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13 Implementing the Vision: Toward Treatment Systems To provide the reader with an overview of its conclusions on the treatment of alcohol problems, in the first chapter of this report the committee presented its perceptions about the probable form toward which the treatment effort is evolving. The preceding four chapters in this section of the report have discussed some important components of this proposed treatment system: the community share of treatment, which involves the identification of alcohol problems by community agencies, as well as dealing with them either by brief intervention and referral for specialized treatment; and the specialized treatment of alcohol problems, which involves the processes of comprehensive assessment, matching of individuals to the most appropriate treatment options, and determining the outcomes of the treatments provided. It is now time to revisit the structure that ensues when these components and others are combined into an integrated whole (Figure 13-1~. In this system, which was previously discussed in Chapter 1, a concerted effort is made by community agencies to identify all persons with alcohol problems by evaluating those individuals who come to their attention. (Some proportion of persons with alcohol problems will, of course, enter the treatment process after identifying themselves as having alcohol problems.) Those persons who are identified are dealt with through brief interventions provided by the various community agencies if their problems are mild or moderate or are referred for specialized treatment if their problems are substantial or severe. Those referred for specialized treatment are first provided with a comprehensive assessment that specifies in detail both their alcohol problems and those of their individual needs and characteristics that are treatment relevant. This information is then used to select the treatment that is most likely to facilitate a positive outcome. In moving between the elements of the specialized treatment sector, which is sometimes a difficult process for some individuals, provision is made for the assurance of continuity of care. Following the completion of treatment, the outcome achieved is monitored at regular intervals to determine whether it has been positive. This information is used both to reach a decision regarding future treatment of the individual and to provide guidance for the more precise matching of other individuals seeking treatment. What is outlined in Figure 13-1 and the accompanying text is simply an example of one possible systems approach. Systems designs often differ greatly in form, but they serve similar purposes. Fundamentally, they are carefully planned approaches for the efficient and cooperative solution of various problems. It is this generic approach that the committee frauds compelling, rather than any specific design, although the presence of certain elements is viewed as critical. Most of the elements have been developed at length in their own chapters; the system is simply a way of linking the elements together into a coherent whole. There are parallels in the development of the computer chip, also by definition a system, in which the principal innovation was the inclusion of the links between elements as an integral element (Reid, 1984~. To components of the committee's proposed system for treating alcohol problems still require consideration here: the assurance of continuity of care and the feedback of outcome information. They are discussed below as a preface to an audit of the implementation and evaluation of such systems. 329

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330 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS Assuring Continuity of Care Care is appropriately provided for those who require it because they have problems of various kinds. On account of these problems, as well as for other reasons (for example, Community Treatment of Alcohol Problems Health Care Identification _ _ _ _ _ _ _ _ _ _ Brie! Int`!rvention octal Servic Identificatio Brief Intervention Workplace 1 dentirication Brief Intervention . . Other. dentitication l Brief Intervention *Other=Education, Criminal Justice, etc. Specialist Treatment of Alcohol Problems ( Continuity of Care ) Comprehensive Assessment Feedback F l 1 o or u p o r 0 u t c 0 m e . ~ | Type "a" l | Intervention |- Type "B" Intervention _ Type "C" _ intervention Type "D" intervention _ \ | Type "X" L intervention _ FIGURE 13-1 The committee's view of the evolving treatment system. All persons seeking services from community agencies are screened for alcohol problems. A brief intervention is provided by agency personnel for persons with mild or moderate problems. Persons with substantial or severe problems are referred for a specialized comprehensive assessment. Where treatment is indicated, they are matched to the most appropriate specialized type of intervention. The outcome of treatment is determined and feedback of outcome information is used to improve the matching Guidelines. Continuitv of care is provided as required to guide individuals through the treatment system. because of personal characteristics and attributes such as diminished capacity to understand, impaired sensory functioning, and so