Therapeutic Community

What is a Therapeutic Community?

Therapeutic Communities [TCs] often referred to as “community as method” utilized for addiction treatment for about 40 years. In general, TCs are drug-free residential settings that use a hierarchical model with treatment stages that reflect increased levels of personal and social responsibility. Peer influence, mediated through a variety of group processes, is used to help individuals learn and assimilate social norms and develop more effective social skills. TCs differ from other treatment approaches principally in their use of the community comprising treatment staff and those in recovery, as key agents of change. TC members interact in structured and unstructured ways to influence attitudes, perception, and behaviors associated with drug use.

Many individuals admitted to TCs have a history of social functioning, education/vocational skills, and positive Community and family ties that have been eroded by their substance abuse. For them, recovery involves rehabilitation –relearning or re-establishing healthy functioning, skills and values as well as regaining physical and emotional health. Other TC residents have never acquired functioning life-styles. For these people, TC is usually their first exposure to orderly living. Recovery for them involves habilitation learning for the first time the behavioral skills, attitudes, and values associated with socialized living. In addition to the importance of the community as primary agent of change, a second fundamental TC principle is “self-help.” Self-help implies that the individuals in treatment are the main contributors to the change process. “Mutual self-help” means that individuals also assume partial responsibility for the recovery of the peers – an important aspect of an individual’s own treatment.

How Beneficial Are TCs in Treating Drug Addiction?

NIDA has conducted several large studies to advance scientific knowledge of the outcome of drug abuse treatment as typically delivered in the United States. These studies collected baseline data from over 65,000 individuals admitted to publicly funded treatment agencies. They included a sample of TC programs and other types of programs [i.e., methadone maintenance, out-patient drug-free, short-term inpatient, and detoxification programs]. Data were collected at admission, during treatment, and in a series of follow-ups that focused on outcomes that occurred 12 months and longer after treatment. These studies found that participation in a TC was associated with several positive outcomes. For example, the Drug Abuse Treatment Outcome Study [DATOS], the most recent long-term study of drug treatment outcomes, showed that those who successfully completed treatment in a TC had lower levels of cocaine, heroin, and alcohol use; criminal behavior; unemployment; and indicators of depression that they had before treatment.

How is Treatment Provided in a Therapeutic Community?

TC treatment can be divided into three major stages:

Stage 1: Induction and early treatment typically occurs during the first 30 days to assimilate the individual into the TC. The new resident learns TC policies and procedures; establishes trust with staff and other residents; initiates an assisted personal assessment of self, circumstances, and needs; begins to understand the nature of addiction; and should begin to commit to the recovery process.

Stage 2: Primary treatment often uses a structured model of progression through increasing levels of pro-social attitudes, behaviors, and responsibilities. The TC may use interventions to

change the individual’s attitudes, perceptions, and behaviors related to drug use and to address the social, educational, vocational, familial, and psychological needs of the individual.

Stage 3: Re-entry is intended to facilitate the individual’s separation of the TC and successful transition to the larger society. A TC graduate leaves the program drug-free and employed or in school. Post-residential aftercare services may include individual and family counseling and vocational and education guidance. Self-help groups such as Alcoholics Anonymous and Narcotics Anonymous are often incorporated into TC treatment, and TC residents are encouraged to participate in such groups after treatment.

The National Institute on Drug Abuse [NIDA]. {2002}. Therapeutic Community. National Institute of Drug Abuse Research Report Series. NIH Publication Number 02-4877

Social Psychiatry

What is a Social Psychiatry?Social psychiatry s a branch of psychiatry that focuses of the “interpersonal” and cultural context of mental disorder and mental wellbeing; it involves a sometimes disparate set of theories and approaches, with work stretching from epidemiological survey research on the one hand, to an indistinct boundary with individual or group psychotherapy on the other. Social psychiatry combines a medical training are perspective with fields such as social anthropology, social psychology, cultural psychiatry, sociology and other disciplines relating to mental distress and disorder. Social psychiatry has been particularly associated with the development of therapeutic communities, and to highlighting the effect of socioeconomic factors of mental illness. Social psychiatry can be contrasted with bio psychiatry, with the latter focused on genetics, brain neurochemistry and medication. Social psychiatry was the dominant form of psychiatry for periods of the 20th century but is currently less visible than bio psychiatry.

