Continuing Care and 3-Year Outcomes in Adolescents: Moving Toward a

Disease Management Model

Cynthia Campbell, PhD 1

Constance Weisner, DrPH, LCSW 1, 2

Felicia Chi, MPH 1

Stacy Sterling, MSW, MPH 1

AcademyHealthJune 9, 2008

Washington DC

1 Division of Research, Northern California, Kaiser Permanente

2 Department of Psychiatry, University of California San Francisco

Funded by National Institute on Drug Abuse, National Institute on Alcohol and Alcoholism,

Robert Wood Johnson Foundation and the Center for Substance Abuse Treatment

Continuing Care: What is it?Continuing Care: What is it?

Typically presented as aftercare services Additional chemical dependency (CD) treatment after

usual care 6 mos - 1year

Stepped down, lower intensity

Other psychosocial services

Any type of intervention between treatment system and patient (McKay, 2005)

12 step programs Adolescents are less likely to attend

Associated with better SU outcomes (McKay, 2005)

LiteratureLiterature Recovery Management Checkups

Dennis, Scott et al. Quarterly assessments over two years after intake

Those with problems referred to linkage managers Used MI approach to address SU and other problems

Aim is for ongoing monitoring and linking them back to SU treatment More likely to return to treatment; longer retention; improved outcomes

Assertive Continuing Care Dennis, S. Godley, M. Godley Specific to adolescents Assertive case management for 90 days post discharge Community outreach, home based Associated with improved participation in continuing care, and outcomes

Telephone interventions McKay et al Evidence of association with improved outcomes, although might be more

appropriate for less severe patients (McKay et al., 2001)

Treatment Outcomes Treatment Outcomes Stronger in Short TermStronger in Short Term

Substance use is a chronic problem but treatment is episodic

Typically less than 90 days

Effects of index treatment decrease over time

Treatment careers of multiple uncoordinated episodes (Hser et al., 1997)

Low engagement with continuing care among adolescent patients

How to think of ongoing services for adolescents?

Disease Management ApproachDisease Management Approach

Conceptual approach grounded in the chronic disease management framework

Individual with a serious chronic problem (e.g., diabetes) is treated in specialty care, and when stabilized returns to PC for management and monitoring referred back to specialty care for services as needed in the

course of their health care

Similarly, SU is a chronic condition requiring ongoing care or management delivered in more than one setting (McLellan, 2000; McLellan, 2002; Hser et al, 2007)

A person may do well after treatment, but then relapse

What might an integrated care modelWhat might an integrated care modelfor substance use problems look like? for substance use problems look like?

Lessons from disease managementLessons from disease management

Specialty Care(CD and Psychiatry)

Primary Care

Screen and treat in PC if moderate problem

Continue monitoring

Specialty care if needed

Back to PC for monitoring

Continuing care

Von Korff M, Gruman J, Schaefer J, Curry SJ, Wagner EH. Collaborative management of chronic illness. Ann Intern Med. 1997;127:1097-102. Bodenheimer T, Wagner EH, Grumback K. Improving primary care for patients with chronic illness. JAMA 2002; 288:1775-9.

The Case for Primary CareThe Case for Primary Care

Post-CD treatment primary care management

There is little coordination with CD treatment by PC after treatment

Specialty treatment does not last someone’s whole life, but they will have ongoing medical care

Another opportunity to engage

Population also has a high level of medical conditions, even in adolescents

Need to have these addressed as well

Institute of Medicine, “Improving the Quality of Health Care for Mental and Substance-Use Conditions,” 2006

What are adolescents like by the time they get to treatment?

Setting: Northern California Kaiser Setting: Northern California Kaiser Permanente (KP)Permanente (KP)

Private, group-model managed care health plan

Serves 3.5 million members in 15 counties (about 40% of population in the region)

~400,000 members aged 12-18

16 hospitals, 23 outpatient clinics

~500 pediatricians

Integrated health care system (medical, psychiatry, chemical dependency services)

Study Design and Data SourcesStudy Design and Data Sources

Baseline interviews with adolescents (and a parent) at intake to CD treatment at 4 Kaiser sites (Oakland, Sacramento, Vallejo, Vacaville)

Follow-up interviews with adolescents and parents at 6 months and 1,3, and 5 years (Response rates = 92%, 92%, 86% and 85%, respectively)

Clinical ICD-9 diagnoses from automated records

Health plan administrative utilization and cost databases

Treatment ProgramsTreatment Programs Each offers 1-year program Same modalities of other CD programs in the country Intensive, structured outpatient treatment

Abstinence based Breathalyzer and urine screens

Services include group therapy, education, relapse prevention, family therapy. Individual counseling with a CD clinician available as needed Require participation of a parent or guardian Attendance at 12-step programs expected and monitored

3 Phases Eight weeks more intensive treatment 4 months of relapse prevention/continuing recovery 6 months of after care to maintain abstinence

