Great Lakes ATTC 2009 Regional Advisory Board Meeting April 16-17, 2009 Chicago, Illinois

1. Great Lakes ATTC2009 Regional Advisory Board MeetingApril 16-17, 2009Chicago, Illinois Developing a Recovery Oriented System of Care: Strategies and Lessons Learned Ijeoma Achara PsyD

2. Purpose • To review the need for a recovery focused transformation of addiction Tx systems • To explore different models of a Recovery Oriented System of Care • To examine effective strategies for system and community leaders to create a recovery oriented system of care • To assist you in determining concrete next steps for your community

3. © Performance Management Company, 2004

4. Those pushing often don’t have a Vision of the future Leadership feels isolated Goals? Vision? Goals! InefficientSystems and Processes Vision! Waning Staff Motivation? Slow Progress forward… People are working REALLY hard © Performance Management Company, 2004

5. Potential Paradigm Shift More of the Same? Transformational ideas are always around us Round Wheels are already in the wagon! Best Practices already exist within our systems

6. What do We Know About Recovery? Chronic Course • Stable alcoholism recovery is not reached until 4-5 years of sustained remission, longer for other drugs. • Short periods of abstinence are really periods of brief dormancy and not sustainable recovery. • Linking reduces number of episodes of care and expedites re-entry • Post discharge continuing care enhances recovery outcomes but only 1 in 5 clients receive such care. Peer Support is Critical • Enhances long-term recovery outcomes for a broad spectrum of individuals. Community Variables Impact Relapse • Community recovery resources are just as important as individual factors in tipping the scales of recovery maintenance versus relapse • Recovery can be initiated in an artificial environment, but successful recovery maintenance can only be achieved in a natural community environment William White

7. What do We Know About Recovery? • Family Inclusion and Support Promotes Long-term Recovery • Addressing Basic Needs is essential for long term recovery • A strong therapeutic relationship can overcome low motivation for treatment and recovery. • Those who drop out of treatment or who are administratively discharged from treatment are those who need treatment the most. William White

8. What do We Know About People’s Experiences in Tx? Growing Body of Research Shows Improved Effectiveness and Outcomes • National Treatment Improvement Evaluation Study • 5 year study of treatment effectiveness of almost 4500 addiction clients nationwide reduced substance use by 50% • reduced criminal activity up to 80% • increased employment and reduced homelessness • improved physical and mental health

9. What do We Know About People’s Experiences in Tx? Research also highlights limitations of prevailing models • High recidivismThe majority (64%) of those entering publicly funded treatment in the United States already have one or more prior admissions, including 22% with 3-4 prior admissions and 19% with 5 or more prior admissions • High attrition during treatment ( more than half of those admitted to tx do not complete, and 18% are administratively discharged • Low percentage of aftercare participation and low dose of aftercare (less than 30% participate in 5 or more sessions) • Poor Outcomes (Of those who complete Tx, most resume substance use) • High readmission rates within 12 months

10. Conclusions from the Research • The current structure of our service systems do not maximize all that we know about how to promote sustained recovery • The acute model that characterizes most addiction treatment conflicts with research findings on recovery stability • We need to align our systems with what we know are the critical factors necessary for sustaining long term recovery. • We Need a New Paradigm!

11. ANY DEAD HORSES IN OUR SYSTEMS?

12. Dakota tribal wisdom says that when you discover you are riding a dead horse, the best strategy is to dismount. However, in human services, we often try other strategies with dead horses, including the following:

13. Saying things like “This is the way we have always ridden this horse.”

14. Appointing a committee to study the dead horse.

15. Arranging to visit other sites to see how they ride dead horses.

16. Harnessing several dead horses together to establish a continuum of dead horses.

17. Creating trainings to ensure that we use best practices to ride the dead horse.

18. Finding a consultant knowledgeable about dead horses.

19. Promoting the dead horse to a supervisory position.

20. The real risk comes not from changing, but from trying to maintain the status quo in a rapidly changing world.

21. StrategiesThat work

22. The Philadelphia Model What are the Elements of a Recovery Oriented System of Care? It…. • Promotes Community Integration and mobilizes the community as a resource for healing • Facilitates Family Inclusion • Facilitates a Culture of Peer Support and Leadership • Values Partnership and Transparency • Provides holistic, Individualized, Person Directed Tx which Supports Multiple Pathways to Recovery • Creates Mechanisms for Sustained Support

23. What Does a Recovery Oriented System of Care Actually Look Like? System Level Organizational Level Program Level

24. Getting Out of the Treatment Box

25. Community Integration • System Level • Faith Based Initiative • Community Coalitions • Inclusive Trainings • Aligning funding so services can take place in the community rather than on site • Organizational Level • Linkages with indigenous healers • Unit of intervention – beyond individual • Role is to build recovery capital • Address Stigma

26. Community Integration • Program Level • Assess community recovery capital • Assertively link people to appropriate resources • Don’t create artificial settings for activities that can occur in natural settings • Engage people in healing their community

27. If my neighborhood’s tore up, what’s going to happen to me when I go out there. Some programs tell you to stay away from people, places and things that’ll trigger you. I can’t do that. I live in a sober house. Next door’s a crack house and across the street is the package store. This place is tore up! What am I supposed to do? If my community don’t get better, I ain’t getting better. Client in Amistad Village Project, New Haven, CT

28. Peer Culture, Support and Leadership • The most undervalued/used resource is the knowledge, skills and abilities of PIR. System Level Strategies • Peer Specialists Initiative • PIR training on starting support groups • Recovery Centers • Storytelling Training • Informal and formal (paid) peer support is a part of all services in the system. • Leadership Academy • Inclusion in system development, consultants, training, program evaluation