The events of the first half of the 20th century brought the issue of the relationship between the individual and the community to the fore. Psychiatrists, who showed a willingness to confront these issues at home, alter the war, called themselves social psychiatrists. Psychoanalytic psychotherapy and all its offshoots were grounded in an approach to the patient that focused almost exclusively on the individual – the relational aspects of therapy were implicit in the relationship between therapist and patient, but the main source of problem and motivation for change was seen as being intra-psychic (within the individual). The social and political contexts were largely disregarded. Early landmarks in social psychiatry included: Karen Horney, MD, who wrote about personality as it interacts with other people (1937); Erik Erikson, who discussed the influence of society on development (1950); Harry Stack Sullivan’s (1953) integration of sociological and psychodynamic concepts, and his work or the role of early interpersonal interactions in the development of the self; Cornell University’s Midtown Manhattan Study which looked at the prevalence of mental illness in Manhattan; August Hollingshead, PhD, and Frederick Redlich, MD, looked at the influence of social class an psychiatric conditions (1958); Alexander H. Leighton, MD, looked at the relationship between social disintegration and mental illness (1959); Burrow was an early pioneer of the social cause of mental disorder and suggested “Sociatry” as the name for this new discipline.

Over the years many sociologists have contributed theories and research which has enlightened psychiatry in this area (e.g. Avison and Robins); The relationship between social factors and mental illness was demonstrated by the early work of Hollingshead and Readlich is Chicago in the 1930s, who found a high concentration of individuals diagnosed with schizophrenia in deprived area of the city has been replicated numerous times throughout the world, although controversy still exists as to the extent of drift of vulnerable individuals to these areas or of a higher incidence of the disorder in the socially disadvantaged; the Midtown Manhattan Study conducted in the 1950s by Cornell University hinted at widespread psychopathology among the general population of New York City (Srole, Sanger, Michael, Opler and Rennie, 1962); the Three Hospitals Study (Wing JK and Brown GW, Social Treatment of Chronic Schizophrenia: a comparative survey of time mental hospitals 1961, Journal of Mental Science, 107, 874-861) was a very influential work that has been replicated, that demonstrated forcefully that the poverty of the environment in poor mental hospitals lead to greater handicaps in the patients.

Social psychiatry was instrumental in the development of therapeutic communities. Under the influence of Maxwell Jones, Main, Wilmer and others (Caudill 1958; Rapoport 1960), combined with the publications of critiques of the existing mental health system (Greenblatt et al. 1957, Stanton and Schwartz 1954) and the sociopolitical influences that permeated the psychiatry

world, the concept of the therapeutic community and its attenuated form – the therapeutic mileu –caught on and dominated the field of inpatient psychiatry throughout the 1960s. The aim of therapeutic communities was a more democratic, user-led form of therapeutic environment, avoiding the authoritarian and demeaning practices of many psychiatric establishments of the time. The central philosophy is that clients are active participants in their own and each other’s mental health treatment and that responsibility for the daily running of the community is shared among the clients and the staff. “TCs” have often eschewed or limited medication in favor of psychoanalytically-derived group-based insight therapies.

Wikipedia, (2010). Social Psychiatry. Retrieved on December 29, 2010.http://en.wikipedia.org/wiki/Social_ psychiatry

Social Medicine

What is a Social Medicine?

The field of social medicine seeks to:

1. Understand how social and economic conditions impact health, disease and the practice of medicine and

2. Foster conditions in which this understanding can lead to a healthier society.

This type of study began formally in the early 19th century. The Industrial Revolution and the subsequent increase in poverty and disease among workers raised concerns about the effent of social processes on the health of the poor.

Prominent figures in the history of social medicine include Rudolf Virchow, Salvador Allende, and more recently Paul Farmer and Jim Yong Kim.

