Acute Care Model for a Chronic Disease Recovery

Acute Care Model for a Chronic Disease Recovery Oriented Systems of Care OETAS Fall 2009

Past Models of Addiction § All pathology focused § Moral Model, Public Health Model, Disease Model

Past Models of Addiction § All based on acute models of care

Acute Care Model of Treatment Services are delivered in a uniform series of encapsulated activities § screening, § admission, § a single point-in-time assessment, § a short course of minimally individualized treatment, § Discharge and brief “aftercare”, followed by termination of the service relationship.

Acute Care Model § Focused on symptom elimination for a single primary problem § A professional expert directs and dominates decision-making throughout this process. § Services transpire over a short period of time. § pre-arranged, time-limited insurance payment designed specifically for addiction disorders and “carved out” from general medical insurance

Acute Care Model § At discharge, “cure has occurred: ” long-term recovery is then viewed as self-sustainable without on-going professional assistance. § Evaluation of success occurs at a single point -in-time follow-up, typically just months after treatment. § Post-treatment relapse is viewed as the failure (non-compliance) of the individual, rather than potential flaws in the design of the treatment protocol.

Evidence from Pathology Acute Care Models 1. Low Treatment Compliance § § 50% of outpatients drop out of treatment within one month 40% of court-ordered patients do not complete treatment (Hubbard, Flynn, Craddock, & Fletcher, 2001); (Watkins, Pincus, Tanielian, & Lloyd, 2003)

Evidence from Pathology Acute Care Models 2. Relapse Rates are High • About 60% use drugs within six months following treatment discharge • About 45% apply for residential treatment within 12 months (Hubbard, Marsden, Rachal, Harwood, Cavanaugh, & Ginzburg, 1989)

Conclusion of Pathology Acute Care Model: § Public expectations have not been met § Treatment is not very effective; or § We have the wrong model for the illness

Chronic Disease Characteristics § Influenced by genetic inheritance and other personal, family, and environmental risk factors § Can be identified and diagnosed using well validated screening questionnaires and diagnostic checklists

Chronic Diseases § behaviors begin as voluntary choices but become deeply ingrained patterns of behavior that are further exacerbated by neurobiological changes in the brain that weaken volitional control over these contributing behaviors § Are marked by patterns of onset that may be sudden or gradual

Chronic Diseases § Have a prolonged or permanent course that varies from person to person in intensity (mild to severe) and pattern (from constant to recurrent) § Are accompanied by risks of profound pathophysiology, disability, and premature death

Chronic Diseases § Have effective treatments, self-management protocols, peer support frameworks, and similar remission rates, but no known definitive cure § Often generate psychological responses that include hopelessness, low self esteem, anxiety, and depression § Generate excessive demands for adaptation by families and intimate social networks

Outcome in Addiction Treatment Mc. Lellan (2003). What's Wrong with Addiction Treatment?

Addiction/Chronic Illness Compliance Rate Relapse Rate Addiction Alcohol Opioid Cocaine Nicotine 30 -50% 50% 45% 70% Insulin Dependent Diabetes Medication Diet and Foot Care <50% 30 -50% Hypertension Medication Diet <30% 50 -60% Asthma Medication <30% 60 -80% (O'Brien & Mc. Lellan, 1996)

Cost/ Benefit Ratio of Acute Care Model vs. Chronic Care Model for Heroin Users $37. 72 Value of $ Spent $4. 86 (Zarkin, et al, 2005)

Disconnect § If we (the practitioners of addiction treatment) really believed addiction was a chronic disorder, we would not: § view prior treatment as a predictor of poor prognosis (and grounds for denial of treatment admission);

Disconnect § convey the expectation that all clients should achieve complete and enduring sobriety following a single, brief episode of treatment;

Disconnect § punitively discharge clients for becoming symptomatic; § relegate post-treatment continuing care services to an afterthought;

Disconnect § terminate the service relationship following brief intervention; or § treat serious and persistent AOD problems in serial episodes of selfcontained, unlinked interventions.

Treatment Renewal Movement § Addiction is best understood as a chronic illness § Addiction requires continuing care over a continuum of care for life

Treatment Renewal Movement § Chronic vs. Acute Model § Continuum of Care vs. Unit or Episode § Performance Measurement vs. Outcomes § Medication Assisted Treatments

Treatment Renewal Movement § Addiction treatment should adhere to proven practices and principles § Treatment is very effective when these ideas/principles are followed NIDA (1999)