Using Outcome Measures in Addiction Treatment

Dear Reader,
Research has shown that regularly providing clinicians with data about how their patients are feeling helps patients get better faster regardless of the type of therapeutic approach being provided. As a result, interest in using patient-reported results to improve substance use disorder and behavioral health treatment results has been growing rapidly.

But until recently, there haven’t been tools that help centers easily monitor how their patients are doing either during or after treatment. Vista Research Group launched INSIGHT Addiction™, INSIGHT Behavioral™ and RECOVERY 20/20™ to enable programs to effortlessly collect and analyze patients’ outcome measures to enhance the treatment they’re providing.

This eBook summarizes what we’ve learned from our clients and their patients about how clinicians can use outcome measures to help patients get better faster. We also recommend how your management team can use the tremendous insights provided by this type of research to improve your program’s treatment outcomes and bottom line.

If you like Vista’s approach, the final two chapters explain how you can get started using our software to view patient outcome measures today. Alternatively, you can use the principles and examples in this eBook with other measurement-based care options or by building your own tools. Please join me on an exciting journey into the rapidly-emerging world of using outcome measures to provide better care to patients suffering from addiction and other behavioral health disorders. Hang on tight!

Joanna Conti, Founder & CEO
Vista Research Group, Inc.
September 2017

There are a number of different definitions of evidence-based practice and treatment, but the most wellknown is that proposed by Dr. David Sacket in 1996:

Part of what makes this subject so confusing is that an incredible number of different types of clinical interventions have claimed to be evidence-based as a result of one or more (sometimes conflicting) clinical trials. For example, SAMHSA has created a National Registry of Evidence-Based Programs and Practices (NREPP) that includes reviews of more than 350 substance use and mental health interventions. As if this isn’t confusing enough, SAMHSA also links to more than a dozen additional registries with their own lists of approved EBPs.

At some point one must ask the question -- if almost every technique can be classified as evidence-based practice (or evidence-based treatment; the terms are used interchangeably), what does the term really tell us?

Let’s put aside the arguments as to whether particular techniques such as Motivational Interviewing and Cognitive-Behavioral Therapy are more effective as well as what exactly a clinician needs to do in order to fully comply with the protocols. Instead, let’s step back and look at the original definition again.

Rather than focusing on the use of specific therapeutic techniques that have been shown to be effective in clinical trials, let’s think about the requirement that Evidence-Based Treatment use “the best available external clinical evidence from systematic research” to inform clinical care. What would the best form of evidence be? Clearly it would be data about the specific patient we’re treating.

Monitoring how specific patients are feeling during the course of treatment has been called a number of different things, including Progress Monitoring, Measurement-Based Care, Outcome Measures, Routine Outcome Monitoring and feedback systems. Let’s start to clear up the confusion between therapeutic techniques that are evidence-based practices (with an “s”) and the use of patient-reported data to deliver evidence-based practice (without an “s”) by defining a specific subset of Evidence-Based Treatment which we’ll call “Personalized Evidence-Based Treatment”:

The research behind Personalized Evidence-Based Treatment and how to use it effectively in addiction treatment will be the subject of the rest of this eBook.

The vast majority of studies measuring the impact of patient-reported outcome measures have focused on treating patients with mental health issues.

Carlier et al.1 did a meta-analysis of 52 randomized control trials studying the impact of monitoring outcome measures that were published between 1975 and 2009. Of the 45 trials that focused on mental health, 65% found that patient monitoring had a significant, positive impact on patient outcomes. The impact of monitoring was even higher for the studies that narrowed their focus to specific mental disorders. 76% of the 21 studies monitoring patients for specific disorders such as depression or anxiety found better outcomes among patients whose therapists were using outcome measures. And while Carlier found only 3 studies that monitored outcome measures in addiction treatment, it is important to note that all three of them reported positive effects from the monitoring.

A separate study by Brodey et al.2 further confirms the usefulness of tracking the severity of depression and anxiety symptoms. Patients of clinicians who received a report of patient-reported symptom severity at the start of treatment showed 28% greater improvement at 6 weeks than those whose clinicians did not receive feedback.

The presence of one or more co-occurring disorders makes the SUD treatment process more difficult. Not only does the therapist need to help the patient commit to and learn how to stop using, they must also address their mental health issues. And research shows that the presence of depressive symptoms not only makes it harder for the patient to stop using alcohol or drugs during treatment, it also increases the risk of relapse after treatment.