More specifically, Farmer et al. (2006) state that “Biosocial understandings of medical phenomena [such as the social determinants of health] are urgently needed”. Paul Farmer’s view is that modern medicine is focused at the molecular level, and there is a “gap” between social analysis and everday clinical practices. Moreover, Farmer, Nizeye, Stulac and Keshavjee (2006) view social medicine with increasing importance as scientific inquiry is increasingly “desocialized”. The latter refers to “…a tendency to ask only biological question about what are in fact biosocial phenomena.”

The field of social medicine is most commonly addressed today by public health efforts to understand what are known as Social determinants of health.

Wikipedia. (2010). Social Medicine. Retrieved on December 29, 2010.http://en.wikipedia.org/wili/Social_medicine

Toxicology Testing

Why Is Toxicology Testing Important?

Methods for urine drug testing have been available for several decades. These procedures are useful in assessing and identifying substance use in treatment programs, research program, law enforcement, the workplace, and school. Despite widespread adoption of such techniques, limited knowledge exists regarding their valid use and interpretation among many who frequently perform these tests. Obtaining a valid test result is a complex process because its results are affected by several factors, including the substance of interest, test methodology, pharmacokinetics, chain of custody procedures, and international tampering.

A number of current approaches employ urine testing as a means of determining and enhancing treatment efficacy. Regarding adolescent substance abuse treatment, urine testing is particularly salient, 95% of physicians who provide primary care to adolescents order urine drug tests.

The DSM-IV distinguishes 11 categories of use able substances, including amphetamines; cannabis; cocaine; hallucinogens; inhalant; opioids; phencyclidine (PCP); sedatives, hypnotics, and anxiolytics, alcohol; caffeine; and nicotine. Despite this many tests screen only for marijuana, cocaine, opioids, amphetamines and PCP (the NIDA five). Although these substances are the most frequently tested for, no industry standards exist. It is important to note that several substances, notably ecstasy, oxycodone, hydrocodone, buprenorphine, and clonazepam are not included in many drug screens and must be ordered separately. Thus one of the most readily remedied sources of inaccuracy in result interpretation is the use of insufficiently broad tests.

Methods of urine drug analysis fall into two general categories – screening assays and confirmatory test – although some methods of analysis are used for either purpose. Two characteristics of the test are particularly important, sensitivity and specificity refers to the lowest detectable concentration of drug whereas specificity refers to how selective an assay is for a particular drug. Ideally the standard procedure for urine drug testing should involve highly sensitive screening techniques followed by the use of highly specific confirmatory techniques for samples identified as potential positives during screening.

Many screening procedures use immunoassay techniques that rely on competition between drug chemically labeled with an enzyme, radioisotope, or flurophore and the drug present in the biological sample. The labeled drug and the sampled drug compete for binding sites on drug-specific antibodies. The ratio between the two is used the determine the presence or absence of the drug in the biological sample.

During confirmatory testing, drugs in the specimen are separated before detection. Separation is usually accomplished by using a method such as gas chromatography high performance liquid chromatography. After separation analytes reach the detector at different rates. This information provides evidence as to whether the drugs in question are present in the specimen.

Four possible outcomes exist for interpreting results: true positive, true negative, false positive, false negative. However, it is important to notes that when interpreting results, drug concentrations in the body may be lower that the designated cutoff. Thus an individual may be using drugs in such a manner that a test result may appear to be negative when drugs are in fact

present. It is also important to note that the legitimate source of false positives do exist, including pseudophedrine, dextromethorphan, and poppy seeds.

One variable influencing drug detection is the cutoff threshold. Any sample having a drug concentration equal to or above a specified level is considered a positive result. This threshold may vary from context to context as well as from screed to test. Lowering the cutoff increases sensitivity although it also increases the potential for false positive results by decreasing specificity.