forth), some persons will require guidance through the process of care in order to engage it effectively. The need for such guidance is neither a new concept nor one uniquely related to alcohol problems; it has been claimed that all societies have created functionaries Who can listen, clarify needs, provide responses, and who will bear the responsibility for the continuity of care" (Parker, 1974:16~. Terminology has flourished in the area of continuity assurance, which creates some difficulties for the present discussion. Case manager" has been most frequently used to refer to those who provide continuity assurance. Other terms enjoying some frequency of use include primary care worker, indigenous paraprofessional, mental health expediter, integrator, broker, ombudsman, advocate, patient representative, personal program coordinator, systems agent, continuity agent, clinical secretary, and (in one extremely large individual program offering multiple services) personal services shopper (cf. Intagliata,

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IMPLEMENTING THE VISION: TOWARD TREATMENT SYSTEMS 331 1982~. These differing terms may be understood to designate the same individual perform- ing similar functions, but the various terms give particular emphasis to one among the many possible functions that may accrue to the role. What makes Case managers problematic for the committee in the current discussion is the association of that term with managed care in the treatment of alcohol problems (Korcok, 1988; Lewis, 1988~. The committee believes that the term has become linked to the notion of making decisions regarding care with a principal regard to cost savings. It is aware that distinctions have been made between Financial case management" and Clinical case management," but it prefers in this discussion to avoid the use of the term altogether. The committee's concept of continuity assurance is not tied to notions of cost containment, although savings may, indeed, be effected. In what follows, then, reference will simply be made to "the person who assures continuity of care, except in cases in which direct quotation of other sources involves alternative designations. Discussions of continuity assurance in the literature are characteristically framed in terms of the individuals designated to fulfill this function. Although the discussion in this chapter will follow suit, it is worth noting that alternative strategies are available. One is to design the treatment system in such a way that the system itself, rather than specific individuals within it, provides for the assurance of continuity. For example, highly structured interrelationships among components of the system could serve this purpose. Another approach is to make the individual seeking treatment responsible for the continuity of care. The committee considers any or all of these to be effective strategies in particular circumstances. lhe crucial matter is that continuity of care be assured; how this is accomplished Is of secondary importance. However, because the most prevalent approach is to assign the role of continuity assurance to an individual or individuals, the committee's discussion will continue in this vein. In recent years the provision of continuity assurance has received increased emphasis because of the growth in size and complexity of treatment services. It is a practice that is more common in areas other than the treatment of alcohol problems for example, in the treatment of the chronically mentally ill, in which it has attained great importance in the wake of deinstitutionalization initiatives. There are many definitions of the function, but Their common theme suggests that case management is a process or method for ensuring that consumers are provided with whatever services they need in a coordinated, effective, and efficient manner" (Intagliata, 1982:657~. The same authority goes on to say that The specific meaning of case management . . . depends upon the system that is developed to provide its (p. 657~. There are some examples of continuity assurance in the treatment of alcohol problems. The role of the AA sponsor comes to mind (although this role, as with other examples, tends to serve more than continuity assurance functions). For many years the Donwood Institute in Toronto, a treatment facility for alcohol and drug problems, made use of "clinical secretaries, lay persons who served continuity assurance and other functions for small groups of individuals in treatment; regrettably, there appears to be no published record of this experience. One of the functions of the primary care workers in the Core-Shell Treatment System Project at the Addiction Research Foundation was continuity assurance (Glaser, 1984; Pearlman, 1984a, by. It is likely that there are other examples of personnel who serve the function of continuity assurance in treatment for alcohol problems that have not come to the notice of the committee, but it can probably be said with confidence that the practice has not been widespread. Other elements of the system, such as assessment, matching, treatment, and the determination of outcome, can be viewed as the vertical components of care; they occur in more or less serial order and are time limited. Continuity assurance is the horizontal element in the system, cutting across the other elements and providing a coherent experience for the individual. The continuity assurance role is usually played by the same

