Chronic care and recovery management

DJ Mac posted a review of an article about applying a chronic care model to addiction treatment. The 6 elements identified in the article are:

1. Changing from acute and reactive care to preventative, continuing and patient-oriented practice.
2. Improving healthcare organisation support through investment in teams, information systems and outcome monitoring.
3. Expert-informed decision support for providers, given through training, facilitated expert consultation, standardised assessment tools and evidence-based treatment guidelines and algorithms.
4. Improved clinical information systems.
5. Fostering patient self management.
6. Linking people to community resources.

He listed them and included his reactions and assessments of how the U.K. systems measure up. We have a long way to go to apply this to addiction in the U.S.

Here are my reactions to them:

1. Changing from acute and reactive care to preventative, continuing and patient-oriented practice. The U.S. system is making some progress, but most treatment is still characterized by brief (sometimes high intensity) care during crises and insufficient long term care and support to maintain stable recovery. At Dawn Farm, we’ve managed to extend recovery support and monitoring to as long as 2.25 years.
2. Improving healthcare organisation support through investment in teams, information systems and outcome monitoring. Some very small steps have been taken here. We’re talking more about primary care integration. However, there is no real infrastructure to support information sharing and monitor outcomes. For about 2.5 years, Dawn Farm has been actively linking all residential clients with primary care settings that are aware of their addiction and have committed to recovery monitoring and support.
3. Expert-informed decision support for providers, given through training, facilitated expert consultation, standardised assessment tools and evidence-based treatment guidelines and algorithms. Considerable efforts are underway on this front. My concern is that all of these efforts are focused on the use of medications, some of which have shaky outcomes, others have strong evidence bases for reducing harm, but not for recovery. When we’re discussing a chronic illness that needs to be managed for decades, whose success will depend upon patient compliance, what about informed decision support for patients?
4. Improved clinical information systems. From my vantage point, I’ve seen public funding sources adopt/develop new information systems. Many providers are doing the same. However, it’s hard to say what the benefit has been.
5. Fostering patient self management. One of the strengths (and weak links, I suppose) of the traditional treatment system was it’s emphasis on recruiting patients into long term behavior change to manage their illness/recovery. We’ve had very limited success facilitating wellness-oriented behavior change in other chronic illnesses. The movement toward medication as the primary treatment tool is positioning patients as passive recipients of treatment.
6. Linking people to community resources. Again, this had been a strength of the traditional model–facilitating linkages to communities of recovery. However, the current trend appears to be focused on moving the locus of care and management to a physician’s office.

The American Journal of Lifestyle Medicine recently posted an article on the Promotion of Long-Term Adherence to a Healthy Lifestyle.

The writers reviewed what we know:

Currently researchers have identified efficacious interventions to address lifestyle behaviors underlying obesity that have demonstrated efficacy to promote and maintain weight loss for up to 8 years. However, these interventions are typically labor intensive for both the health care provider (HCP) and recipient . . .

. . . we know how to encourage adherence in order to promote weight loss maintenance in controlled research settings, but we lack evidence regarding practical ways to achieve long-term adherence in real-world settings. Specifically, it is of great importance to examine whether results from intensive research trials can be translated into clinical and community settings.

And, they reviewed some of the barriers to wider adoption of these behavioral strategies. The desire for “magic bullet” solutions is identified as one of the barriers to adherence with these lifestyle changes:

One barrier to achieving long-term results is the desire for a quick fix or “magic bullet” solution to obesity. If supply is any indication of demand, this phenomenon may be best illustrated by the large number of commercially available weight loss products and fad diets that guarantee to provide a quick fix. However, the weight loss results purported by these products and fad diets often do not have a scientific basis and their long-term effectiveness have not been documented. Achieving weight loss is a significant endeavor involving changes to diet and physical activity levels, daily routines, and social and educational support. These changes not only affect the patient but everyone in their support network. Patients seeking a magic bullet solution are often not willing to make these significant changes. As a HCP, it is important to identify when a patient appears to be seeking a magic bullet solution and counsel them that the treatment of obesity requires dedication on their part.20 However, once lifestyle transformation is achieved, the rewards can be meaningful and long-term.

I’m convinced that this is one important way in which addiction care and treatment for other chronic illnesses are very similar. We’ve gotten pretty good at medical interventions to manage the symptoms of a lot of chronic illnesses, but we’re pretty lousy at facilitating the behavioral strategies that would reduce symptoms, reduce vulnerability to other health problems and improve quality of life. And, our health care system is getting crushed under the burden of this chronic disease burden.

I hope that we come up with pharmacological interventions that facilitate full recovery from addiction. I also hope we don’t abandon lifestyle and behavior approaches that can put patients in the role of managing their illness and recovery.

Fortunately, someone has detailed a model to do just that.