Some individuals may be motivated to avoid detection of their drug use. Methods for avoiding detection of substance abuse include dilution of the sample with water or other liquids, substitution with a clean or synthetic urine specimen, and adulteration with other chemicals. Several characteristics of urine may indicate whether the sample has been adulterated including pH, temperature, creatinine, specific gravity, and human immunoglobin (IgG) levels. In a healthy volunteer, urine is expected to be 90 degrees F to 100 degrees F within several minutes of producing a sample, temperatures outside of this suggest substitution. Additionally eliminating water sources, prohibiting outer garments and personal belongings from the collection room, having subject wash their hands, and direct observation of the specimen collection are useful.

To ensure the accurate interpretation of urine drug testing it is important to consider the following topic

Are the substances of interest included in the test? Because no standard for terms such as “routine” or “comprehensive” exist it is important to ensure that the analyses performed will detect the specific substances of interest. Requesting a category of drug is insufficient.

Will the requested test provide the desired information? Screening procedures provide qualitative information. Whereas confirmatory testing generally provides both qualitative information, whereas confirmatory testing generally provides both qualitative and quantitative information. Confirmatory testing is generally more sensitive and specific but it is also more expensive. Qualitative screening with confirmatory test for positive results typically provides the desired information although some clinical situations require quantitative information.

Will the testing procedure detect the amount of use within the time frame of interest for a give substance? Urine testing procedures generally only detect relatively recent use. Additionally, the time frame for detection varies by substance as well as by the frequency and intensity of use. Regular and heavy use may be more easily detected, but intermittent are lighter drug use may be missed.

Has the sample been diluted, substituted, or adulterated? These are methods used to falsify test results. Proper collection techniques, confirmation of pH, temperature, specific gravity, creatinine, and IgG levels as well as checks for adulterants, including glutarldehyde, potassium, chloroshomate, and nitrates, should be performed whenever tamping is suspected.

Have accurate chain of custody procedures been implemented and followed? Ensuring that a specimen has not been mistakenly or intentionally switched with the specimen of another individual is fundament to obtaining a valid result.

Jaffee, W.B., Trucco, E., Teter, C., Levy, S., and Weiss, R. (2008). Focus on Alcohol & Drug Abuse: Ensuring Validity in Urine Drug Testing. Psychiatric Service 59(2), 140-142.

Medical Home Model

What is a Medical Home Model?

The medical home, also known as the patient-centered medical home (PCMH), is defined as “an approach to providing comprehensive primary care… that facilitates partnerships between individual patients, and their personal providers, and when appropriate, the patient’s family.” The provision of medical homes may allow better access to health care, increase satisfaction with care, and improve health.

The concept of the medical home has evolved since its introduction at the American Academy of Pediatrics in 1967. In 1992 the Academy published a policy statement defining a medical home, and in 2002 they expanded and operationalized the definition.

In 2002, seven U.S. national family medicine organization created the Future of Family Medicine project to ”transform and renew the specialty of family medicine.” Among the recommendations of the project was that every American should have a “personal medical home” through which to receive his or her acute, chronic, and preventive services. The services should be “accessible, accountable, comprehensive, integrated, patient-centered, safe, scientifically valid, and satisfying to both patients and their physicians.”

American College of Physicians has developed an “advanced medical home” model. The model involves the use of evidence-based medicine, clinical decision support tools, the Chronic Care Model, medical care plans, “enhanced and convenient” access to care, quantitative indicators of quality, health information technology, and feedback or performance.

In 2007 the largest primary care physician organizations in the United States released the Joint Principles of the Patient-Centered Medical Home. The principles listed were:

Personal physician: “each patient has an ongoing relationship with a personal physician trained to provide first contact continuous and comprehensive care.”

Physician directed medical practice: “the personal physician leads a team of individuals at the practice level who collectively take responsibility for the ongoing care of patients.”

Whole person orientation: “the personal physician is responsible for providing for all the patient’s health care needs or taking responsibility for appropriately arranging care with other qualified professionals.”

Care is coordinated and/or integrated, for example across specialists, hospitals, home health agencies, and nursing homes.

Quality and safety are assured by a care planning process, evidence-based medicine, clinical decision-support tools, performance measurement, active participation of patients in decision-making information technology, a voluntary recognition process, quality improvement activities, and other measures.

Enhanced access to care is available {e.g., via “open scheduling, expanded hours and new options for communication”}.

