Yet very few scientific advances have translated into broad use – many prevention interventions, treatment practices and public policies are scientifically uninformed, out of date and costly. While research remains critical as the foundation for behavior change – it is clear that research by itself will not bring about that change. Broad change in public behavior with regard to substance use problems will require research combined with commerce and communication. Such a combination could create public awareness of and demand for science-informed alternatives to outdated practices and policies.
TRI’s unique mission is to develop tools that meet the needs of the many affected stakeholders; TRI strives to create research-based solutions to the multifaceted problems of substance abuse. It is our belief that science should drive improved policies and practices, but that science alone is not enough. To impact broad systemic change, science must be translated into practical solutions.
We call the practical tools, clinical practices and government policies that are derived from this translational engineering TRI Impact Solutions; and the following examples illustrate just a few project that are using research to make a difference.
Medical education has never included information or training about substance use disorders. Only one US medical school has a required course. This leaves physicians unable to identify, intervene, manage or medicate the 20% – 50% of their current patients who have substance use problems.
Among the more important adjuncts to course work in medical education are “medical cases” designed to illustrate the presentation, diagnosis and management of common, significant illnesses and conditions. There have never been standard cases illustrating clinical presentation and management of alcohol, opioid or marijuana problems. We are creating three such cases, which will be reviewed by a board of medical experts (from ASAM) and then distributed by a national company that now services 130 of the 164 US medical schools (approximately 15,000 students per year).
Working with a panel of 15 medical school deans and teaching faculty, we created a web-based course for second or third year students comprised of 14 video modules, each devoted to an important topic in alcohol and other substance use disorders. Each of these modules is presented by the topic expert and include engaging graphics and reference material. These modules can be used together as a course, or as stand-alone segments that are part of other medical courses.
Because most medical schools do not have faculty with this type of training, participating schools will “pay” for the course by sending a mid-career clinical faculty member to a one-week program at Betty Ford where they will receive in-depth, immersion exposure to all stages and clinical practices used in contemporary substance abuse treatment. This will help ensure the course fits into the rest of the medical school curriculum and students will have qualified mentors to guide their questions and further training.
This initiative will assimilate substance use disorder knowledge into healthcare. By educating the next generation of physicians on how to identify and treat emerging substance use disorders earlier in their course of education, this initiative will ultimately reduce the burden of disease, improve clinical outcomes and avert the enormous and unnecessary healthcare and social costs associated with substance use disorders.
With the implementation of the Affordable Care and the Mental Health Parity and Addiction Equity Acts, millions more Americans will be eligible for substance use disorder treatment. As the demand for services increases, there will be a greater expectation from payers that programs be able to demonstrate that the services they provide meet level of care criteria. The American Society of Addiction Medicine (ASAM) has developed the criteria for matching a patient’s clinical need with level of services at a treatment program, but there is not an existing, standardized approach to measuring the capacity in which care is delivered at the recommended criteria level necessary to meet patient needs. As such, payers currently have no objective way to assess whether a program has in place the services and staffing necessary to deliver a specific level of clinical care, much less a measurement of its quality. This can result in patients attending programs that do not actually meet their clinical needs, and insurers paying for a level of treatment that is not being provided.
States continue to look to the U.S. Centers for Medicaid and Medicare Services (CMS), the largest substance abuse treatment payer in this country (approximately 80% of the total costs), for solutions that will support quality improvement initiatives related to substance use disorders. With initial funding from the Scattergood and Open Society Foundations, the Treatment Research Institute (TRI) is working with CMS to develop a standardized, transportable and objective measurement process that will assess both the level of care-capacity and service components of licensed treatment programs. These specifications are imperative to creating a comprehensive means for assessing quality elements within the service specifications.
The proposed project has the capacity to immediately and significantly improve the quality of treatment and the services that are delivered and financed in this country. Until treatment is measured and assessed in an accurate and consistent manner, there will be little improvement to quality or outcomes. We believe that the development of a standardized level of care measure for the field of addiction will pave the way to major improvements in the way that substance use treatment is managed and financed, at a national level, and local state levels.
As the adolescent brain is still developing, the physiological and developmental impact of substance use has particularly substantial and potentially life-long consequences. Research has provided effective, practical prevention and early intervention services that have been demonstrated to reduce substance use and related harms – but there has been little effort to identify “at-risk” teen substance use at a time and in a place where these interventions could be most effective – during school.
