

14. Four Reasons  a. The Infrastructure b. The Acute Care Model The Way it is Evaluated The State as the Only Market

15. Phone Interviews With National Sample of 175 Programs regarding personnel, management, information McL, Carise & Kleber JSAT, 2003

16. The Treatment System  Modality 1975 1990 2005

17. 12% had closed 13% had changed service operation RESULT � 25% FEWER PROGRAMS  31% of the rest had been taken over, usually by MH agencies RESULT � STAFF CONFUSION Program Changes In 16 Months:

18. Counselor turnover 50% per year 50% of directors have been there Less Than 1 year

19. 17% No College Education 58% Had BA Degree 20% Had a MA or MSW 2 Physicians in 175 programs 28% NOT Working Full Time Most had been clinicians @ program

20. Modest Computer Availability Mostly For Administrative Work 80% Had a Computer 50% had Web Access Still very little computer/software availability for CLINICAL STAFF Information Systems:

21. Other Staff 54% Had no physician 34% Had P/T physician 39% Had a Nurse (part of full time) < 25% Had a SW or a Psychologist Major professional group - Counselors

24. The Acute Care Model Treatment Models for Other Illnesses

25. A Nice Simple Rehab Model

26. ASSUMPTIONS Some fixed amount or duration of treatment will resolve the problem Clinical efforts put toward correctly placing patients and getting them to complete treatment Evaluation of effectiveness should occur following completion Poor outcome means failure

28. A Continuing Care Model

32. A Comparison With Three Chronic Medical Illnesses Hypertension Diabetes Asthma

33. Why These? No Doubt They Are Illnesses All Chronic Conditions Influenced by Genetic, Metabolic and Behavioral Factors No Cures - But Effective Treatments Are Available

39. Implications of How We Evaluate Differences in Outcome Expectations

40. If many or most cases of addiction are really chronic then: 1) We may be evaluating the effectiveness of addiction treatments in the wrong way. 

41. Studies show few differences between� Brief and Intensive Treatments Inpatient and Outpatient Treatments Conceptually Different Treatments �Matched� and �Mismatched� Trt. Gender or Culturally Oriented Trt.

45. Studies show few differences between� Brief and Intensive Treatments Inpatient and Outpatient Treatments Conceptually Different Treatments �Matched� and �Mismatched� Trt. Gender or Culturally Oriented Trt.

46. Serving the Customer Helping the Counselor

47. Demands on Counselor Do Comprehensive Assessement Develop Individual Treatment Plan Provide Services to Meet Needs of Patient Be Culturally and Gender Sensitive

48. Computer Assisted System for Patient Assessment and ReferralCASPAR Start with Computer Assisted ASI Reduced training & administration time Generates, state forms, JCAHO narrative and treatment plan Add Free or Low Cost Service Referral From United Way�s First Call for Help Easy match of services to problems

49. Problem-Services Linkage

50. Problem-Services Linkage

51. Results of CASPAR Training Counselors now �get� ASI Now seen as part of engagement They love United Way services Most counselors use it for most patients Many counselors use it themselves Patients who get more services stay longer Finally, we expected to find more off-referred services received by EA patients due to their counselors access to off-site \services through the DENS-RG Finally, we expected to find more off-referred services received by EA patients due to their counselors access to off-site \services through the DENS-RG

52. Mean Number of Services Received We compared the groups on mean # of general services received at both on-site and off-referred. Findings indicated that in all prbl areas, the patients in the EA group recievd more services than tose in the SA group. General Services = On-site + Off-Referred General Services D/A Med Emp Legal Family Psych Enhanced Assessment Group 10.94 9.19 3.06 0.52 1.58 13.48 Standard Assessment Group 2.15 0.63 0.33 0 0.75 0.7 We compared the groups on mean # of general services received at both on-site and off-referred. Findings indicated that in all prbl areas, the patients in the EA group recievd more services than tose in the SA group. General Services = On-site + Off-Referred General Services D/A Med Emp Legal Family Psych Enhanced Assessment Group 10.94 9.19 3.06 0.52 1.58 13.48 Standard Assessment Group 2.15 0.63 0.33 0 0.75 0.7

53. Percent Retained at 30 Days

54. Percent Retained at 60 Days

55. Average Percent Positive

56. Regulating Treatment Process Vs Purchasing Results

57. 13,200 programs in US 65% private, not for profit 80% primarily government funded Private insurance <12% 31% treat less than 200 patients per year Sources � NSSATS, 2002; D�Aunno, 2004

59. Delaware Situation 2002 11 Outpatient Providers Limited Budget No success with outcome evaluation Providers won�t/can�t use EBPs

60. Delaware�s Performance Based Contracting 2002 Budget � 90% of 2001 Budget Opportunity to Make 106% One Criterion: Active Participation Audit for accuracy and access

61. Delaware�s ResultsYears 1 & 2 One program lost contract Two new providers entered, did well Mental Health and Employment Programs Programs worked together First, common sense business practices Second, incentives for teams or counselors 5 programs learned MI and MET

62. Utilization

63. % Attending

65. 40 � 70% of all Addiction Treatment Episodes are Detox-Only Cost $1,750 - $2,400 per episode Re-Detox only tracked by 7 states Average = 40% (23 � 78% range) 28% admitted 3+ times/yr

66. Detox-Only Inpatient Detoxification: 1-year Follow-UpDavison et al., J. Add. Dis. 25, 2006

67. Inpatient DetoxificationShort Term Results

68. Inpatient Detoxification1-Year Results

69. State is the market for D-O State could make market for continuity 85% Detox-only reimbursement 115% Detox+5 sessions of OPT 100% Detox + 5 days Residential

70. Specialty care system is in trouble Customers Do Not Want the Product Ruled by Gov, Not Market Forces System Change is Necessary Public Health Value thru Patient Value Treatment Programs MUST Change Meet Customer Needs � Offer New Options

71. Specialty care system is in trouble Customers Do Not Want the Product Ruled by Gov, Not Market Forces System Change is Necessary Public Health Value thru Patient Value Treatment Programs MUST Change Meet Customer Needs � Offer New Options

72.