In a study by Suter et al.3 of 441 patients with Alcohol Use Disorder in Swiss long-term residential SUD treatment programs, the patients who had clinically-significant depressive symptoms at admission had both a significantly higher incidence of alcohol use during treatment and a much higher rate of posttreatment relapse:

The good news is that if a patient’s depressive symptoms can be alleviated, their likelihood of achieving long-term sobriety improves. Research among 298 American male veterans completing 21-day residential treatment by Curran et al.4 found that only 14% of the veterans who exhibited depressive symptoms three months after leaving treatment were able to remain sober for a full year. By comparison, 28% of those who were not depressed at either the time of admission or 3 months post-treatment were able to remain sober for the full year:

An extremely positive finding from this research is that patients who were depressed at admission but not three months after treatment had even better results than those who were never depressed. The fact that 35% of this group were able to maintain sobriety for a full year after treatment shows how important it is to identify and resolve depressive symptoms during SUD treatment.

Outcome measures monitoring appears to make the biggest difference for patients who are not responding as expected to treatment. Research by Hannan et al.5 showed that psychotherapists have a strong tendency to overestimate client improvement and often fail to recognize patients who plateau or worsen during treatment. Confronted with graphical evidence that their patient is not making the expected progress, therapists are more likely to modify treatment to make it more effective. In a separate meta-analysis of three large-scale studies, Lambert et al.6 found that among the patients who initially responded poorly to treatment, those whose therapists were monitoring their patients had better outcomes.

This was confirmed in the only rigorous study to date of the effect of monitoring outcome measures for patients in community-based substance abuse treatment programs. Crits-Christoph et al.7 found that among patients who weren’t progressing as expected during treatment, those whose clinicians were receiving monitoring data had significantly better outcomes than those whose clinicians were not. Even though patients whose progress went “off-track” had somewhat higher levels of alcohol use before treatment, the alcohol use of those being monitored declined substantially over time. In fact, by the end of 12 treatment sessions, this group’s alcohol use was similar to that of patients who progressed as expected throughout treatment. By comparison, the off-track patients who were not receiving monitoring showed very little improvement over 12 treatment sessions.

Drs. Goodman, McKay and DePhilippis summarized their research findings in a 2013 journal article titled Progress Monitoring in Mental Health & Addiction Treatment: A Means of Improving Care as follows:

“The research described above demonstrates that progress monitoring can have significant positive effects on treatment outcomes. In particular, studies found better drug outcomes, faster rate of improvement, and greater likelihood of experiencing reliable change, indicating symptom improvement or remission. More rapid improvement could translate into greater cost effectiveness of treatment. Studies found that improvement using progress monitoring was especially notable for those at risk for negative outcomes.”

In response to the growing body of research showing its effectiveness, several national organizations such as the Institute of Medicine, the American Psychological Association and the Kennedy Forum have begun encouraging the use outcome measures for mental health and substance use disorders. In December 2015, the zzissued the following recommendation in their issue brief A National Call for MeasurementBased Care in the Delivery of Behavioral Health Services:

“All primary care and behavioral health providers treating mental health and substance use disorders should implement a system of measurement-based care whereby validated symptom rating scales are completed by patients and reviewed by clinicians during encounters. Measurement-based care will help providers determine whether the treatment is working and facilitate treatment adjustments, consultations, or referrals for higher intensity services when patients are not improving as expected.”

The Joint Commission has responded to these strong research findings by requiring that all of its accredited behavioral health organizations start monitoring outcome measures by January 1, 2018. In January 2017, Standard CTS.03.01.09 was revised to require organizations to do the following:

• Use a standardized tool or instrument to monitor the individual’s progress in achieving his or her care, treatment, or service goals. Ideally, the tool or instrument should monitor progress from the individual’s perspective.
• Use the results of the standardized monitoring to inform the individual’s clinical care.
• Periodically aggregate the data gathered through the standardized monitoring to evaluate treatment outcomes.

CTS.03.01.09 also establishes additional requirements for organizations providing eating disorder treatment.

