Words & underlying concepts; Stump the Shrink on individualized treatment; Pressing buttons

savvy

• Addiction treatment is often viewed as a person entering a program, often for a fixed length of stay, and then “completing” and “graduating from the program”.
• Addiction as a disease which needs ongoing disease management “transitions” people from one level of care in a flexible, seamless manner.
• In no other chronic disease do we “graduate” people from treatment’.
• You can still celebrate a client’s achieving a certain level of stability and hard work without giving the message that they are “done with”, “completed” or “graduated” from treatment.

• While a patient may be “discharged” from a certain level of care to home or to another level, it is more productive to conceptualize as a “transfer” to the next level of care.
• “Transfer” emphasizes a smooth continuum of care versus silos of treatment from which one is “discharged”.
• When levels of care are siloed, there is a tendency to “refer” a person to the next level of care hoping the person follows through.
• We need to “link” people to the next level by literally or figuratively walking them to engage in the next level, much as a good hotel or even a drugstore, walks you to the restaurant or the shopping aisle to make sure you get what you want.
• Instead of giving a client a number to call (“refer); we could overlap levels of care.  We could have a person in residential treatment attend and bond with the outpatient group they will be attending before being transferred to outpatient treatment.

• When treatment is conceptualized as matching the severity of illness (SI) and level of function (LOF) with the needed intensity of services (IS), then treatment levels are described in terms of “intensity” not “restrictiveness”, which is a disempowering and stigmatizing concept; nor “higher” or “lower”, which can connote one level is better than the other.
• Levels of care are simply different benchmarks of intensity of services. In a hospital it is called the “intensive care unit” not the “restrictive or higher care unit”
• In mental health it is called a “secure intensive psychiatric unit”, not the “higher restrictive psychiatric unit”.
• The penthouse and expensive cabins are on the “higher” floors and decks whereas the cheaper and less desirable units or cabins are on the “lower” or basement levels.

• Sometimes people are placed on a waiting list while they wait to get into “real” treatment thus “pre-treatment”. Programs have experimented with a “pre-treatment” group to keep the person engaged while waiting for a treatment slot or bed.”
• Some of those clients actually do well in the so-called “pre-treatment” group and then don’t need the “real” treatment group or bed because they are doing well already. In other words the “pre-treatment” group is just “treatment”.
• “Post-treatment” does not exist in disease management of chronic disease. There is no “real primary treatment” to come first before the “post-treatment”. When a client needs ongoing care from whatever level of care they started in, then they are just receiving “treatment”.
• If there is no program in which a person usually stays a certain predetermined length of time, then there is no concept of “prolonged” or “extended” stay. The patient simply stays for whatever time is needed in that intensity of service.

• We are moving from a sick-care system, where treatment providers, hospitals and programs have been funded to treat patients and clients who were sick, and needed a residential or inpatient bed or an outpatient slot or group.  A patient is stabilized, treated and discharged, but if they become sick again, or never really got into good health, then they are readmitted for acute stabilization, and the provider gets paid regardless of the outcome.
• A true health care system focuses on positive results in health and well-being. They are paid for keeping clients and populations well, not just for providing a treatment service.

• Policies and procedures still require programs to close a case if the client has not been seen, for example, for 60 days. This is inconsistent with disease management that continues even if a patient is stable but still needs to be monitored.
• As the person stabilizes, the frequency of visits can and should be decreased even to 3, 6, 9 or 12 monthly visits. Just because a patient is not seen, doesn’t mean their case should be closed. That belongs to the idea that if the client is not in the “program” then the case should be closed.

skills & stump the shrink

• Average length of stay in methadone treatment
• Percentage rates for successful discharge after 1 year, 2 years in methadone treatment

• If a person stays on methadone for 2 years, doesn’t grow in recovery, doesn’t become self-sufficient, nor embraces wellness, but doesn’t share needles, nor spreads HIV and Hepatitis C, is that a successful client outcome?

• If another person is on methadone for 3 months, stabilizes and for them, is attracted into abstinence, non-medication recovery, is that a successful client outcome?

• If another person is on methadone for 10 years, grows in recovery becoming a fully independent, employed person blossoming physically, mentally, socially and spiritually, is that a successful client? And why would you want to “discharge” him/her off methadone?

• How well are providers engaging their methadone clients into a full recovery process?
• Are there clients for whom methadone treatment is a public health intervention regardless of whether they are interested or successful in achieving robust recovery?
• What is the success of the methadone clients in blossoming physically, mentally, socially and spiritually and are the providers working on that?
• Are some providers just handing out medication, doing cursory counseling to comply with Federal regulations, and not doing full addiction treatment and recovery?

soul

• I like to track the number of miles I actually travel. So the first thing I do is set the Trip mileage monitor to zero.  Older style odometers have an actual button you just have to press to reset the Trip odometer to zero.  It is right there in front of you in the speed and mileage window.
• The new fangled, digital touchscreen, computerized models don’t have a physical button to press.  You have to find the screen to locate the virtual touchscreen “button”.   There are different screens on the dashboard for the speedometer, the radio, the tachometer,  temperature gauge etc. It’s anybody’s guess where to locate the right “button”.

• I like to tune into the local National Public Radio (NPR) station for the latest news and balanced analysis.  With the older technology, when the right station was found, you just held down the radio Preset button.  That station would be locked in.
• Again, the new fangled, digital touchscreen, computerized models don’t have a physical button right under the radio stations.  It’s not easy to figure out where and how to digitally touchscreen a radio station to lock it in.