Can specially trained community and recovery support specialists improve linkage to post-detoxification care?

Inpatient detoxification (“detox”) provides medical stabilization but is not considered treatment for substance use disorder. Initiating recovery often requires follow up treatment after a detoxification episode; however, the majority of patients leaving detox do not pursue recommended care, thus increasing risk for future detox readmissions, poorer recovery outcomes, and death. To help overcome this, researchers developed, implemented, and evaluated a recovery support navigation intervention designed to link individuals to care following discharge from inpatient detox. 

WHAT PROBLEM DOES THIS STUDY ADDRESS?

Inpatient detox provides medical stabilization and withdrawal management to help initiate recovery among patients with substance use disorder and may be an important access point for linkage to ongoing treatment. Treatment after detox is recommended and has been shown to improve long term recovery outcomes, particularly among patients who engage in treatment within two weeks of discharge. Unfortunately, the majority of patients who receive detox services do not attend follow up treatment, which increases rates of costly and ineffective detox readmissions. To address this “revolving door” issue, the authors of this study used “recovery support navigators”, who were individuals trained and tasked with facilitating follow up care for patients following discharge from inpatient detox.

Figure 1.

HOW WAS THIS STUDY CONDUCTED?

This quasi-experimental study used Massachusetts Behavioral Health Partnership and MassHealth general medical care administrative data to examine whether individuals receiving a novel, recovery support navigation intervention were more likely to receive treatment within 14 days of detox charge relative to those who receives detox services as usual.

For this study, recovery support navigators at select sites were used and outcomes of patients at these sites were compared to outcomes of patients at other sites that offered services as usual. Recovery support navigators included a collection of new staff or existing staff from the Community Support Program (CSP). Recovery support navigators, some of which were identified as “peers” but not all, received training in Motivational Interviewing, received monthly coaching and quarterly education regarding substance use disorder, and received training in Brief Negotiated Interview and Active Referral to Treatment. Some, but not all, of the Recovery Support Navigators had lived addiction experience, were in recovery, but this was not required.

Patients in the dataset who received detox services between March 29, 2013 and March 31, 2015, were between 18 and 64, and had at least 1 prior detox admission in the 12 months before the index detox episode were included in analyses. For this study, all detox providers in the state of Massachusetts were included, with the 4 largest sites assigned to the recovery support navigator condition, in order to focus intervention and resources on fewer sites albeit high volume sites (approx. half of total patients included), and to ensure intervention fidelity. The other 9 sites were designated to provide services as usual. Patients in sites offering services as usual were provided support and referrals from community support program staff on a fee-for-service basis (i.e., case management, community resources including food, housing, transportation, self-help groups). Community support program staff in the recovery support navigator condition were trained in Motivational Interviewing and other specialized aspects of substance use disorder care. They also provided continuous wrap-around support to facilitate post-detox link to care and provided Medicaid-billable services on a daily case rate, rather than as fee-for-service, to provide care as needed based on patient needs.

The primary outcome was whether or not patients received any substance use disorder (SUD) treatment with 14 days of discharge from inpatient detox. Eligible SUD services for a successful linkage included inpatient hospitalization, residential treatment, intensive outpatient treatment, or outpatient care. When comparing the intervention to services as usual, authors statistically controlled for a number of individual variables (e.g., age, gender, psychiatric diagnosis) as well as program variables (e.g., percentage of patients in the clinic who were women, nondisabled, on Medicaid Basic, enrolled in Medicaid for less than a year, and who had a psychiatric diagnosis), to try and isolate any independent effect of adding the navigator intervention approach to services as usual.

Patients included were between 18 and 64 who were enrolled in the Massachusetts’ Medicaid Programs’ (MassHealth) Primary Care Clinician plan. The authors included 4,236 complete cases for analysis (i.e., 2,520 in the recovery support navigator condition and 1,716 in the services as usual condition), for whom information regarding post-detox treatment data within the first 14 days post-detox was available. Participants were predominantly male (67.8%), 30 years of age or older (70.5%), had a co-occurring psychiatric diagnosis, based on Medicaid claims data (78.9%), and had completed another detox episode prior to the current, index detox episode (52.1%).

Figure 2. While the difference between conditions was statistically significant, it is worth noting that these particular numbers are raw values and were not statistically controlled for. However, an absolute magnitude difference of 7% translates to a relative advantage of 18.42% in favor of recovery support navigators – a clinically-meaningful added benefit.