Choose the measures to monitor that are most likely to be meaningful to your patient’s recovery. For patients in treatment for substance use disorder, we recommend considering tracking depression, anxiety, trauma and eating disorders since each of these conditions is prevalent among a high percentage of people suffering from drug or alcohol abuse. This might be overkill, however, for patients in psychotherapy, for whom the strength of the therapeutic relationship might be sufficient to gauge how therapy is progressing.

Rather than arbitrarily choosing which co-occurring disorders to monitor each patient for, we recommend giving the patient a series of screening questions to accurately predict which issues they are struggling with. They need only be given full academically-validated scales (such as the PHQ-9 for depression and GAD-7 for anxiety) if they answer the relevant screening questions positively. By letting the patient tell us what they’re feeling, users of Vista’s INSIGHT Addiction™ have discovered that a substantial number of their patients are suffering from unsuspected co-occurring disorders.

Once a patient has completed a baseline screening, future surveys only need to ask about those issues they’re known to be affected by.

The magic of monitoring outcome measures comes from presenting each patient’s results to their clinician in easy-to-understand graphs. Vista’s INSIGHT graphs are color-coded to make it instantly obvious how a patient is doing:

As you can see from the bar on the left, this patient arrived in treatment suffering from severe symptoms of depression. Over the next several weeks, the patient began to feel significantly less depressed.

In our experience, most patients in SUD treatment make fairly rapid progress in reducing their levels of depression, anxiety and Post-Traumatic Stress Disorder (PTSD) symptoms. Clinicians should pay particular attention to those patients whose progress plateaus and who report they are still experiencing severe or moderately severe symptoms of one or more co-occurring disorders after several weeks of treatment. In this case, some modifications to treatment may be advisable.

A second issue to watch for is if a patient’s symptoms suddenly spike. We often see the severity of several of a patient’s issues increase simultaneously, such as happened with this adolescent patient:

In such a case, we recommend quick action. Otherwise, the risk that a patient will relapse or decide to leave treatment against medical advice increases substantially. In fact, this particular patient relapsed and had to return to residential SUD treatment within a few days of submitting this survey.

Monitoring outcome measures works its magic by identifying patients who are not progressing as well as expected. Rather than asking a Clinical Director to look through 50 individual reports each week, we recommend consolidating the data for them so the patients who are struggling are more apparent.

Building upon the expectation that patients will improve during their early time in treatment, INSIGHT displays the most recent data points for all patients of a particular clinician being monitored for a condition as a function of how long they’ve been in treatment. For example, the following clinician summary graph shows all of Jane’s patients being monitored for depression:
 

Each dot represents the most recent PHQ-9 score for a patient plotted against how many weeks they’ve been in treatment. Since we expect patients suffering from depression to arrive in treatment with relatively severe symptoms, the only data point we find truly concerning is the one that the arrow points to. Despite being in treatment for five weeks, this patient still reports experiencing severe symptoms of depression.

INSIGHT consolidates all of the data for a particular clinician or program on one report and labels those patients reporting symptoms in the yellow or red danger zones. This makes it immediately obvious which patients are struggling and may need additional attention:

A number of the Clinical Directors using INSIGHT have told us that they tend to learn different things from the comments made on our surveys compared to in face-to-face discussions. Apparently many people are more comfortable talking to the anonymous world of their computer or tablet and will more easily share their deepest concerns that way.

Peter Drucker ushered in a new era of productivity improvement in the business world with his maxim:

Once you have hard data in hand, you will be amazed by the insights it gives you into options for improving your program’s treatment effectiveness.

Creating the data is only the first step, of course. Once you have reliable patient data, you’re well on your way to becoming more effective. However, change is hard. Many organizations find it challenging to get over the hurdle to actually using the data effectively to inform clinical care. Often the change needs to be driven from the top.

We recommend that the Clinical Director use the Group Summaries during clinical staff meetings to raise questions about the patients who are struggling. This should encourage the clinical staff to get in the habit of reviewing their patient reports on a regular basis.

Regular review of the patient reports will probably lead to additional insights. For example, a Clinical Director using INSIGHT Addiction™ noticed that one of his clinicians was able to reduce the severity of her patients’ co-occurring disorder symptoms more quickly than the Clinical Director himself or the other therapists were able to do. After talking with her about what she was doing differently, the entire clinical staff decided to start their counseling sessions with a simple series of questions she was using.

