Two decades of evidence demonstrate that people who continue substance use disorder (SUD) treatment after discharge from detoxification services are more likely to remain drug-free or sober (Mark, Vandivort-Warren, & Montejano, 2006). People with SUDs who continue treatment after detoxification are also less likely to use additional medical resources or be incarcerated (Hubbard, Craddock, Anderson, 2011), become unemployed (Degenhart, Bucello, Mathers, et al. 2011), or die (Di Castelnuovo, Costanzo, Bagnari, et al., 2006).
Yet, just 11-27% of individuals receiving emergency detoxification services for alcohol or drug abuse receive additional treatment or continuing care (SAMHSA, 2012). This is occurring at a time when drug overdose deaths, primarily due to opioids, are the leading cause of accidental death in the United States, having surpassed motor vehicle accidents since 2010 (Chen, Hedegaard, & Warner, 2014). While post-detoxification care should be the standard of care (Lee, Horgan, Garnick, et al., 2014) many detoxification centers consider care to be complete upon discharge (McKay, 2006).
Detoxification services as an opportunity and a gap
The Centers for Disease Control (CDC) lists expanding access to addiction treatment services as an essential component in the response to the opioid overdose epidemic (CDC, 2013). Detoxification services provide the greatest opportunity for the addiction treatment system to prevent adverse SUD outcomes, as patients entering detoxification recognize that they are suffering physically, emotionally, and financially from their substance misuse and may be motivated to accept continuing treatment.
The LINK System integrates three approaches that have proven effective in improving transitions from detoxification to continuing care:the practice bundle, the process checklist, and the NIATx organizational change model.
By itself, however, detoxification does little to address long-standing psychological, social, and behavioral issues associated with SUDs. Rather, detoxification serves as a way to prepare and connect individuals with continuing care through formal substance abuse treatment. (Carrier et al., 2011). The health benefits of timely follow-up care after detoxification are widely acknowledged (Stein, Kogan, & Sobero, 2009). Yet, nationally, only 11% are transferred to SUD treatment after leaving detoxification services. (SAMHSA, 2012).
This missed opportunity for continuing care following detoxification services has significant consequences on the SUD services system’s ability to address the clinical issues underlying the high rates of SUDs in the United States. System solutions are needed to improve detoxification to continuing care transitions and make continuing care after discharge the norm.
The Link System
One example of a system solution is The Link: Care Transition Implementation System (the Link System) System, developed at the Center for Health Enhancement Systems Studies at the University of Wisconsin-Madison.
This system was tested in a pilot project conducted in Wisconsin between 2014 and 2016, with funding from University of Wisconsin Institute for Clinical and Translational Research (UW ICTR). This integrated implementation approach improved detoxification to continuing care transition rates from 20% (baseline average) to 43% (post-intervention) in (n=6) Wisconsin detoxification centers.
One of the participating detoxification centers, Ministry Behavioral Health, increased transitions from detoxification to continuing care from a baseline of 33% to 63%, or an increase of 91%. Read the case study here.
The LINK System integrates three approaches that have proven effective in improving transitions from detoxification to continuing care: a practice bundle (Shah & Ward, 2003), a process checklist (Haynes, Ward, & Gawande, 2015), and the NIATx organizational change model (McCarty, Gustafson, Wisdom, et al., 2007).
Practice bundle
A practice bundle is a set of evidence-based practices that has been shown to improve treatment outcomes when performed together. As The Institute for Healthcare Improvement (IHI) states:
“The power of the bundle comes from the body of science behind it … It’s not that the changes in a bundle are new; they’re well established best practices, but they’re often not performed uniformly, making treatment unreliable, at times idiosyncratic. A bundle ties the changes together into a package of interventions that people know must be followed for every patient, every single time.” (Institute for Healthcare Improvement)
The evidence-based practices in the LINK System bundle include:
Process checklist
Research on transitions from detoxification to continuing care tends to focus on the clinical care provided during detoxification, with limited attention paid to the organizational processes that bridge the two levels of care (Timko, Below, Schultz, Brief, & Cucciare, 2015). The medical field also focused primarily on the role of clinical care in transitions, until the medical error movement began to identify the errors that can arise as a result of poor “hand-offs.” With the emerging focus on improving patient hand-offs, the medical field has begun to apply a tool long used by the engineering field to standardize practice and reduce undesirable variation: the process checklist. (Morgan & Liker, 2006).
The NIATx organizational change model
NIATx (formerly the Network for the Improvement of Addiction Treatment) was developed specifically for behavioral health organizations to improve access to and retention and treatment. It has been shown to be effective in a large randomized trial, as well as in field tests (Gustafson, Quanbeck, & Robinson, et al., 2013).
The NIATx model is based on five evidence-based principles identified in a Gustafson meta-analysis (Gustafson & Hundt, 1995) that predict the adoption of successful innovations:
1. Understand and involve the customer,
2. Have executive support for an overarching organizational goal
3. Seek ideas from outside the organization,
4. Select a change leader with substantial influence, and
5. Pilot test changes using the Plan-Do-Study-Act cycles before adoption.
The NIATx model will guide the implementation of the practice bundle and accompanying process checklist. NIATx has been used to improve access, regimen adherence, and evidence-based practice uptake.
Significance to the healthcare system
Examples of effective processes to connect patients between detoxification to continuing care are relatively rare. The LINK System, tested on a large scale, could provide evidence-based on relevant examples that other providers, payers, and health policy makers could follow and replicate. Testing this system in a larger setting with more providers could have a timely public health impact, as the addiction treatment field and society at large seek ways to address the opioid addiction epidemic.
Engaging individuals in treatment services when they are often most vulnerable and ready to address their addiction: following an adverse addiction-related event. The LINK System offers an innovative approach to increase engagement in treatment, based on use of practice bundles and process checklists that have been successfully applied in acute care hospital settings, with varied approaches to implementation. With a standardized implementation approach, the LINK System also offers a way to examine how using bundles and checklists is generalizable to community-based behavioral health settings. Should the LINK System prove to be generalizable and beneficial, it could provide a tool to address other long-standing public health challenges that are exacerbated by poor transitions between levels of care.
Todd Molfenter, PhD, is a senior scientist at the University of Wisconsin-Madison’s Center for Health Enhancement Systems Studies (CHESS). He also serves as the Deputy Director for NIATx (formerly the Network for the Improvement of Addiction Treatment), a performance improvement and workforce development resource center housed within the Center. He is currently leading a National Institutes of Health (NIH) Dissemination and Implementation Research in Health (R01) study titled “To Test a Payer/Treatment Agency Intervention to Increase Use of Buprenorphine.” Dr. Molfenter has led a variety of other NIATx projects that use systems and organizational change approaches to implement evidence-based practices and improve processes in healthcare settings