Few stay that long, true across the literature

Adolescent CD Patients & Matched ControlsAdolescent CD Patients & Matched Controls

Sample:

419 adolescents (143 girls, 276 boys)

Mean age of initiation (11.5)

Age ranged from 13 to 17 years (mean = 16.15)

Ethnicity: 6% Asian

9% Native American

16% African-American

20% Hispanic

49% White

Matched Controls:

2,084 adolescents from the health plan

No documented alcohol or drug history

Matched on gender, age, length of health plan enrollment, and catchment area

Sterling S, Weisner C. Chemical dependency and psychiatric services for adolescents in private managed care: Implications for outcomes. Alcohol Clin Exp Res. May 2005;25(5):801-9.

Substance use (%) at Treatment Entry Substance use (%) at Treatment Entry (N=419)(N=419) %

Any alcohol 855+ drinks of alcohol at one time 45Marijuana 92Tobacco 76Hallucinogens 25Stimulants 21Party drugs 20Sedatives 10Painkillers 25Cocaine (powder or crack) 17Inhalants 12Heroin 2

Girls had significantly higher use than boys of alcohol, stimulant, sedative, cocaine, heroin and party drugs

Sterling S, Kohn C, Lu Y, Weisner C. Pathways to substance abuse treatment for adolescents in an HMO. Journal of Psychoactive Drugs. Dec 2004;36(4):439-453.

Medical Conditions among Adolescent Medical Conditions among Adolescent CD Treatment Intakes (%) CD Treatment Intakes (%)

Tx Intakes Controls p-value

Abdominal Pain 10.6 5.7 <.001Respiratory System Cond. 54.5 37.8 <.0001Gastroenteritis 6.5 3.9 <.05Conjunctivitis 6.9 3.2 <.001Muscle Pain 8.4 3.9 <.0001Scoliosis 3.1 1.3 <.01Benign Uterine Cond. 7.7 3.2 <.0001Injury & Poisoning 49.6 36.4 <.0001Urinary Tract Infection 3.4 2.0 <.05STDs 4.8 1.5 <.0001

*One-third of parents reported that their child had chronic health problems (asthmaand allergies most commonly). Past pregnancies: 15% of girls

Mertens JR, Flisher AJ, Fleming MF, Weisner CM. (2007). Medical conditions of adolescents in alcohol and drug treatment: comparison with matched controls. Journal of Adolescent Health Feb;40(2):173-9.

Mental Health Conditions of AdolescentsMental Health Conditions of Adolescentsin CD Treatment & Matched Controls (%)in CD Treatment & Matched Controls (%)

Tx Intakes Controls p-value

Depression 36.3 4.2 <.0001

Anxiety Disorder 16.3 2.3 <.0001

Eating Disorders 1.2 0.43 .067

ADHD 17.2 3.0 <.0001

Conduct Disorder 19.3 1.2 <.0001

Conduct Disorder (w/ODD) 27.3 2.3 <.0001

Any Psychiatric DX 55.5 9.0 <.0001

Gender Differences in Mental Health Comorbidities:Gender Differences in Mental Health Comorbidities:Adolescents in CD TreatmentAdolescents in CD Treatment (in %) (in %)

30

17

10

2 2

14

21

14

43

28

05

1015202530354045

GirlsBoys

**<.01

HIV Risk Behaviors amongHIV Risk Behaviors amongAdolescents in CD TreatmentAdolescents in CD Treatment

14*3Male homosexual activity or female related sexual activity

37

52

39

43

Sex with multiple partners, past 6 months + never/inconsistent condom use

53*35Never/inconsistent condom use (of those reporting ever having sex)

11Sharing needles or works

42Injection drug use (IDU)

Girls(N=143)

%

Boys(N=276)

%Risky Behaviors

Ammon L, Sterling S, Mertens J, Weisner C. Adolescents in private chemical dependency programs: who are most at risk for HIV? J Subst Abuse Treat. Jul 2005;29(1):39-45.

AdolescentAdolescent Chemical Dependency Chemical Dependency Patients: HIV Risk BehaviorsPatients: HIV Risk Behaviors

Rate of at least 1 reported HIV risk behavior was 47%

Boys who drank 5 or more drinks in a day at least once during the past 6 months were 4 times more likely than other patients to engage in multiple HIV risk behaviors.

Girls who used narcotic analgesics (painkillers) without prescription at least once during the previous 6 months were 5 times more likely to engage in multiple HIV risk behaviors.

Ammon L, Sterling S, Mertens J, Weisner C. Adolescents in private chemical dependency programs: who are most at risk for HIV? J Subst Abuse Treat. 2005;29(1):39-45.