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332 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS person during a given episode of care and ideally thereafter; should a problem develop again after an episode of care has been concluded, the person who provided continuity assurance is the logical point of recontact. A common example will perhaps help to bring home the importance of designating a specific individual as responsible for continuity of care. Following the completion of a period of inpatient care, it is common to refer many persons to outpatient care. Let us suppose, however, that the referred person does not keep the first outpatient appointment. Under such circumstances, continuity of care can fall victim to a disjuncture in the treatment system. The inpatient service has discharged its responsibility by making the referral and therefore has no sense of responsibility for the individual's care. The outpatient service has not seen the individual and therefore has no sense of responsibility for his or her care. Thus, no one is responsible for continuity assurance, and the individual may be lost to care. If, however, responsibility for continuity of care is a specifically designated function-if some particular staff person is responsible for it it is that person's job to bridge the gap and reestablish the thread of continuity. Although many professional persons and such highly trained nonprofessional persons such as counselors could carry out the role well, an additional and perhaps more suitable source of personnel to assume the continuity assurance function may be the lay public. Those with extensive training might more appropriately occupy the formal thera- peutic roles in the system. Assigning the continuity assurance function to lay persons does not gainsay the need for careful selection, training, and supervision, as in any role that has responsibility for the care of others. Yet the literature on continuity assurance stresses the importance of the personal qualities of those who assume this function. Consider the following list of attributes that are desirable for a Primary care workers (slightly modified from Pearlman, 1984a): 2. 5. 6. 7. 8. 9. 10. 11. 12. 14. perseverance-an ability to follow through; comfort in working with difficult, marginally motivated patients; knowledge about and comfort in a supportive counseling role; knowledge about community resources; comfort in working in a secondary capacity with other treatment staff; relative ease in handling crises; an ability to relate to and cope with many people and problems simultaneously; thoroughness, organization and responsibility in the area of recordkeeping; willingness to get involved in a relatively unstructured and evolving work role; flexibility in terms of relating differentially to patients in a less formal, structured manner than is characteristic of psychotherapy; patience and a sense of humor; some knowledge of alcohol and drug dependency and the pharmacology of alcohol and drug abuse; an ability to formulate and sustain realistic expectations for self and patient; and ease in shifting among the various roles and functions inherent in the primary care role-counselor, ombudsman, facilitator, problems solver, and coordinator. These are largely personal characteristics. They tend to be present in a given individual independently of the professional training he or she may have received, or perhaps even in spite of it (Becker et al., 1961; Shem, 1978; LeBaron, 1981~. The literature on the effectiveness of nonprofessional therapists supports the presence in lay people of

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IMPLEMENTING ITIE VISION: TOWARD TREATMENT SYSTEMS Aim interpersonal characteristics favorable to positive therapeutic outcomes (Carkhuff, 1968; Lynch et al., 1968; Bergin, 1971; Emrick et al., 1978~. The foregoing should not be read as a brief against professional therapists. Continuity assurance is not in itself therapy. It might be said that therapeutic effects ensue from the efforts of those who provide continuity assurance, but are not pursued by them. That is, they provide continuity of care as an essential component of treatment in its own right and not because it may have a therapeutic effect which it sometimes does. Those who assure continuity primarily facilitate the therapeutic efforts of the system as a whole, and therefore are a key element in whatever success the system may have. Research on the impact of continuity assurance has been limited to the study of case management in the aftercare of the chronically mentally ill. One review noted mixed results: some studies had positive outcomes while others showed no significant addition to outcome over customary mental health altercate services (Anthony et al., 1988~. However, a recent study in which individuals who received case management were compared to matched controls found that the case managed individuals exhibited better occupational functioning, improved living conditions, and were less socially isolated (Goering et al., 1988~. Certainly, further research is needed on this important function. Indeed, the