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Aftercare planning goes formal

January 19, 2016
by Alison Knopf, Contributing Writer
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Cheryl Knepper, Caron Treatment Centers

The emphasis on long-term outcomes in addiction treatment is relatively new, even though leaders in the treatment field have been saying for years—and some, for decades—that four weeks of inpatient treatment is not adequate. Whether someone attains recovery with or without treatment, it takes sustained commitment, and in relapse-prone patients one acute phase of the most intensive services isn’t enough.

Many critics of industry practices charge that 28 days of treatment alone is not even appropriate, if the patient is left with no support after discharge. Addiction treatment providers, stung by this criticism, are starting to provide long-term follow-up care, and many have long provided referrals to continuing care after discharge. However, the latter doesn't equate to assuming the responsibility for that care, which is the emerging model.

Addiction Professional spoke with leaders of two programs that have refined their aftercare to make sure patients have better outcomes, and to prevent relapse before it happens.

Calls from Sierra Tucson

Connect365 is a new program from Sierra Tucson, offered free to all discharged patients. Jaime Vinck, chief operations officer of the Tucson, Ariz., facility, explains that a similar program prior to Connect365 was an outsourced effort.

Under the former Connections program, replaced by Connect365 last November, former patients would receive one telephone call a week in the first month after discharge, followed by a once a month frequency, and then every other month, for a year. From May 13, 2014 to March 26, 2015, 932 patients and family members utilized Connections; 87% reported an improved quality of life.

Connect365 is a much more intensive program. Now, patients get a phone call once a week for the entire year after discharge, and the person making the calls is a staff recovery coach to whom the patient is introduced while still in treatment.

“We’re being extremely bold with this,” says Vinck. The outcomes are better for long-term recovery if the recovery coach and the patient can be connected during treatment, she says. So at Sierra Tucson, the patient meets with his/her recovery coach during the second, third and fourth weeks of treatment. This helps establish a rapport between the two, who will communicate by phone for the 12 months following. The weekly appointments occur at a pre-set time, and the recovery coach makes the phone call.

More than a continuing care “department,” which Sierra Tucson also has, the recovery coaches establish a closer bond with the individual patient. The same service also is available to family members.

Caron's 'My First Year'

Caron Treatment Centers, based in Wernersville, Pa., has been involved in post-discharge follow-up of patients for the past 10 years, and was a pioneer in the establishment of the concept of a post-discharge continuum. Originally, its program was called Recovery Care Services, with outcomes all based on self-report, explains Cheryl Knepper, vice president of Continuum Services at Caron.

Recovery Care Services followed about 100 patients a month, asking them about their ability to maintain abstinence. After six months, only about 50% of the patients would even answer the calls; this dropped off to 30% at the end of 12 months. Caron didn’t know the reasons for the lack of response. It could have been that patients had moved, or that they were doing well and didn’t need the calls, says Knepper—or it could have been that they had relapsed.

Caron was not happy with the 30% figure, and that’s why Knepper developed a new initiative called My First Year of Recovery. “We as an organization said we could definitely do better,” she says. “We needed to capture a better snapshot of how well our patients are doing.”

My First Year of Recovery, which was designed two years ago and has seen 229 patients complete the program, is different from Recovery Care Services in several ways. In particular, it uses urine drug testing as an evaluator of progress. My First Year differs from Sierra Tucson’s aftercare program in that it is not free: It costs $10,000 for the year.

My First Year was designed in consultation with Robert DuPont, MD, president of the Institute for Behavior and Health and a former national drug czar, and James R. McKay, PhD, of the Treatment Research Institute at the University of Pennsylvania, who looked at the data from Recovery Care Services for Caron.

My First Year covers about 12 to 18 random urine screens, and at least two phone calls a month from a master’s-level specialist, whose goal is to help the patient with the “recovery action plan,” says Knepper. The specialist also communicates with the patient’s outpatient provider and helps to ensure that all appointments in the aftercare plan are made. In addition, two family members are part of My First Year.

The number one drug of choice for patients at Caron is alcohol, followed by opioids, says Knepper. Since traditional urine drug screening doesn’t work well for alcohol, Caron uses EtG testing, which can detect alcohol use within the past 48 hours, she says.

So far, 68% of all scheduled urine drug screens in My First Year of Recovery were completed, says Knepper. Of those, 93% were negative for drugs or alcohol. The overall abstinence rate among these individuals at discharge from My First Year—which is 12 months after discharge from the residential program—is 76.8%. Of the people who slipped during My First Year, 50% got back on track and were sober at discharge.

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What Sierra Tucson & Caron Foundation are doing to continually engage patients is moving toward a chronic care model. It's really good. I've become sensitive to the language I use. "Aftercare" (afterthought), "Alumni" (implies that a patient graduated), "Outcome" (prefer "progress) are acute care terms. The words that we use influence how we think and what is conveyed.

I'm continually amazed how the family member/caregiver is left out of the conversation. Family recovery hasn't changed for decades even though we know without a doubt that they are critical to the positive outcomes for the addicted loved one.

Regrettably, no family is born with the knowledge of how to deal effectively with addiction. It is a skill that must be learned and practiced daily.
- NCAAD, The National Council on Alcoholism and Drug Dependence, Inc.

I've been pounding the pavement for years and NO ONE is really listening. If you might be listening right now then know that there's programming available. We offer a safe, relevant, user-friendly, convenient, supportive, online, over the phone, affordable, & professionally facilitated program.

The family deserves a level of care and support that matches the importance of their role in their loved one's recovery. Who dares to take the lead?

Thank you.

This is wonderful news. Of course it will take time to get things figured out in terms of implementation and getting industry-wide participation, but this is a great step. After care and ongoing support is critical following inpatient "abstinence-based" rehab... the relapse rates specifically for opioid addiction are astronomical. This will help support long-term recovery. As Bill White has said before, for no other disease do we just say "good luck" and send them on their way with no follow up care like we have traditionally done with substance use disorders.

I was a member of an independent alumni organization (not affiliated with any treatment center) and there were 15 of us that have all stayed sober for 30+ years and without 1 case of relapse. Bill White has been interested in researching alumni organizations and has started collecting data. With the case of independent alumni organizations, he suggested that raises another question: Which is more effective? The independent or the treatment center affiliated? I have some theories and hope someday there will be more research money available to research alumni organizations in depth.

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