Another treatment center discovered that many of their residential patients were dealing with rather severe eating disorders that they had been unaware of. They were able to bring in an eating disorder specialist who could separately bill Medicaid, resulting in a dramatic decrease in the compensatory eating behaviors their patients were exhibiting:

In addition to reviewing individual patient and counselor or program summary reports regularly, we recommend systematically aggregating your overall treatment results so you can look for trends and compare them to similar programs.

The Pro version of INSIGHT Addiction™ facilitates this type of analysis by producing a comprehensive Outcome Measures Report for each client once per year. This includes comparisons of the prevalence and severity of different co-occurring disorders among your patients at admission as well as the improvement experienced by your patients by the time they are discharged:

The report also analyzes patient satisfaction with treatment, both overall and by clinician:

Additionally, the report includes summaries of the following:

• Patient demographics
• Primary drug of choice
• What brought patients to treatment
• Number of previous SUD treatments
• Treatment completion rate and comparison to national norms
• Satisfaction with medication-assisted treatment (if offered)
• Patient comments about the program

One of the ways the field of SUD treatment is unusual is its resistance to following up with patients after they leave treatment to learn if they’ve been able to stay clean and sober over time. Instead, some in the industry seem to want to be given credit for successfully treating the chronic disease of addiction based solely on what happens during active treatment.

To understand how different this is, what would you think of a medical doctor who declared a patient with a chronic disease like hypertension or diabetes to be cured because their blood pressure or glucose levels were under control the moment they left their doctor’s office? The only way one could really learn that a treatment was effective would be to monitor them over time, correct?

The same is true for addiction. If we base our definition of substance use disorder treatment effectiveness solely on whether a patient is clean and sober the moment they leave treatment, we’re doing both our patients and the most effective treatment centers a disservice. By that definition, some jails would get high marks for SUD treatment!

In fact, as we all know, there’s a tremendous amount of hard work involved in breaking the bonds patients have developed to their drug of choice and helping them develop the motivation and skill set to remain clean and sober after treatment.

The best way treatment program can learn how well they’re really treating addiction is to systematically follow up with their patients after treatment and compare their results to national benchmarks.

Vista’s RECOVERY 20/20™ follows up with patients one month, six months and twelve months after they leave treatment to learn how successful they’ve been in staying clean and sober and the impact treatment has had on their quality of life.

Because patients are already experienced in taking our quick online questionnaires (and because we pay them a small stipend), we’ve been getting a strong response rate to our follow-up surveys.

Treatment centers using RECOVERY 20/20 receive two comprehensive annual reports. The Treatment Effectiveness Report is a marketing report designed to show payers and future prospective private-pay clients how successful the patients of a treatment center have been at achieving sobriety. For example, RECOVERY 20/20 provides independent verification of the percentage of patients who were reachable and claimed to have been abstinent for at least the last 30 days at one-year post-treatment:

The report also can break this down by program and compare to national benchmarks:

Because Vista has a wealth of data about how patients report feeling emotionally both during and after treatment, the Treatment Effectiveness Report can also provide proof of the impact treatment has had on patients’ emotional health:

RECOVERY 20/20 also reports the impact treatment has had on various quality of life measures such as whether they are employed or going to school:
 

The report compares the number of emergency room visits, unplanned hospital stays and detox treatments during the year before treatment versus the first year post treatment:

And to address the insurance company’s desire to reduce total health care spending, the report also includes a Health Risk Assessment comparing the patient’s likely health care costs in the post-treatment year to those in the year before treatment. In this case, a higher score is better:

Finally, because Vista’s mission is to help treatment centers improve the treatment they’re providing, Vista supplements the Treatment Effectiveness Report with a Strategic Analysis report in which we dig deep into the data to identify areas where the treatment center is doing particularly well as well as potential areas for improvement.

Analyzing the results of the Outcome Measures, Treatment Effectiveness & Strategic Analysis Reports is tremendously valuable in understanding what your program is doing well and where it can improve. Armed with this knowledge, we strongly recommend you take the next step of developing a strategic plan that uses outcome measures to continuously improve your organization.
 

Receiving the first hard evidence of how successful your patients have been in maintaining their sobriety after treatment can be very satisfying. Most programs will find that it also motivates them to want to deliver even better results in the future.

