Aftercare planning goes formal

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.

Drug testing alone would not be effective in preventing relapse, says Knepper. “I believe in the value of staying connected to the facility, with a human element,” she says. “Someone who shows up for a urine drug screen might still test negative, but through interactions with a specialist and family member, we might get a suspicion that there is high stress, and we would try to get in front of a relapse or slip before it actually happens. Drug testing isn’t going to have that human element.”

Caron also believes in mutual support group participation during post-discharge care. “We believe that going to 12-Step meetings is important,” says Knepper. “We believe that your spiritual care is important, your connection with a Higher Power whatever that may be, as well as finding healthy sober activities.”

The program's data show that 93% of My First Year participants are attending 12-Step meetings at discharge from the aftercare program, and 74% have a sponsor.

Marketing to referral sources

The focus on continuing care is meant to benefit patients, but the real attraction at this time is for referring professionals, who are more likely to appreciate the importance of such care.

While Sierra Tucson’s Connections program was marketed to patients, Connect365 is being marketed to professionals, says Vinck. “I think this would be a differentiator when thinking about sending my client, especially a relapse-prone client, to this program,” she says. The referent who is looking for a center for someone who has relapsed before will be impressed by the program, she says. “They’ll think, ‘This guy has gone to the best treatment centers and relapsed. We need something extra for him.’”

Melissa Gettler, vice president of marketing for Caron, agrees that referring clinicians “recognize the value of long-term accountability, and this can be a differentiator.” So Caron’s My First Year of Recovery is marketed primarily through the business development office.

“From a consumer perspective, we’re not there yet,” Gettler says. “They’re not looking at or even willing to think about what happens after treatment. They’re just worried about getting them detoxed, and about that first 30 days.”

When a family is in a state of crisis, the presence or lack of a continuing care program is “not a closing factor,” says Gettler, even though it’s clearly connected to long-term success.

Most family members are “not even aware of the fact that recovery will be an ongoing process for their loved one—and themselves—for the rest of their lives,” says Gettler. So the fact that Caron has a continuing care program that they can purchase “is not much of a differentiator for them until they’ve gotten to the point where they’re doing some comparison calling.”

The increased media attention to addiction issues is helping communicate the nature of recovery to a broader audience, beyond clinicians, says Gettler. “More people are thinking positively about treatment, and also understanding that it’s a little more complicated than going away for 30 days,” she says.

Perspective on outcomes

Gettler says that addiction, like diabetes, requires the patient to pay attention to self-care. “If you relapse, that doesn’t mean that you’ve failed, but you have to work harder,” she says. Treatment programs can be there to avert a relapse, or to make sure a slip doesn’t turn into a full-blown relapse.

“We’re talking about the re-engagement process, not just the outcomes” when there is a slip or a possibility of relapse, says Gettler. “What’s the ability of a program to get people back to sobriety if they have a relapse, and how quickly will that take place?” The message should draw in everyone, but is particularly appealing to families who understand that relapse constitutes part of the disease.

At Sierra Tucson, one patient already has come back to treatment to prevent a relapse, says Vinck. “Her husband said, ‘I’m seeing relapse behaviors, and let’s get her back so she won’t have to go through the horror'” again, she recounts.

Leaders at both Sierra Tucson and Caron say that the 12-month aftercare clock does not stop if a patient disengages from support for a period of time. Efforts would be made to engage the family during this period, however.

More than just alumni

“There’s some sophisticated programming for continuing care out there,” says Marvin Ventrell, executive director of the National Association of Addiction Treatment Providers (NAATP). “But my sense is that these programs are mainly being built through the alumni department function, which carries significant challenges.”

In some cases, patients will need to come back for treatment; this kind of engagement requires clinical expertise, not just marketing. Treatment center alumni departments are typically “understaffed by people who are well-intentioned and not trained,” says Ventrell. “It’s not like the alumni department of Harvard, which first of all has tons of money, and second of all is an academic collegiate model, not a treatment model.” Alumni go back to Harvard because they’re proud of having graduated and “want to hobnob,” says Ventrell. “They don’t go back for more education.”

Ventrell is a founding board member of the national organization Treatment Professionals in Alumni Services (TPAS), which is based on William White’s concept of recovery-oriented systems of care.

Still, it’s important that residential treatment programs are recognizing that “they need to do more than recommend a continuum of care,” says Ventrell. “They need to provide a continuum of care.”

The first step is to create the program, says Ventrell. “The next step is to get patients to buy in.” Patients typically go to treatment to “get their medicine and go back to their lives,” he says. “We need a fundamental change. They need to know that they’re on a journey.”

Ventrell notes that the treatment providers well know that relapse happens. “Since the 1950s, nobody has been confused about this,” says Ventrell. “But as they say in AA, we don’t shoot our wounded.” Relapse should be treated, and, if possible, prevented, he says.

“What’s evolved from the days of early treatment is that successes and failures are acknowledged,” Ventrell says. “We need to reinvest and double down on our work.”

Alison Knopf is a freelance writer based in New York.

Technology can assist aftercare

Technology can be helpful in promoting effective aftercare, says National Association of Addiction Treatment Providers (NAATP) executive director Marvin Ventrell. When he was a program director at Harmony Foundation in Colorado, Ventrell developed an application that allowed former patients to check in, answering nine questions. Responses go into a database that counselors can review.

“Harmony is a small treatment program but we were able to do this,” Ventrell says. Harmony paid about $10,000 a year for the program.

In Sierra Tucson’s Connect365 program, there is a software tool that patients can use after they are discharged, designed so that it mirrors the structure of treatment in order to “reinforce positive gains,” says chief operations officer Jaime Vinck. For example, at 7:30 every morning, there is an “intention meeting” at which patients state what their intention for the day is. Then in the evening, there is a gratitude meeting, for patients to declare their greatest success for the day. Patients in Connect365 log in every day with their “intentions” and “gratitudes,” and know that they can message someone if they need support.

Included in Caron Treatment Centers' My First Year of Recovery package is the Caron Recovery Network, an online platform allowing patients to journal every day and to communicate with an online community that includes other patients in My First Year as well as the larger peer community of Caron patients. “They can post, ‘Hey, I just got out of Caron,’ and get responses from the peer community,” says vice president of Continuum Services Cheryl Knepper.