The delivery system approach presented in Table 5-2 is based on the committee’s operationalization of the CSAT principles.

Transitions to different levels of care are most successful when they occur between settings of care that employ similar philosophies and can transfer client records efficiently. A step down or step up in treatment intensity within the same program or through referral to a nonaffiliated provider can be disruptive for the patient and lead to dropping out of treatment (CSAT, 2006). Mee-Lee and Shulman (2003) suggest that an effective continuum of care successfully transitions the patient to the next level of care; successful transition is defined as the patient remaining engaged in treatment posttransition and not dropping out during the critical transition period. Transitioning to a different level of care also requires a clear delineation of the appropriate clinical characteristics of the patient to ensure that they match the new level of care.

Given that SUD is often a chronic illness, long-term monitoring supports maintenance of recovery (Dennis et al., 2003; McKay et al., 2005; Scott et al., 2005); however, research has not determined an optimal duration for long-term monitoring. An analysis of 1,271 admissions to a publicly funded treatment center found that 47 percent of the sample achieved 12 months of continuous sobriety within 3 years of entering the study (Dennis et al., 2005). The mean time from first treatment to last use was 9 years, and increased for men, individuals who began using at a younger age, and participants with comorbid mental illnesses (Dennis et al., 2005). On the other hand, physician assistance programs and other assistance programs for professionals often require 5 years of continuous monitoring ( McLellan et al., 2008). What is important is that treatment systems be structured to monitor a patient as long as possible and in the same objective manner as is applied to other chronic conditions. An ideal care delivery system is comprehensive and includes long-term services in addition to preventive services, community or workplace initiatives, primary care screening and brief interventions, and specialized treatment services (McLellan, 2002). In some systems, primary care physicians assume the role of screening, brief intervention, referral, and long-term monitoring of abstinence from substance use. In general medical practices, however, the engagement of primary care physicians in best-practice treatment for alcohol use disorders was found to be very low (rates of adherence to treatment guidelines were 10.5 percent for these disorders versus 57.7 percent for depression and 64.7 percent for hypertension) (McGlynn et al., 2003). Specialty programs therefore may need to assume the role and accountability for long-term recovery monitoring.

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