always on time: a flexible appointment-less service designed to support the successful engagement...
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Always On Time: A Flexible Appointment-Less Service Designed to Support the Successful Engagement and Retention of Persons
Not Well-Suited to Traditional Outpatient Care
Brendan Kelly, LMSW, CAACCurtis Bryant, Peer SupportCyndi Musto RN, MA, LLP, CCS-M
Arbor Circle Corporation, Grand Rapids, MI
Substance Use Disorders (SUDs)
In 2008, an estimated 22.2 million persons aged 12 or older were classified with substance dependence or abuse in the past year. (NSDUH, 2008))
Severe Mental Illness
In 2002, 17.5 million adults aged 18
or older were estimated to have severe mental illness (SMI) in the prior year. (NSDUH, 2004)
Co-Occurring Disorders (COD’s)
About 23 percent (4 million) of adults with
SMI in 2002 also were dependent on or abused alcohol or an illicit drug (Co-Occurring Disorders).
(NSDUH, 2004)
Access To Care
Over 50% of adults with co-occurring SUD and SMI (approx 2 million persons) received no treatment of any kind in last year.
34 % received mental health treatment only
12% received both mental health and substance use treatment.
“Gap” Clients
“Quadrant III” population identified as not severe enough for Mental Health Case Management, but often too severe for successful engagement in outpatient treatment.
Results in inadequate service provision and high utilization of crisis services.
Typically not covered under other funding sources (3rd party, Medicaid, Medicare).
Risk Factors Associated With COD
Higher use of Emergency Rooms. More likely to seek treatment, but less likely
to complete. Higher risk of co-morbid physical health
issues: HIV, Hep C, TB Higher risk of incarceration. Higher risk of suicide. Higher risk of homelessness.
Difficulties with Traditional Treatment
No shows/ late attendance/ frequent cancellations.
Long absences from treatment. Repeated process of engagement,
disengagement and re-engagement (often in crisis).
Bounce between treatment providers. Frequent discharges from treatment due to
non-attendance.
Barriers To Treatment Success
External:– Variable employment schedule.– Homelessness/unstable housing.– Lack of transportation.– Lacks telephone/internet.– Intermittent incarceration.
Internal:– Moderate to severe substance use.– Mental illness– Crisis orientation– Low/inconsistent motivation.
Always On Time (AOT)
Collaborative Initiative Between Network 180 (CMH) in Kent County, and Arbor Circle.
Grant Funded (explain grant) Dates
AOT Treatment Is:
Stage-Matched Individualized Comprehensive Cost-effective Consistent with IDDT/COSIG and ROSC.
Criteria
Co-Occurring Disorder (Quadrant III)– High Substance Use and Moderate Mental Illness.
History of “unsuccessful” discharge from treatment for “non-compliance”. (dropout)
Experience barriers to regularly scheduled treatment attendance.
Population uses more crisis services and may have long history of treatment, with few positive outcomes.
Harm Reduction
Goal is to improve engagement/retention. Enhance protective factors/reduce risk factors. Facilitate engagement in traditional services when
ready/able, while maintaining structure to prevent recurrence of barriers.
Philosophy is to provide what client needs, at the time they need it, and for as long as they need it.
Access
“No Wrong Door” Referral from existing OP clinicians
identifying Quadrant III individuals as at-risk of treatment failure and dropout.– Crisis prone, inconsistent attendance, frequently
late for scheduled sessions, resulting in shortened/staff-cancelled sessions .
Jail referral upon re-integration. Referral by Network 180 and Peer agencies
Staffing
Therapist Peer Support/Recovery Coach Supports Coordination Parallel to existing programs:
– OP, IOP, Psychiatric Services, Specialty Programs.
Expectations of Staff
Therapist– Assessment, Individual and group therapy, case
coordination.
Peer Support– Recovery coaching/mentoring, supports
coordination.
Structure
Clients can schedule appointments or “drop-in” to be seen anytime during business hours.
Availability of primary AOT Therapist, Peer Support Staff, or back-up clinicians at all times.
Daily therapy/support group.
No expectation of “compliance”. Client can attend sessions as often as they perceive need.
Session length is determined by client.– I.e. 5 minute “check-in” or traditional 50 minute
session.
Level of care is adjusted as client is ready– Can increase/decrease intensity as desired.
Implementation
Typical 6-month service authorizations expanded to 12 months.
Standard discharge expectation if no service within 30 days is suspended.
Layered authorization allows AOT services as both primary treatment, or concurrent with other “traditional” services.
AOT therapist as case manager:– Individual Tx, coordination of all care.
Service Expectations
Identified clients are seen with less than two business day wait- often same day contact with AOT clinician or Peer Support.
Peer Support is integral part of assessment and treatment.
AOT clinician completes comprehensive needs assessment, and coordinates and monitors access to collateral services.
Peer Support
Peer Support provides recovery coaching, as well as supports coordination.
Facilitates referral and access to:– Employment support, Primary Care Physicians, housing
support, food, transportation, etc. – Supports clients in applying for Medicaid and other
available benefits. Use of telephone/internet in order to expedite access
to supports. Meet clients at support meetings to help bridge
transition into new settings.
Outcomes
Reduced wait time for treatment. Immediate return to treatment after absence
instead of waiting for intake. Facilitated access to services. Service Coordination.
Cost-Effectiveness Goals
Efficiencies in system lead to savings: Drop in availability reduces no show for scheduled
appointments. Immediate return to treatment within 12 month auth
bypasses costly intake process and enhances retention. Despite higher cost of COD Tx, long-term cost reduction
from effective intervention leading to reduced use of crisis services, health-risks, incarceration, etc.
Outcomes
Studies indicate use of recovery support can double duration of treatment adherence.
Thank You!