whole area of what happens following the initial treatment effort with the individual is one that requires much further investigation (cf. Moos et al., 1988; Moos et al., 1990~. For example, two studies have already suggested that matching individuals to the appropriate inter- vention approach in this phase of their treatment is associated with more positive outcomes (McLachlan, 1972, 1974; Kadden et al., 1989~. With the further development of relapse prevention techniques a variety of highly suitable approaches for this crucial phase of treatment are becoming available (Marlatt and Gordon, 1985; Annis, 1986~. Nevertheless, the committee believes that, attract for some persona, continui~assurar~ce is a pressing and immediate requirement tam should be acted union' forthwith. As services in general increase in number and complexity, the need will be even greater. There are already a variety of implementation strategies, as has been discussed above. Practical and theoretical advantages may be found for all of these options. That the function be available to those who need it is the crucial consideration. Feedback of Outcome Information Feedback may be defined as the use of information to modify the system that gathered the information. Provision for feedback makes a system self-reflecting and greatly increases its options (Hofstadter, 1979~. Where it is present in biological systems, it facilitates their ongoing adaptation to current reality (Young, 1957~; what has happened is taken into consideration, and future action is directed accordingly. All too frequently a particular treatment is provided repeatedly without knowledge of its effects. For example, the antialcohol drug disulfiram (Antabuse) has enjoyed widespread general use in the treatment of alcohol problems since its introduction into clinical use more than 40 years ago (Hald and Jacobsen, 1948~. Only recently have the results that accrue to its use been definitively examined in a large-scale investigation (Fuller et al., 1986~. Those results suggest a much more discriminate and selective use of the drug than has often obtained in the past. It is good to have this information, but it would have been preferable to have it within a shorter time frame. Feedback has eventually occurred but has been much delayed. The feedback that the committee sees as an integral part of the proposed treatment system is the feedback of outcome results in order to modify guidelines for matching persons to treatments. Simply put, if a particular set of matching guidelines is not

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334 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS productive of a reasonable level of positive outcomes, that information should be available within a reasonable time frame and should lead to a modification and retesting of those guidelines. Nor does the committee foresee a time when this process will not be necessary and when matching guidelines can be permitted to go untested by outcome results. There is too much change in too many of the key parameters of treatment on too regular a basis to assume that the guidelines will remain optimal for a prolonged period (cf. McLellan et al., 1983a). Rather, they must be tested constantly against the realities of outcome and readjusted frequently according to what is learned. Active feedback of this kind permits the responsible evaluation of matching guidelines within standard clinical settings and within a shorter time frame than is possible using more rigorous methodologies-for example, the randomized controlled trial. RCIs have an important role to play in the evaluation of treatment, but so, too, do observational outcome studies of the kind the committee envisions as informing this sort of feedback (cf. Chapters 5 and 12; GelIjns, 1989; Greenfield, 1989~. More of both are required, but outcome monitoring is more congruent with the circumstances of clinical treatment than is the conduct of RCIs. Outcome monitoring is also able to focus much more precisely on particular treatment programs, which is very much to the point. Over the longer term there is another use to which the feedback of outcome information can be put. It may happen that, however creatively matching guidelines are modified during several iterations of the modification process, some proportion of individuals seeking treatment may persistently fail to achieve positive outcomes. These failures may signify a gap in treatment services; that is, some treatment that is not currently being provided may be necessary for a particular subgroup of the population being served. Given, however, the existence of the feedback loop that facilitated this conclusion, a new treatment can be identified, set in place, and evaluated in the same manner as already described. Thus, the successful closure of potential gaps in treatment services is another possible benefit of feedback. Finally, it is worth stressing that generating outcome data is one thing, but using it to provide feedback is something else again. The first is a precondition to the second-outcomes that are not known cannot be used to provide feedback- but feedback does not necessarily occur simply because the results of treatment are available. Effort, planning, and vigilance will be required to ensure that outcome