Building from the Screening and Brief Intervention (SBI) research in medical settings, TRI has developed a standardized prevention and early intervention protocol, tailored to different school settings and to different age groups. This approach combines techniques used in adolescent risk assessment and public health messaging to create a combined prevention/early intervention program that is effective, sustainable and comports with student curricula and teaching operations. The program includes a web-based screening that is educational and motivational for all students regardless of their use. Motivational sessions for students who do not use are effective in strengthening positive decision making and private sessions with students who report use can be effective in reducing use. When identified use is severe, parents can be engaged and specialized care can be recommended. The program has been approved for Medicaid funding in most states and can be delivered at least annually throughout the middle and high school years.
Because school-based health counselors are truly on the front-line monitoring and protecting adolescents from substance use, they will now be armed with the training and protocols so they can effectively identify and decrease substance use. The financially self-sustaining program implies lasting impact and continuous influence. By allowing anonymous participation and unidentified students’ opportunities for face to face counseling sessions, more students will be willing to volunteer full and accurate reporting which increases the school’s success in prevention.
- Training and education around MAT best practices to jurisdictions and individual courts facilitates the process of integration.
- Enables states and jurisdictions to identify and address obstacles to program implementation and sustainability.
- Simultaneously assesses courts, treatment systems and client data to provide key guidance to states on effectiveness of the MAT program, both in terms of client outcomes and cost efficiencies.
- Supports ongoing best-practices within the individual courts by incorporating TRI research-derived case management tools
Current Sample Project
The Treatment Research Institute research team is currently conducting a state-wide evaluation on the effectiveness of providing MAT to opioid and/or alcohol dependent drug court participants in 13 counties throughout a large mid-western state. The primary goals of this evaluation are to examine the effectiveness of the MAT program on multi-dimensional client outcomes, assess the comparative effectiveness of the different medications, identify obstacles and barriers to program implementation and sustainability, and calculate the cost efficiency of the program.
- Supports federal funding mandate to offer MAT in drug courts.
- Effective utilization of MAT improves outcomes and reduces recidivism for substance-involved offenders.
Patients with opioid use disorders (OUD) often receive treatment in settings that are separate from the rest of medical care. This treatment often lacks key components of evidence-based care, and may not meet the needs of some patients.
TRI has designed a holistic, flexible and patient-centered approach to treating opioid use disorder – Personalized Addiction Treatment to Health Model (PATH) – which will be integrated it into existing primary care systems as part of a new study. With funding from the Patient-Centered Outcomes Research Institute (PCORI), TRI researchers will compare two options for OUD treatment. OUD patients from two large Federally Qualified Health Centers (FQHCs) in Philadelphia and two in Washington D.C. will receive either a standard care referral to local community programs, or the PATH program, with onsite, integrated OUD treatment.
Treatment will be provided by a specialized team and will include a menu of evidence-based practices: medication assisted treatment, relapse prevention, contingency management, and peer support. In both conditions, treatment will last for 1 year with research assessments at baseline and at 3, 6, 9, 12, 15, and 18 months. This project will determine whether a more holistic, flexible and patient-centered OUD treatment approach can be integrated in existing primary care systems, and whether that approach is more effective than standard care for OUDs.
The primary outcomes expected will be a reduction in opioid use and ongoing retention in OUD treatment. TRI will also measure other important outcomes important to patients including medical functioning, employment/educational attainment and engagement, a reduction in psychiatric distress/improvement in functioning, social engagement/positive quality of life outcomes, and HIV risk reduction.
This project will provide a personalized and comprehensive alternative to standard care for OUDs, and it will help patients make decisions about what type of OUD treatment will be most effective for them. It will be the first large-scale trial to compare a menu of evidence-based practices delivered in FQHCs against the standard care patients with OUDs typically receive. If the PATH intervention is found to be effective, it will improve access to care, help patients make informed healthcare decisions, and improve healthcare delivery and outcomes.