29. Peer Culture, Support and Leadership • Organizational Strategies • Consumer Advisory Groups • PIR involved with change management teams • Hiring PIR and facilitating partnerships • PIR involved with program development – what helps and what hurts • Program Strategies • PIR led groups • PIR provide continuing care/support e.g. telephonic aftercare • perform active recovery coaching • facilitate early re-engagement

30. Individualized, Person Directed Tx • System • Re-writing CBEs • Person centered planning trainings Program • Program fits person, not person working rigid program • Menu of services and supports • Goals- broader focus than symptom reduction, life goals are primary focus • Collaborative • Treatment goals and strategies are not determined by the professional based on the presenting problems, but determined in collaboration with PIR and directed by PIR • Self determination is valued over compliance

31. Sustained Support • We expand the points of intervention so that there is a greater continuum of care from pre-engagement to “aftercare” • Outreach and early identification plays a critical role - people don’t have to hit rock bottom before having interactions with system • Readiness is not an all or nothing thing, emphasis is on pre- action stages of engagement • The burden for successful engagement is on the provider and not on the person in recovery • Motivation is not a requirement of services, it is an outcome William White

32. Sustained Recovery Supports • Systems Level • System facilitates mechanisms for boosters, ongoing support and early re-intervention • Organizational Level • A culture of community and belonging is created • Flexible structure and roles • Program Level • Low threshold engagement, even for those “not ready” for tx • Providers recognize that early post treatment recovery is when PIR are most fragile. As such, treatment relationships do not end with graduation, telephonic aftercare, recovery coaches, • Staff and PIR conduct assertive outreach and follow-up • PIR not administratively discharged for being symptomatic

33. Meet People Where They Are • My clients don’t hit bottom; they live on the bottom. If we wait for them to hit bottom, they will die. The obstacle to their engagement in treatment is not an absence of pain; it is an absence of hope. —Outreach Worker (Quoted in White, Woll, and Webber 2003)

34. How do You Structure a ROSC?

35. The Additive Model

36. Challenges and Benefits of the Additive Model Challenges – Change at the Margins • Oftentimes the focus primarily centers on pre and post treatment supports, treatment context does not change • Rigid boundaries between treatment and the community, so tx is still taking place in an artificial environment • Recovery supports are disconnected appendages or adjuncts to treatment • No connection between Tx and other peer and community supports, therefore the burden is still on individuals to navigate complex systems Benefits • More community based supports are available!!! • Catalyst to start grassroots push for transformation

37. The Interactive Model

38. Challenges and Benefits of the Interactive Model Challenges: Interactive Model – Enhancements = Change • Rigid boundaries still exist between the treatment setting and peer driven and community supports • Treatment setting is enhanced by presence of peer based supports, but nature of treatment itself is unchanged. • Primary focus is still on the treatment system and other supports supplement the existing tx system • Treatment system can protect itself from change Benefits • Additional recovery supports within tx context • Increased collaboration/partnership between treatment, community and PBRSS • Assertive linkages are made promoting sustained recovery

40. Challenges and Benefits of Transformative Model Challenge: Paradigm shifts are difficult • It takes intentional, sustained planning and effort to align all levels of the tx system Benefits: People get what they need, tx remains relevant • The unit of intervention moves beyond the individual to the family and community thereby creating a context to sustain recovery and wellness • Service philosophy changes and is consistent for tx and RS • Treatment is no longer the primary focal point but one of several critical resources that promote recovery • The nature of treatment changes and there is regulatory and fiscal alignment consistent with the vision of recovery oriented care

41. Comparison of ROSC Models

42. Aligning Concepts: Changing how we think Aligning Practice: changing how we use language and practices at all levels; implementing values based change Aligning Context: changing regulatory environment, policies and procedures Conceptual Framework Guiding the Transformation Process

43. Conceptual Alignment • Set the Context and Establish a Sense of Urgency - Establish a baseline - compare status with national/regional efforts - seek out the voices of people in recovery 2. Form Powerful Guiding Coalitions • Change management team • RAC, OAS Advisory 3. Create a shared vision for change 4. Develop a conceptual framework for transformation that encompasses all related initiatives

44. Conceptual Alignment 5. Over-communicate the vision 6. Develop participatory and transparent approaches 7. Create Forums for Knowledge Sharing and Exploration of New Ideas 7. Address Perceived Loss and Facilitate Engagement

45. Practice Alignment 1. Establish Priorities - community integration, peer support/leadership, sustained recovery supports, holistic care, family incl. 2. Examine their implications for all levels of the system 3. Develop Mechanisms for Skill Building and Aligning Practices with Priorities - RFT, Tools for Transformation, Practice Guidelines 4. Empower all Stakeholders 5. Identify and mobilize the early adopters - Invest in the enhancement/development of model programs

46. Practice Alignment 6. Tackle the tough issues (regulatory changes, fiscal alignment, risk and liability) 7. Create Short-term wins 8. Celebrate the successes 9. Begin to shift from invitation to expectation

47. Context Alignment • Align Organizational Structure • Learn what the barriers to recovery oriented care are from your emerging practices • Address policy and fiscal issues for long-term sustainability • Address Stigma • Strengthen the community and build Indigenous recovery capital • Move beyond the choir – link it to other political agendas

48. Where is Your System? • Pre-contemplation • Contemplation • Preparation • Action • Maintenance

50. Three Types of Change Developmental New State Old State Transitional Transition State