information is developed and is actually used to modify the functioning of treatment. Feedback will not happen automatically. An Audit of the Systems Approach The committee has now identified and described the key components of its proposed treatment system. To summarize briefly, they include (in addition, of course, to the availability of a reasonable number of alternative treatments) a community component, consisting of identification followed by brief intervention or referral for specialized treatment; and a specialized treatment component, consisting of comprehensive pre- treatment assessment, matching to a variety of treatment options, assurance of continuity of care, determination of outcome, and the effective feedback of outcome information. It now seems in order to audit the degree to which the system has been implemented in practice, and the existing evidence that, taken as a whole, it works. As a preface to the audit, it is worth noting that there are considerable practical difficulties in implementing a systems approach. Most treatment programs do not offer more than a single treatment option (cf. Glaser et al., 1978~. Perhaps because in the absence of treatment alternatives there seems little reason for it, neither do most offer the kind of comprehensive assessment discussed in this report. Even if they did, the assessment

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IMPLEMENTING THE VISION: TOWARD TREATMENT SYSTEMS 335 could not be carried out prior to a commitment to a particular kind of treatment; where only one treatment option is available, admission to the program entails a commitment to that treatment. With only a single treatment option, matching cannot be carried out, as it requires the availability of multiple treatment options. Although external referral could serve the purpose of matching, it is rare in practice (Pattison, 1974; Glaser et al., 1978) and in a fee-for-service system there are financial incentives against it. Finally, few treatment programs engage in comprehensive outcome monitoring, and without monitoring there can be no feedback. Reasoning from this perspective, it is unreasonable to expect more than a few examples of the implementation of a systems approach. On the other hand, the organization of activities into planned systems to achieve particular goals in an efficient and effective manner, as an alternative to independent activity at multiple sites, has a long history. An early example was the rapid re-outfitting of Admiral Nelson's fleet during the Napoleonic wars. Pulley-blocks were the problem. They were traditionally made, very well but very slowly, by individual craftsmen. Under the supervision of the engineers Sir M. I. Brunei (1769-1849) and H. Maudslay (1771-1831), the work was systematically organized, and the blocks were produced very well, very rapidly, and in large numbers. The improved condition of the fleet was a major factor in the victory at Trafalgar in 1805. The integration of the Assessment devices" of the newly developed radar and ground observers with a central command structure and multiple ~interventions" (e.g., antiaircraft defenses and the many fighter squadrons) was essential to victory in the Battle of Britain in September, 1940. Out of this and other wartime experiences evolved operations research, the beginning of the formal study and application of systems approaches (Miser, 1980~. To date the adoption of systems approaches has been widespread in health care generally (cf. Van Eimeren and Kopcke, 1979; Tilquin, 1981~. From this historical perspective, then, there might be some reason to expect the applica- tion of systems approaches in the treatment of alcohol problems. In searching the literature, the committee has concluded that both of its presumptions are correct. The components of the proposed system are not represented in most treatment that is currently provided for alcohol problems. On the other hand, there are a number of examples in which one or more of the components are represented in programs that have existed, are currently viable, or are planned for the future. It is unlikely that all such programs have come to the committee's attention; and with some that have, the information is less complete than might be hoped. Bearing these cautions in mind, Table 13-1 summarizes this information by indicating those components of the system that are represented in particular treatment efforts. Description of the Table To facilitate an understanding of the table, the committee briefly discusses each of the individual examples offered. It should be understood that the designations in the table are often arbitrary because information on a number of the examples is incomplete or dated or both, and that the exercise is intended to be illustrative rather than definitive. The following section discusses the conclusions that arise from the table as a whole. Oklahoma State System This system is basically for outcome monitoring, and was discussed earlier (see page 315; see also Paredes et al., 1981~. The system collects initial data on individuals, but the data are gathered after admission to treatment programs and are not used to determine which treatment is to be delivered. Outcome determinations are made on a systematic sample of individuals admitted to treatment.