Recent data shows that nearly 20 percent of fee-for-service hospital patients are re-hospitalized within 30 days after discharge. Seventy-five percent of these rapid re-hospitalizations (RRH) are avoidable and responsible for $12 billion in excess healthcare costs. While many medical systems are rapidly evolving community disease management (CDM) strategies to help patients transition post-discharge and avoid re-hospitalization, many individuals with substance use disorders (SUDs) may not be well served by existing CDM programs because the interventions do not address their SUDs and associated problems such as mental illness, HIV infection, unstable housing, etc.
TRI and Temple University Hospital have developed and will test a patient-centered behavioral intervention for patients with SUDs who are ambivalent about addiction treatment or face significant barriers to engagement. The intervention focuses on continuity of care, reduction of substance use and engagement in addiction treatment after discharge from the hospital. The study will adapt evidence-based interventions into a specialized community disease management program and will provide evidence-based telephone continuing care, home visits, and increased focus on patients’ substance use. This project will adapt and design health education materials that address the health challenges and needs experienced by patients after hospital discharge.
This project provides an opportunity to demonstrate that flexible treatment for persons with substance use disorders integrated into medical care can improve the health outcomes and service utilization of addicted patients. By evaluating the effectiveness of this specialized community disease management program, there is potential for persons with substance use disorders to reduce substance use, increase engagement in addiction treatment, and reduce acute care service utilization (hospitalizations and emergency rooms). The project will aim to impact re-hospitalization rates for six-months, longer than the current CMS-designated 30 days.
With the passage and implementation of Healthcare Reform and Parity legislation, it is now possible to integrate substance use and mental health disorders into the rest of healthcare, to ensure that these illnesses are cared for at par with other medical disorders, and to improve outcomes for patients and society. With this, there is great need to provide states interested with the type of technical support needed to ensure accelerating the development and testing of Substance Use Disorder (SUD) service delivery innovations.
The Centers for Medicare and Medicaid Services (CMS) recently launched the Medicaid Innovation Accelerator Program (IAP) in an effort to improve health, health care and lower overall costs. The IAP consists of SUD and Integration cohorts. As a sub-contractor with Truven Health Analytics, the Treatment Research Institute will be working on the SUD cohort to help states introduce necessary policy and infrastructure changes to improve the care and outcomes for individuals with SUDs. States will be able to leverage IAP resources to introduce system reforms that better identify individuals with a SUD, expand coverage for effective SUD treatment, and enhance SUD practices delivered to beneficiaries.
The current effort is focused states who are increasingly responsible for implementing quality standards, as well as the financing and reimbursement of substance use disorder treatments.
Through tailored learning approaches, TRI will work with participating states throughout the year to support states to better use evidence-based benefit designs to improve care for individuals with SUDs; unified measures to learn, share lessons and drive quality improvements; and data analytics to size and identify solutions for pressing problems, such as high-cost populations and prescription drug use.
The work being carried out through the substance use disorder IAP will increase quality improvement, performance metrics, and implementation of integrated care. As states work to improve care for individuals with SUDs, it is our responsibility to provide them with the evidence-based practices, solutions and ample guidance to address these challenges; this program is important to address the direct needs and challenges states report as they work to reform their service delivery system to achieve better care for the SUD population.
For far too long, substance use and mental health disorders have been segregated from the rest of healthcare, at policy, programmatic and funding levels. This separation has resulted in consistently underfunded programs, lack of coordinated, evidence based treatment and relentless stigma. Those suffering from behavioral health disorders have essentially not had access to quality care across the course of their illnesses. And unlike other chronic diseases, there is currently no trusted resource of information for this type of care, creating significant barriers to accessing and advocating for improved care.
Like no other time in our history, we now have an enormous opportunity to significantly impact the way in which these illnesses are perceived and the way that treatment is designed, delivered and funded. The passage and implementation of Healthcare Reform and Parity legislation make it possible to finally integrate substance use and mental health disorders into the rest of healthcare, to ensure that these illnesses are cared for at par with other medical disorders, and to improve outcomes for patients and society.
In order to provide key information to all stakeholders about the way in which these critical regulations are interpreted, TRI will launch a comprehensive initiative to track, analyze and provide technical support on the implementation of new substance use and mental health policies and programs under the Affordable Care Act and Parity legislation. Our findings will be made widely available to the public through a variety of mechanisms, including an online tracking system and ‘report card’ publications. Patients, advocates, purchasers and policy-makers will have a comprehensive and dynamic source of data about how these regulations are being implemented. This initiative will include several major components:
- Tracking and publishing information about state-by-state implementation of Essential Health Benefits and Parity requirements for substance use and mental health disorders.