We recommend agreeing on one overall goal that the entire team will focus on achieving during the following years. Obvious choices would be the percentage of patients who are abstinent for at least the last 30 days at one-year post-treatment or who are abstinent for the entire post-treatment year. And it’s important to choose a specific numeric goal so there’s no question if and when you achieve it.

Just setting this goal, however, is not likely to make much of a difference. You need to take it to the next level and think deeply about which factors your employees can truly impact that will contribute to meeting this goal. We recommend selecting no more than three key performance indicators (KPIs) that are measurable and impactful, and publicly sharing the team’s progress on meeting these KPIs on a regular basis.

The following example might help make the process more understandable:

Apollo Treatment Center is a hypothetical 28-day residential SUD treatment program. Upon receipt of their first outcomes data, they learned that 34.7% of their 2016 patients had been fully abstinent for at least the last 30 days at one-year post treatment. While they felt good about this result, they decided to set themselves a stretch objective of increasing this to 40% over the following two years.

Overall Goal: 40% abstinent for at least the last 30 days at one-year post-treatment

One of the first things the team discussed was their unhappiness that 24% of their patients had walked out against medical advice (AMA) the previous year without completing treatment. They realized that they could use the data in the outcomes report to show current patients that the likelihood they would be sober one year later was much higher if they completed treatment than if they left early. While this might not make a difference to the patients who were adamant about leaving so they could use, it might be persuasive to some of the patients who seemed to believe they were ready to return to the real world and would have no problem staying clean and sober.

KPI #1: Decrease number of patients leaving AMA to 20%

As the team dug into the rest of the outcomes report, they were surprised to see that only 31% of these patients had attended an outpatient program for at least one month after leaving Apollo treatment center, even though this was almost always recommended. Because they felt this was so critical to success, they set themselves a KPI of increasing this to 40% the following year.

KPI #2: Increase patients attending IOP for at least one month after treatment to 40%

Finally, in talking to several of the patients in their alumni program who had relapsed, one of the team members thought they might be self-medicating due to becoming deeply depressed or anxious again. When they looked back at these patient’s reports, the clinicians realized that these patients had still been exhibiting fairly severe symptoms of co-occurring disorders when they left treatment. The team agreed that the third KPI they would try to reduce was the percentage of patients who had moderate or severe symptoms of one of more co-occurring disorders at discharge.

KPI #3: Decrease patients with moderate or higher co-occurring disorder symptoms at discharge to 20%

Apollo agreed to track each of these KPIs on a quarterly basis by combining statistics from their monitoring program, outcomes research and census. When they didn’t see the improvement they were hoping for by the mid-year point, they doubled down on their efforts. By the end of the year, they had succeeded in meeting two of their three KPIs:

As a result of the hard work of the entire Apollo team, when the one year post-treatment data was received for those patients who had been in treatment during the first year the strategic plan was implemented, Apollo was able to celebrate having met their objective of increasing the last 30 day abstinence rate to 40.1%:

Embarking on a program of monitoring outcome measures marks you as an innovative leader in the behavioral health world. Take advantage of this by communicating what you’re doing and your results on your web site and in other marketing materials as well as to accreditation and licensing agencies. The fact that you’re now using outcome measures to help patients get better faster while they’re in treatment and to track their long-term abstinence provides a real reason for prospective patients to prefer your program over others. And once you have hard data on your patients’ long-term success rate, use it to qualify for higher insurance reimbursement rates and for access to insurer’s networks of preferred providers.

As the advantages of systematically monitoring your patients’ co-occurring disorder symptoms become better known, more state licensing agencies are joining the Joint Commission in making such tracking mandatory.

Using Vista’s INSIGHT program allows you to almost effortlessly comply with these accreditation and licensing requirements.

In the cut-throat world of SUD treatment marketing, programs look for any point of differentiation to set themselves apart from location to equine therapy to chef-prepared food. The truth of the matter is that the one thing that matters most to families and individuals looking for treatment is this question – “Does my loved one have a fighting chance of getting and remaining alcohol- and drug-free if they attend your program?”

Prospective patients and their families are hungry to see proof that SUD treatment works. Publicize how many of your patients are clean and sober one year after treatment on your web site. In fact, consider posting the entire report from your research company!