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336 Ct .c o Hi . a a - o to o - E Ct s - o - J:: Cal do Q. Q. U) E :~` - o - ._ o C) Ct ID C: o ._ - _ ._ o ~ _ _ O ~ 3 ~ :' ~ : Ct . - .~ C: ~ ~ E a an A: a OF ~ C) Ct A_ ~- a ~ Ct - vat a ~a _ Cal t3., Cal Cal Cal ~ o . Cal ~ a At: ~ ~ 0 of ^: =~ Q ~0 - a ~ iU - ~0 ~- C~- ~ g o ~E . _ ~ a E ._ s - ct c' .7 .~ ct - - o .~ - 0 _ Z _' 43.) c' co D C: ~ O V) - ~: ._ _ O <; ~: S O O Z ~ G C C 5) o G 11 X a~ ~C o Q. a - a . . - V) - 5 G C~ ~11 . . o z

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IMPLEMENTING THE VISION: TOWARD TREAI~IENT SYSTEMS 2 ~ 7 Ontario Assessment and Referral System In this system of multiple independent assessment and referral programs, a pretreatment assessment is carried out, and the data are used to match individuals seeking treatment to the most appropriate programs (see pages 265-266; see also Marshman et al., 1978; Ogborne et al., 1984; Malta et al., 1985; Rush, 1988~. Other components of the committee's system have not been a planned part of this approach. Although there is an extensive program of prevention activities in the province, they do not appear to be explicitly connected with the assessment and referral system. Brookffeld Clinics A private treatment program operating at multiple sites in Michigan and Ohio, the Brookfield Clinics have adapted practices of the core-~ne~ Treatment System Project (see the discussion below) to their operations (MacDonnell, 1981a,b; O'Dwyer, 1984, n.d.~. They provide an individualized pretreatment assessment that is used to match individuals to very carefully specified treatments by using explicit guidelines. Continuity assurance is also provided. Chemical Abuse/Addiction Treatment Outcome Registry (CATOR) CATOR is a private St. Paul-based program that provides outcome monitoring (see page 316; Harrison and Belille, 1987; Harrison and Hoffmann, 1987; Harrison and Hoffmann, 1988~. It was also the primary contractor in the development of the so-called Cleveland criteria, which are designed to match individuals to various "levels of care" (see pages 289, 303-312; see also Hoffmann et al., 1987~. In addition to outcome determination, CATOR provides feedback on this information to its subscribers, but whether it is used to modify the operations of those subscribers (an integral part of the definition of feedback) is uncertain. Although in the course of its usual operations CATOR, like the Oklahoma State system, obtains staff-generated information on individuals after admission to treatment, the Cleve- land criteria are clearly intended to be used prior to treatment and to match individuals to the appropriate "level of care." Minnesota State System In the state of Minnesota the legislature has mandated a pretreatment assessment to determine the appropriate treatment setting through matching guidelines that are required by law and specified in explicit regulations (see Chapter 10~. Yet whether this pretreatment assessment can accurately be described as comprehensive is questionable. Although the gathering of additional information on individuals entering treatment is also mandated (through the state's own Drug and Alcohol Abuse Normative Evaluation System [DAANES] or an acceptable equivalent), this additional information is not at present used in matching. Determining the outcome of treatment is also mandated, and staff of the state program have begun to use this information to examine the state's matching guidelines. Managed care systems A feature of recent years has been the growth of managed care in the treatment of alcohol problems (Korcok, 1988; Lewis, 1988) as well as in medical treatment generally. The data presented in the table are based on an imaginary composite of such programs and must be considered only approximate, as managed care programs vary a good deal. Almost all provide a pretreatment assessment of some sort and use this information to place individuals seeking treatment; however, the information gathering often cannot be realistically described as comprehensive. Monitoring of the individual's status while in treatment and afterwards is a reasonably consistent features of these programs. Penn-VA Project Investigators in this research project, conducted jointly at the University of Pennsylvania and the Philadelphia and Coatesville Veterans Administration Hospitals. first described a system of care involving many of the components of the . rid ~ ~ -.. . . _. committee's vision (McLellan et al., 1980b). They then conducted a prospective study using the system in which the outcomes of those matched to treatment and those not matched were compared (McLellan et al., 1983a; see also below). A particular feature of this series of exercises was their stress on the use of feedback data to modify matching guidelines. The investigators continue to examine issues related to assessment and matching on a

