Performance Measurement in Addictions Treatment Programs

1. Performance Measurement in Addictions Treatment Programs A series of briefings offered to state legislatures through a collaborative effort of the State Associations of Addiction Services, National Conference of State Legislatures, and the Treatment Research Institute. Funded by the Substance Abuse and Mental Health Services Association (SAMHSA) under the Partners for Recovery Initiative through a contract with Abt Associates Incorporated.

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.

4. Weisner et al., 2003

5. Baseline Comparisons  Data Treat. Com Male 64% 68% Age 42 36 Married 33% 30% Poverty 62% 38%

6. Alcohol abstinent at 12 months

7. Non-problem use @ 12 months

8. What predicts abstinence?

9. 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?

10. An FDA Perspective

11. 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

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

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

14. 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

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

16. Substance Use Pyramid

18. 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%

19. Why Won�t Programs Deliver Quality Care? The Infrastructure Acute Care Treatment Model The Evaluation Model

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

21. The Treatment System  Modality 1975 1990 2005

22. 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:

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

24. 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

25. 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:

26. The Acute Care Model Treatment Models for Other Illnesses

27. A Nice Simple Rehab Model

28. ASSUMPTIONS Some fixed amount or duration of treatment will resolve the problem Outcomes Determined After Discharge Clinical efforts put toward matching treatment and getting patients to complete treatment Evaluation of effectiveness following completion Poor outcome means failure

30. A Continuing Care Model

31. ASSUMPTIONS Patient will continue in treatment There are agreed upon clinical targets at each stage of treatment Achieving the clinical targets will prepare you for the next (reduced intensity) stage There will be no discharge � just reduced intensity of care

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

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

40. Implications of How We Evaluate Differences in Outcome Expectations

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.

42. Comparing Treatments Testing Three Treatments in an Acute Care Model

43. Project MATCH Testing Three Versions of the Rehabilitation Model in Alcohol Dependence

48. Improvement in Project MATCH

49. Comparing Treatments Testing Three Treatments in a Continuing Care Model

50. ALLHAT The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack

51. ALLHAT

52. ALLHAT

53. ALLHAT

55. Improvement in ALLHAT

57. Improvement Comparison

58. Lessons from Chronic Illness: Medications relieve symptoms but�. behavioral change is necessary for sustained benefit

59. Lessons from Chronic Illness: Treatment effects usually don�t last very long after treatment stops.

61. 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.

64. Physician Health Plans

65. Evaluation and Contracting

66. Formal Treatment

67. Monitoring & Support

68. Results During Contract

69. Urine Testing Over 4 years

70. Results at 5-7 Years

71. Results at 5-7 Years

72. PHP vs Drug Court  Component PHP Drug Court

73. Relapse Rates @ 1 Year

75. 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

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

77. Delaware�s Performance Based Contracting 2002 Budget � 90% of 2001 Budget Opportunity to Make 106% Two Criteria: 80% Utilization/Occupancy Active Participation Audit for accuracy and access

78. 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

79. Utilization

80. % Attending

81. 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

82.