Where recovery residences and addiction treatment meet

Substance use problems are preventable; if they are left unaddressed, they often progress into a chronic disorder. While episodic, acute-care treatment is vital, it alone does not offer a holistic solution. A recovery-oriented system of care (ROSC) is a chronic-care approach that encompasses prevention, early intervention, treatment engagement and ongoing recovery management and support services. The lifeblood of ROSC is the collaboration among and between service providers and systems based on the needs of the individuals, families and communities that they have in common.

Whereas recovery is a process, people’s needs change over time. This calls for a diverse and flexible matrix of both clinical services and non-clinical recovery support. Within this matrix, recovery residences and addiction treatment meet in a number of ways. These natural partners have long referred to each other, and in some cases, they are integrated to varying degrees. As healthcare reform unfolds, the partnership opportunities between recovery residences and addiction treatment will increase.

To better understand these crossroads, one needs to unpack three concepts: the categorization of recovery residences within four distinct levels of support; what are we calling “treatment” today; and third-party reimbursement in a world of parity and affordable care.

Levels of support

In 2011, the National Alliance for Recovery Residences (NARR; formerly the National Association of Recovery Residences) defined a comprehensive recovery residence nomenclature and standard that distinguishes 4 levels of support. A certification program was developed based on the NARR standard. State affiliate organizations license the program and are responsible for certifying recovery residences in their jurisdiction. At a minimum, all four levels provide sober, safe and peer supportive environments where individuals can start and sustain long-term recovery. Service type and intensity differ across recovery residences.

The different levels can be found along a non-linear spectrum, meaning that a person seeking recovery can enter in and move between any level of support based on current need:

• Level 1 - Democratically run households where peers provide support to one another; an Oxford House serves as the primary example.
• Level 2 - Sober, safe and peer supportive living environments that are monitored by a peer, such as a resident house manager.
• Level 3 - Peer supportive environments overseen by supervised staff that provide a range of non-clinical recovery and life skills development programming as well as actively link individuals to third-party clinical services as needed.
• Level 4 - Residential programs with a foundation in peer-to-peer support that offer recovery, life skills development and clinical services.

Note, the higher levels of support integrate the medical model with the social model of recovery to varying degrees. So, the belief that “Some sober homes move dangerously close to treatment” presented in the Addiction Professional article posted on Nov. 4 is incongruent with NARR philosophy because persons in recovery need a full spectrum of options ranging from a democratically run Level 1 to a robust set of clinical and non-clinical services found in a Level 4.

Defining ‘treatment’

Whereas the NARR standard is universal, laws defining licensed treatment differ from state to state. In general, all states require facilities providing clinical services in a residence to be licensed as inpatient residential treatment. As such, all certified Level 4 recovery residences must also be licensed by their respective state. For example, in Texas, a Level 4 recovery residence would apply for a Supportive Residential license, and in Tennessee, a Level 4 would apply for an Alcohol and Drug Halfway House Treatment Facility license.

Beyond Level 4s, there will be little to no state licensure of recovery residences. Due to federal fair housing laws, recovery residence level 1s, 2s and most 3s cannot be regulated by government. There is only one known exception. California law is written in such a way that requires Level 3 recovery residences’ non-clinical programming to be licensed as treatment.

The state-by-state confusion around what is and is not “treatment” is one of the many reasons why NARR developed a single standard that articulates the spectrum of choices that are available. Recovery residence providers need a way to promote their services ethically, in a way that does not confuse consumers or state regulators.

In the bigger picture, “treatment” is often considered more than just licensed clinical services. According to the National Survey on Drug Use and Health (NSDUH), only 10% of the population that needs addiction treatment services receives it, and the most common form of “treatment” received was through non-clinical, mutual-aid support groups such as 12-Step groups. From a historical perspective, it has only been in recent decades that addiction treatment (or the concept of treatment) has been medicalized. As we move away from an acute-care focus toward a chronic-care approach, the emphasis will be placed more on what starts and sustains recovery and less on what is used to treat the disease. And, when it comes to supporting recovery, even the lowest level of recovery residence support, a Level 1 as iconically represented by Oxford House, is listed on the Substance Abuse and Mental Health Services Administration’s (SAMHSA’s) National Registry of Evidence-based Programs and Practices (NREPP).

Insurance opportunities

In an ideal world, individuals should be able to choose from an array of services that support their recovery, including counseling, recovery housing, recovery coaching, socially supportive activities, job placement, parenting classes and legal aid, just to name a few. In reality, they often get what they can afford to pay out of pocket or what is paid for by a third party.

Before the federal parity law and the Affordable Care Act (ACA), third-party payment primarily reimbursed for clinical services. Even in this old system, some Level 3 and most Level 4 recovery residences billed insurance. So did intensive outpatient programs that closely collaborated with recovery residences to house their clients in recovery-conducive living environments.

Historically, most recovery residences have operated on a self-pay and/or private donor revenue model, and for many reasons they may choose to stick with that. But government programs such as Access to Recovery have funded individuals living in Level 2 recovery residences across the nation. It is the cost-effective recovery outcomes of these programs that are now opening third-party payment doors for individuals seeking sober, safe and peer supportive living environments.

As healthcare reform unfolds, the services that improve recovery outcomes and/or decrease system costs will be financially rewarded. This period of transition has stimulated a great deal of vertical and horizontal integration in the industry. While there is much to be said about economies of scale and a diversified revenue mix, persons seeking recovery have diverse and changing needs. One size will not fit all.

A person-centered, chronic-care approach requires all providers, large and small, to collaborate within a recovery-oriented system of care. And nowhere within the ROSC matrix will you find two groups with stronger pre-existing relationships than between recovery residences and addiction treatment. This is a strength that can be built upon as we move toward a future that embodies ROSC principles.

Jason Howell is President of the National Alliance for Recovery Residences. He is also Executive Director of SoberHood in Austin, Texas. His e-mail address is jason.howell@soberhood.org.