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338 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS research basis; it is uncertain whether the program is used in either setting as a basis for routine clinical operations. National Collaborative Matching Project Recently announced by the Treatment Research Branch of the National Institute on Alcohol Abuse and Alcoholism (RFA AA-89-02A and AA AA-89-02B), this project will set up multiple clinical research units and a coordinating unit to conduct "multisite trials of patient-treatment matching." In these studies, individuals seeking treatment will be assessed on relevant variables, randomly assigned to treatment conditions, and be followed up to determine the outcomes of treatment. The purpose of these studies is to test matching guidelines that may subsequently be utilized by other treatment programs. They are expected to be completed in approximately five years, that is, in approximately mid-1994. The Core-Shell Treatment System Project During the period 1975-1981 a model treatment system was evaluated in the Clinical Institute of the Addiction Research Foundation in Toronto (Glaser et al., 1984~. Persons seeking treatment were given a lengthy and uniform pretreatment assessment in a discrete assessment unit; they were then assigned to treatment through a detailed set of explicit matching guidelines. Continuity assurance was the responsibility of the Primary Care Unit. Determination of treatment outcomes for the clinical population and the use of this information to modify the matching guidelines were a prominent part of the plans for this project but were not implemented. Northern Addictions Centre Some years ago the Alberta Alcoholism and Drug Abuse Commission (AADAC) prepared plans for an adaptation of the Core-Shell treatment system model to be located in Grande Prairie, a rural setting (Bazant, n.d.; Glaser and Hubbard, 1985; Skirrow, 1986~. Its original implementation was delayed by an economic recession, but the project was reactivated recently and is expected to receive persons seeking treatment in its specially designed facility within two years. Pretreatment assessment, matching to a variety of interventions, continuity assurance, outcome determination, and modification of matching guidelines through feedback are planned. Although prevention activities for the region are to be carried out by an office located in the same facility, no specific connection between the prevention and treatment activities has been articulated. Regional Youth Substance Abuse Project A United Way program located in Bridgeport, Connecticut, this project recently received a grant from the Robert Wood Johnson Foundation to set up the Youth Evaluation Service (YES) in cooperation with the Alcohol Research Center at the University of Connecticut (Babor and Del Boca, 1988~. Focusing on adolescent problem drinkers and drug abusers, the program includes the following components: (1) a community action component that is concerned with access to treatment, availability of services, integration of services, and identification of high risk youth; (2) comprehensive pretreatment assessment using standardized questionnaires, structured interviews, and laboratory tests; (3) a rational treatment matching strategy that presents the individual with a long-term treatment plan and referral options; (4) continuity assurance guaranteed by a case manager who follows the individual for up to 18 months; (5) outcome monitoring by an independent university research center; and (6) feedback of outcome and process evaluations to improve treatment response. Although composers of the committee's system are not at present to be found in most treatment sewage, there are (or have beef a number of settings in which they have been present to a variable degree. The data in the table represent a conservative estimate; there are probably other relevant programs that are not listed of which the committee is unaware. Also, some that are known are not listed; for example, a system with many of the proposed components has been proposed for the state of Michigan (Alto et al., 1988), but is not included because its implementation at present is uncertain. Of the proposed components only one program, the Regional Youth Substance Abuse Project, which is planned for the future, embodied all six components (it was the only one to have a community component similar to that envisioned by the committee).

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IMPLEMENTING THE VISION: TOWARD TREATMENT SYSTEMS 339 The community component and the continuity assurance component were the two elements least in evidence in the examples discussed. Comprehensive pretreatment assessment, matching, and outcome determination were most frequently present in these examples. Feedback occupied a middle ground, and was more often planned than implemented. Evaluation of the Systems Approach It is reasonable to ask for evidence that the approach embodied in the committee's perception of the future is valid, that is, that it will improve outcomes following treatment compared with possible alternative approaches. The comparative effectiveness of most of the implemented programs in Table 13-11 has not at this writing been evaluated. The National Collaborative Matching Project offers the possibility of comparing the outcomes of those who are and are not matched to treatment on relevant variables. The Northern Additions Centre and the Regional Youth Substance Abuse Project will determine outcomes in individual cases; however, a comparison with alternative approaches is not contemplated in either project at present. Because the Penn-VA project was a prospective study of the effectiveness of an approach resembling that of the committee, a brief summary of it seems in order. Four hundred seventy-six male veterans were assessed prior to treatment using the Addiction Severity Index (ASI) (McLellan et al., 1980a; McLellan et al., 1985~; 178 are described as alcohol dependent and 298 as drug dependent. Previous work with the ASI had suggested that its scale for rating the severity of psychiatric symptomatology was predictive of outcome in various kinds of treatment. Together with other data, this information was used to construct explicit "program assignment decision criteria" for the alcohol-dependent and the drug-dependent groups. Because the construction of these criteria was based on the known outcomes of persons fully characterized prior to treatment, the criteria used in the study are a product of feedback. Although an attempt