Transitions from One Level of Care to Another

Successfully moving patients from detoxification or inpatient treatment into an outpatient, aftercare program is an important part of the treatment process. Research has shown that patients who receive aftercare have better outcomes in terms of abstinence and readmission rates (McCusker et al, 1995; Daley et al, 1998). Unfortunately, the majority of patients do not continue treatment after detoxification. Chutuape (2001) found in six studies the average rate of transition to aftercare to be only 35%. Detoxification identifies people with substance abuse problems. This presents treatment centers with an opportunity to actively engage this population in some form of continuing care.

The effectiveness of a brief, aftercare orientation session at the end of outpatient treatment was studied by Lash (1998). 40 Inpatients at a substance abuse treatment center in Virginia were randomly assigned to either a 20 minute aftercare orientation session or a minimal treatment condition. The minimal treatment condition involved watching a motivational video and having a staff member instruct them on how to use the information in the video to follow through with their aftercare plans. Patients involved with the aftercare orientation first identified the type of aftercare they would like to be involved in. A counselor from that specific aftercare program would then meet with the individual for no more than 20 minutes, introducing the patient to the aftercare program. And finally, the patient would sign participation contract asking them to commit to an aftercare group for at least 8 sessions. 70% of patients in the orientation group attended aftercare compared with only 40% for the minimal intervention group. The orientation group also attended more aftercare sessions, although the mean number was rather low for both groups, 3.0 to 1.4. The author feels that although this brief intervention was successful in increasing treatment entry, further study is needed to determine how to increase retention.

An earlier study by Lash & Dillard (1996) also examined the effects of an aftercare orientation on inpatient clients. There results found no difference in aftercare participation rates between experimental and control groups. The article included 2 studies. The first study had 22 patients attend a session of the aftercare group while in inpatient treatment. They were not more likely to attend aftercare (5 of 22) when compared with the placebo group (6 of 19), which watched a motivational video. Similar results were found in the second study which had 13 patients attend a more intensive orientation which included attending an aftercare session accompanied by a brief orientation in which they signed a participation contract. Again, they were no more likely to attend aftercare then the control group. 6 out of 13 patients from the orientation group attended at least one aftercare session compared with 5 out of 13 for the control group. The authors feel that one of the reasons for this lack of success was the fact that the orientation session was conducted by a volunteer from the aftercare program and not an actual counselor.

Further studies by Lash & Blosser (1999) and Lash et al (2001) added additional elements to the aftercare orientation programs mentioned above in order to increase patient participation in treatment. Patients were provided feedback and prompts and 4 different forms of social reinforcement which included, 1) being verbally recognized by the group therapist at the first and third aftercare meeting they attended, 2) Receiving a certificate after their sixth aftercare meeting, 3) The patients name appearing on an honor roll posted at the treatment facility after attending their sixth meeting and 4) Receiving a medallion after attending their eighth aftercare group. Social reinforcement participants (80%) were more likely to be in treatment after two months than the control group (40%).

Chuluape (2001) performed a study of two interventions intended to increase attendance to aftercare sessions. Both involved the use of incentives ($13.00 in bus tokens or gas gift certificate) delivered at the aftercare clinic after completing intake procedures while one incorporated a staff escort to the aftercare clinic on the day of discharge from the detoxification unit. These were compared with a control group which received a standard referral to aftercare. To reduce barriers to treatment all groups were able to receive transportation to the aftercare sessions. 76% of patients who received monetary incentives plus an escort completed intake procedures at the aftercare clinic. 44% of those who were just offered incentives and 24% from the control group completed the intake. The authors also note that the use of escorts is relatively inexpensive for clinics, especially if using non-treatment or volunteer staff.

The Key Extended Entry Program (KEEP) is an aftercare enhancement program based in the New York criminal justice system (Fallon, B.M., 2001). KEEP is designed to identify heroin-addicted individuals not enrolled in treatment at the time of arrest, stabilize them on methadone while in jail, and then refer them to aftercare programs upon release. Staff at Rikers Island in New York identify potential patients for the KEEP program who attend an intake session at the Narcotics Rehabilitation Center at Mt. Sinai Hospital when released. They go through a screening process that includes physical examination, urine and blood specimens, and the receive a prescription for either Methadone or LAAM, depending on the physicians recommendation. The patient must also complete an intake appointment where all essential paperwork is collected and information on the program is provided. At the end of intake the patient is assigned a counselor who will attempt to engage them in the treatment process through a case management model that includes a needs assessment and familiarizing the client to treatment procedures. The counselor and patient develop a treatment plan for the next 30 days which includes weekly sessions. A plan for services following six months of treatment is also created to assist in the transition to some form of aftercare. One study which examined the effectiveness of KEEP (Magura et al, 1993) found that 85% of KEEP participants had applied for treatment upon release from jail. Only 37% of the control group had applied for treatment. KEEP was also found to have a positive impact on retention as 27% of KEEP participants were enrolled in treatment at 6-month follow-up interviews compared to 9% for the control group.

Successfully navigating your way through substance abuse treatment is a potentially daunting task. With the normal pressures of everyday life providing distractions, it is important to make sure patients are actively engaged in their treatment. This includes making sure that they are initially entered into the correct level of treatment, they are made aware of any ancillary services that may help them stay in treatment and that they are motivated to continue treatment to avoid relapse. The use of effective, standardized assessment tools, case management and improved transitions to care all show potential to assist in these goals.