Outcome Argument for Continuing Care

One Reason for Continuing Care:One Reason for Continuing Care:Alcohol and Drug Use after TreatmentAlcohol and Drug Use after Treatment

1 year after treatment – doing better, but many not abstinent* 61% abstinent from alcohol 59% abstinent from drugs 47% abstinent from both 36% in remission (non problematic use)

3 years after treatment 38% abstinent from alcohol 57% abstinent from drugs 30% abstinent from both 26% in remission

* 30-day abstinence* Remission: used alcohol but no more than once/week and never more than 2 drinks, OR used marijuana, but only once/month or less, AND b) Used no other drugs (excluding tobacco); AND, c) Had no dependence/abuse symptoms

Initial Exploration of Continuing CareInitial Exploration of Continuing Care

Anchored in PC, with specialty CD and MH services as indicated

Initial specifications tested 1 or more PC visit each year after 1 yr FUSubsequent MH or CD services if needed,

either within or outside KP

Role of PC-based Continuing Care: To Return Role of PC-based Continuing Care: To Return More Severe Teens to Treatment and Improve More Severe Teens to Treatment and Improve

Outcomes Outcomes

Three years after treatment: 1 or more PC visits/year was associated with

abstinence and remission 32% abstinent vs. 18% 28% remitted vs. 14%

For those with any MH symptoms at 1 year, 1 or more MH visits was related abstinence (40% vs. 25%)

Among those not abstinent at 1 year, CD readmission were related to abstinence (40% vs. 33%)

1 or more PC visits was associated with a CD readmission and MH services after index CD treatment

All p <.05

Cost Considerations for Continuing CareCost Considerations for Continuing Care

Medical costs decrease after CD treatment for adults

Medical costs for adolescent CD patients did not decrease in the year after treatment as they do for adults

Parthasarathy S, Weisner CM, Hu T-W, Moore C. Association of outpatient alcohol and drug treatment with health care utilization and cost: revisiting the offset hypothesis. J Stud Alcohol. Jan 2001;62(1):89-97.

Parthasarathy S, Weisner C. (2006). Health care services use by adolescents with intakes into an outpatient alcohol and drug treatment program. The American Journal on Addictions 15(Supp 1):113-21.

Costs at 3 yearsCosts at 3 years

Overall, average costs increased in the year after treatment, then decreased

Costs are higher for the cases compared to the controls, although the difference has narrowed by 3 years

Looking at abstinence at 3 years, both abstainers and non-abstainers had higher average costs than the matched sample (p<.05) Abstainers had higher costs in all departments except ER.

Could be a proxy measure for appropriate use

Disease Management ApproachDisease Management Approach

Specialty Care(CD and Psychiatry)

Primary Care

Screen and treat in PC if moderate problem

Continue monitoring

Specialty care if needed

Back to PC for monitoring

Continuing care

Von Korff M, Gruman J, Schaefer J, Curry SJ, Wagner EH. Collaborative management of chronic illness. Ann Intern Med. 1997;127:1097-102. Bodenheimer T, Wagner EH, Grumback K. Improving primary care for patients with chronic illness. JAMA 2002; 288:1775-9.

What Could This Look Like in PC?What Could This Look Like in PC?

Two approaches

1. Training PC providers to screen for problems, especially in those who have been in treatment or diagnosed

2. “Patient-centered” approach (IOM) Empowers patient Educates patient and family about importance of managing

SU problems similar to medical problems Addresses stigma, communication, how to raise the issue

with providers

SummarySummary Primary care is important after CD treatment as

well - keeping primary care in the loop after treatment

Treatment is not a “magic bullet” and even “aftercare” ends at some point

Important for individuals in becoming accustomed to talking about alcohol and other behavioral problems to physicians as a life pattern

Future Research

COLLABORATORSCOLLABORATORS

Felicia Chi, MPH Sujaya Parthasarathy, PhD Lyndsay Ammon, PhD Cand. Charlie Moore, MD David Pating, MD Steve Allen, PhD Ken Athey, LCSW Michael Leotaud, LCSW Agatha Hinman, CA Georgina Berrios, BA Melanie Jackson-Morris, BA Yun Lu, MPH Cynthia Perry-Baker, BA Gina Smith-Anderson, BA Barbara Pichotto, BA, CADAC

Northern California Kaiser Permanente Adolescent Medicine

and Chemical Dependency Rehabilitation Programs*

*Thanks to clinicians, patients and family members for participating in these studies

Are there opportunities for PC intervention?

Utilization Patterns during 24 Months prior to Treatment Utilization Patterns during 24 Months prior to Treatment IntakeIntake

24 months prior to intake (%)

12 months prior to intake (%)

3 months prior to intake (%)

Primary Care* 89.5 79.2 48.7

Psychiatry 50.1 42.0 30.8

ER 26.3 17.9 11.7

*Includes visits to the following departments: Family Practice, General Medicine, GYN, Medicine, Pediatrics, Physical Medicine and Urgent Care.