- Conducting high-level analyses of these findings relative to correlated data such as substance use and mental health claims data and hospital readmissions; as well as conducting economic analyses on related healthcare and social cost impacts.
- Provision of direct consultation and support to a number of states and/or health plans that have demonstrated interest in system-level change, and making the technical support tools publicly available and easily accessible to all states and health plans.
- Development of a Purchasers’ Institute on how to create a continuum of care model for SUD that complies with legislative regulations, that is efficient, effective and evidence-based.
Successful integration of treatment for mental health and substance abuse disorders into the overall system of healthcare is critical to achieving real cost-savings, improving care and changing the way that these disorders are perceived and managed within society. The interpretation and implementation of new substance use and mental health policies related to prevention, intervention and treatment will determine the scope and quality of services provided; the degree to which real cost-savings are achieved; and the potential to reduce the overall burden of disease on individuals and society.
As provisions to establish Patient Centered Medical Homes through the Affordable Care Act move ahead, the potential to change the way in which we treat alcohol and illicit drug misuse is great. As more treatment becomes available through a primary care setting, behavioral health counselors (BHCs) will increasingly be integrated into the healthcare model to screen, assess, and intervene as well as assist medical professionals in helping patients making important health changes, including use reduction of tobacco, alcohol, or illicit drugs. Because BHC interactions with patients are often briefer than other modalities of addiction treatment, there is a need for treatment and training resources that fit the condensed medical model and are appropriate for a primary care setting.
TRI has developed a BHC-friendly resource for patients to use as a self-guided tool or for use in tandem with clinical BHC contacts. The guide employs an innovative graphic novel approach to communicate important health information in a medium that is attractive to patients. The illustrated guide is solution-focused and encourages patient action through relatable character scenarios. It provides information, inspiration, and application strategies – offering motivational components followed by a preparation component as well as an action/quitting and maintenance component. This resource is intended to be used as a prevention and intervention method for patients who do not have severe substance use problems, yet could benefit from reducing their substance use or quitting all together. The guides have been distributed to 6 counselors and 150 outpatients as part of a larger clinical trial.
Self-guided resources provide accurate, multi-faceted assistance to patients who may have only one contact with a medical provider or BHC, and in that contact, must make some movement toward change. Through the use of relatable characters and accessible health education tools within the guide, there is a greater opportunity to integrate models of behavioral health care directly into primary care, help individuals alter unhealthy habits, and encourage patients to seek further alcohol or substance use treatment.
There is not enough adolescent substance use treatment available to meet the demand. Much of the existing care is age-inappropriate and antiquated, lacking in availability of evidence-based clinical practices. Perhaps worse, there are few market forces available that might enhance quantity and quality of services. In particular, there is very little objective, outcome-relevant information to guide parents on where to send their adolescent. It does not have to be this way.
The TRI Addiction Treatment Program Quality Assessment™ is a comprehensive review of individual treatment programs or full treatment networks. It assesses the degree to which programs are utilizing evidence-based approaches – those therapies and services shown to produce better outcomes. Results from the assessment offer clear, empirical guidance for both programs and payers on how to improve effectiveness and value of care. These results can be made available directly to referral sources, payers and the public at large to guide referral determinations, network inclusion planning and ongoing quality improvement initiatives.
Benefits to State Regulators and Inspectors
- Identifies clinical strengths but also areas where targeted training are needed.
- Allows state agencies to increase efficiency and impact by rewarding high quality programs with fewer site visits, allowing greater focus of training and quality improvement efforts on those programs most likely to benefit.
Benefit to Programs
- Creates a level playing field for programs, helps define and quantify “treatment quality”.
- Guides providers in how to increase their impact and value.
Benefit to the Public
- Quality improves only when both customer and provider understand the elements of quality care.
- Provides comparative quality information on treatment options to help parents and families find the kind of program that offers the highest quality care at the most affordable price.
Benefit to Payers
- A standardized assessment reduces subjectivity and challenge in quality and value estimates.
- Provides an empirical basis to incentivize value rather than just low price in provider inclusion and reimbursement determinations.