Always On Time: A Flexible Appointment-Less Service Designed to Support the Successful Engagement and Retention of Persons Not Well-Suited to Traditional.

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!