was made to match all patients to treatment using these criteria, only 62 percent of the alcohol dependent and 48 percent of the drug dependent patients could be so matched, due largely to such practical matters as lack of treatment slots in the appropriate settings. Treatment staff were blinded to whether a given individual had been appropriately matched. Outcome data were collected on all patients six months after their admission to treatment. For the patients who were dependent on alcohol, 17 of the 19 dimensions on which their outcomes were compared showed better outcome status in the matched patients; 8 such comparisons achieved statistical signifi- cance. The authors stated their belief that Our ongoing 'matching' strategy will continue to be helpful in optimizing outcome" (McLellan et al., 1983a:604~. Yet a number of methodological shortcomings, pointed out by the authors themselves, constrain the conclusions that can be drawn from this study. Assignment to treatment was not random, although multivariate statistical techniques were employed in an attempt to equate the two comparison groups on initial characteristics. The follow-up period was brief and differed for different individuals. Nevertheless, this was a large-scale, creative study. The results are consistent with the potential effectiveness of treatment conducted along the lines envisioned by the committee. There have been other prospective studies of matching of persons with alcohol problems to treatment (see Table 11-1) that have produced positive results. Although not in the area of alcohol treatment, a study of a geriatric assessment unit (GEU) in a VA Hospital in California met methodological criteria similar to those used in screening for the table and produced similarly positive results (Rubenstein et al., 19844. Thus, there is some if not an inordinate amount of evidence for the efficacy of the approach envisioned by the

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340 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS committee. Additional evidence is likely to come from at least one of the major projects planned for the future, the National Collaborative Study on Matching. More evidence would be welcome indeed. Perhaps those responsible for similar projects (e.g., the Northern Treatment Centre and the Regional Youth Substance Abuse Project) will be able to work out ways of including comparative efficacy considerations within their scope of work. Little else is on the horizon. Unfortunately, health services research, the name given to the kind of research aimed at studying questions of this kind, is not currently considered to be of unusual urgency; At the present time, research on alcohol service systems receives a relatively low priority within the Federal Government and in the alcoholism field generally" (Wallen, 1988:605~. Conclusions and Recommendations The committee views the treatment of alcohol problems as evolving toward a system in which an active component of care undertaken by community agencies and consisting of identification, brief intervention, and referral is closely coupled with a specialized treatment sector that includes a comprehensive pretreatment assessment, the matching of individuals to a variety of treatment interventions, the assurance of continuity of care, the regular determination of outcome, and the feedback of outcome information. Many of the components of this system have been separately deployed and tested. The results have been documented in this section of the report and have generally been positive. The committee recognizes the need for a further deployment and evaluation of these individual components of the system. It also recognizes that some work has already been done (Table 13-1) in bringing combinations of these components together. The committee lauds such efforts but believes that they have been too few and far between. It concludes that what is row most rzeeded Is a major initiative to combine these separate components into fulb integrated treaimer~t systems of the sort envisioned in this report and to conduct careful and complete process and outcome evaluations of these model systems. It is likely, and desirable, that alternative versions of such a systems approach should be mounted in a variety of different settings and directed at diverse populations-for example, with medically indigent persons in a public treatment system, with insured persons in a proprietary treatment system, and with particular subgroups such as those discussed in the next section of this report. Ideally, outcomes obtained through the treatment system would be rigorously compared with outcomes obtained through nonsystematic treatment. A purpose of this series of demonstration projects would be to define effective models that could be transferred to the treatment field in general; they would also provide timely evaluation data to guide the formulation of treatment policy. Funds should be made available through public or private sources, or through a combination of sources, sufficient to support a minimum of four to five such demonstrations. Previous and current efforts, such as those discussed in this chapter, could serve as prototypes for these projects. The committee recognizes that this is both a major and a novel undertaking, even though its continuity with the current thrust in the field is quite clear. It is a formidable task. But an undertaking of appropriate magnitude is required if the challenge of alcohol problems is to be met. There is also the promise that what is learned may be useful in advancing the ability of our society to cope with the many other health problems with which it is faced.

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