Look for other avenues to publicize your results too. For example, Conquer Addiction (www.conquer-addiction.org) provides a free searchable database of treatment centers who scientifically track and report their long-term SUD success rates to help families find the treatment centers with the best outcomes.

As pay-for-value funding comes to the behavioral healthcare world, an increasing number of insurance companies, Accountable Care Organizations (ACOs) and Managed Care Organizations (MCOs) are creating their own networks of preferred providers who had the foresight to start developing reliable outcomes data early.

By mid-2016, almost 20% of insured Americans were already being attributed to an ACO, MCO or health home that typically keeps a substantial portion of the savings if they can provide care to their members at less than the agreed-upon annual rate.

If you can show these organizations that you have a good success rate treating the typically very difficult and expensive-to-treat patients who are suffering from addiction or mental health disorders, you will be rewarded with higher reimbursement rates and/or access to more patients. But you have to bring the data.

Dr. Kristofer Smith, the Medical Director of $8 billion Northwell Health Solutions, told an Open Minds conference recently that he’s being contacted by a number of programs offering to share the financial risks involved in Northwell’s pay-for-value agreements if they are chosen as a preferred provider. But “that’s not good enough”, said Dr. Smith. “If they don’t have data, I won’t meet with them”.

Smaller programs can certainly choose a few key scales and use pen and paper surveys to track their outcome measures. However, if you have a lot of patients or it is important to minimize the amount of time your staff spends managing the program, you should automate patient monitoring as much as possible.

INSIGHT Addiction™ is designed to help addiction treatment programs collect and analyze outcome measures almost effortlessly. All data is collected online from patients using a laptop, tablet or cellphone. INSIGHT Addiction™ screens and monitors patients for the following conditions using academicallyvalidated symptom severity rating scales:

• Depression
• Anxiety
• Trauma
• Eating Disorders
• Suicidal Thoughts & Intentions
• Self-Harming Behaviors
• Strength & Frequency of Cravings
• Drug and Alcohol Use
• Quality of Relationships
• Satisfaction with Treatment
• Frequency of Attending Treatment (Outpatient only)

INSIGHT Addiction™ minimizes the need for staff involvement and maximizes the usefulness of the data by providing the following features:

• Collects data from patients via a laptop, tablet or cell phone
• Instantly displays patient results in easy-to-understand, color-coded graphs
• Sends alerts to clinicians of new submissions, including instantly alerting them to dangerous behavior
• Identifies patients not progressing well by summarizing the most recent data by clinician and by program
• Tracks when the last survey was submitted for each patient and when the next one is due
• Requests new surveys from patients with the click of a button
• Automatically contacts patients whose next surveys are due at a specified time each week, if desired
• Aggregates your data in a comprehensive annual report showing how effective your program is at treating underlying conditions, how satisfied your patients are with the treatment they’re receiving, whether your results are improving over time, and how your program’s effectiveness compares
  to national norms. (Requires INSIGHT Addiction™ Pro)
• Provides quarterly audits of the percentage of patients being effectively monitored by INSIGHT as well as the frequency with which your clinicians are logging in to the software so you can show accreditation agencies that your clinicians are using the data to inform clinical care. (Requires INSIGHT Addiction™ Pro)
• Encourages patients to respond to post-treatment follow-up surveys should you also be interested in using RECOVERY 20/20™ to prove your post-treatment success rate.
• Free training sessions for your clinical and data collection staff
• Free telephone and email support

INSIGHT Addiction™ provides all of this at a price that even the smallest treatment center can afford. You can check out INSIGHT’s and RECOVERY 20/20’s pricing at www.vista-research-group.com/pricing.

Getting started using INSIGHT and RECOVERY 20/20 is easy. First, to comply with HIPAA, we need to sign a Business Associate Agreement (BAA) in which Vista Research Group promises to keep your patients’ sensitive information confidential. Second, we need the names, titles and email addresses of all clinicians, managers and data collection staff who need access to the INSIGHT software.

The BAA agreement can be signed and the staff information submitted online. In many cases, we can have your software set up and a training held for your staff within a day or two so you can start collecting patient data almost immediately! However, please be aware that during extremely busy periods (such as the 4th quarter of 2017) we have had to implement a waiting list due to the number of new clients requesting onboarding at the same time, so please don’t wait until the last minute to sign up!

If you have questions or to schedule a demo, please call:
(833) 4-OUTCOMES