WHAT DID THIS STUDY FIND?

Treatment was more likely in the recovery support navigator condition.

A total of 42% of patients attended additional treatment within 14 days of their discharge from inpatient detox. When the authors just compared the number of patients in one condition vs. the other, they found that the proportion of patients who sought additional treatment was significantly higher (45%) among patients who received support from a recovery support navigator compared to patients who received services as usual (38%). 

When examined differently, and when taking into account other variables, patients who received support from a recovery support navigator were 23% more likely than patients in the services as usual condition to attend treatment within the first 2 weeks post-detox. In addition, and regardless of treatment condition, attending a prior detox episode recently, having a current psychiatric diagnosis, a documented disability, or who were on Medicaid less than 1 year (compared to more than a year) was associated with a greater likelihood of attending care within 14 days post-detox.

WHAT ARE THE IMPLICATIONS OF THE STUDY FINDINGS?

This study highlights the ongoing “revolving door” issue of detox and post-detox readmission risk among patients with severe substance use disorders, but also a novel intervention strategy designed to help address it.

The authors developed, implemented, and also evaluated the outcomes of a new and cost-effective intervention designed to link patients to essential treatment post-detox, which used recovery support navigators to facilitate patients’ healthcare transitions. Despite finding that their intervention was associated uniquely with a 23% increase in the likelihood of post-detox treatment engagement, controlling for a host of other variables that might account for the advantage of the intervention (e.g., higher quality services at the programs where the recovery support navigation was implemented), the majority of patients in this large-scale study did not engage in treatment 2 weeks post detox. Individuals who had been in detox recently or who had a psychiatric diagnosis, for instance, were more likely to engage in treatment after detox. Given their higher severity, they might already have connections in the community and treatment resources. As such, recovery support might be less useful to these individuals as they might be to patients with less connection or awareness of treatment options post-detox. It could also be that the types of treatment options available to those who did not engage in treatment post-detox were not appealing or did not meet the needs of these individuals.

This lack of treatment engagement post-detox is critical for individuals with opioid use disorder, in particular, since this initial period after detox discharge is the highest risk time for drug overdose. The authors were unable to examine whether patients enrolled in treatment after 2 weeks, which is still possible, but nevertheless provides important insight into a new and cost-effective strategy that clinics can implement to improve short-term patient care, and potentially long-term outcomes as well. The flexibility of the fee-by-case model afforded clinicians the ability to meet with and provide more active and intensive support that may have been of added value to patients, which might also be needed to effectively engage detox patients in after care. 

LIMITATIONS

1. The authors compared treatment outcomes following assignment of treatment to the 4 highest volume clinics in Massachusetts. This might have influenced results in ways that could have been overcome by randomly assigning clinics, patients, or both to receive the treatment or not.
2. While use of administrative data is a strength in many ways, it can also be a limitation to the extent that it cannot be used to examine or control for other unmeasured considerations. Relevant factors might include healthcare sought after 14 days, patient recovery or relapse post-detox, or unmeasured provider-level factors. These factors might include characteristics of the providers in one condition vs. the other, or the extent and duration of services provided by providers across conditions.
3. The authors were unable to isolate which active ingredients that were largely responsible for the intervention’s observed effect, such as whether it was the Motivational Interviewing or other recovery support services navigators offered, characteristics of the providers or clinics assigned to the treatment vs. services as usual condition, or the enhanced flexibility of recovery support navigators to provide patient-centered treatment outside the bounds of fee-for-service care, or some combination thereof.
4. The authors were not able to take into account factors associated with substance use disorder or types of substance use disorder for which patients received detox services.
5. The primary outcome of engagement in treatment did not include engagement in recovery other support services, such as recovery residences, recovery community centers, or mutual help organizations as these were not measured by administrative claims data.

BOTTOM LINE

CITATIONS

Lee, M. T., Torres, M., Brolin, M., Merrick, E. L., Ritter, G. A., Panas, L., Horgan, C. M., Lane, N., Hopwood, J. C., De Marco, N., & Gewirtz, A. (2020). Impact of recovery support navigators on continuity of care after detoxification. Journal of substance abuse treatment, 112, 10–16. doi: 10.1016/j.jsat.2020.01.019