Payment must “appropriately recognize[s] the added value provided to patients who have a patient-centered medical home.” For instance, payment should reflect the value of “work that falls outside of the face-to-face visit,” should “support adoption and use of health information technology for quality improvement,” and should “recognize case mix Scientific evidence.

Recent peer-reviewed literature that examines the prevalence and effectiveness of medical homes includes:

In 2007, researchers from the Centers for Disease Control and Prevention published a study involving interviews with 5400 parents; the authors concludes that continuous primary care in a medical home was associated with higher rates of vaccinations for the respondents’ children.

Schoen and colleagues (2007) surveyed adults in seven countries, using the answers to four questions to categorize the respondents as having a medical home or not. Having a medical home was associated with less difficulty accessing care after hours, improved flow of information across providers, a positive opinion about health care, fewer duplicate tests, and lower rates of medical errors.

A review of 33 articles by Homer et al. on medical homes for children with special health care needs published in 2008 “provider[d] moderate support for the hypothesis that medical homes provide improved health-related outcomes.”

A 2008 review by Rosenthal determined that peer-reviewed studies show “improved quality, reduced errors, and increased satisfaction when patients identify with a primary care medical home.”

In a survey of parents or legal guardians of children with special health care needs published is 2009, 47.1% of the children had a medical home, and the children with a medical home had “less delayed or forgone care and significantly fewer unmet needs for health care and family support services” that the children without a medical home.

Reid et al. (2010) showed within the Group Health system in Seattle that a medical home demonstration was associated with 29% fewer emergency visits, 6% fewer hospitalizations, and total savings of $10.30 per patient per month over a twenty-one month period.

Wikipedia. (2010). Medical Home Model. Retrieved on December 29, 2010.http://en.wikipendia.org/wiki/Medical_home

Evolving Towards an AccountableCare Organization

What Is an Accountable Care Organization?

Imagine a health system that pays doctors and hospitals to keep you well, not just treat you when you’re sick. A system where doctors would have a financial incentive to limit unnecessary tests and prod patients to exercise more and eat better; A system where hospitals would benefit from – now this is really radical – keeping you out of the hospital. This is the goal behind accountable care organizations, or ACOs, the latest health care delivery model that’s poised to get a test ride in the national health overhaul legislation

In the existing fee-for-service payment system used by Medicare and most private insurers, doctors get paid more by giving more services and hospitals make more by increasing admissions. With ACOs, doctors and Hospitals would get paid based on their ability to hold down overall costs and beet quality-of-care indicators. In effect, their pay would be based on improving care, not driving more of it.

If the ACOs fail to meet certain quality and cost savings targets, the providers in the ACO would face lower payments from Medicare. On the flip side, the ACOs would also be awarded for keeping patients happy and meeting national quality standard such as making sure diabetics get regular foot exams and women get their annual mammograms. In effect, ACOs are an attempt to build integrated health systems like the Mayo Clinic where none exist. But Mayo took several decades to become a global destination for health care.

The accountable care organization (ACO) is one of the latest designs for managing Medicare that is gaining traction among policymakers desperate to control costs and boost quality in the system. Proponents of the concepts want to see it tested along with such alternatives as patient-centered medical homes, pay-for-performance and payment bundling.

A typical Medicare ACO would include a hospital, primary care physicians, specialist and potentially other medical professionals. Services would still be billed under fee-for-service, but the organization’s members would coordinate care for their shared Medicare patients with the goal of meeting and improving on quality benchmarks. Because ACO members are held jointly accountable for this care, they would share in any cost savings that stem from the quality gains.

Medicare spends three times more per beneficiary in some regions than is does in others, with no clear evidence that the additional dollars result in higher quality of care or better outcomes. The system also tends to promote high-volume and high-intensity health services, regardless of the quality of care provided and whether that care is coordinated.

The accountable care organization attempts to address these issues by linking payments to the quality and utilization of health services. Although it is a relatively new concept, it incorporates and builds on ideas from several other reform models that have been discussed for years. An accountable care organization manages Medicare services by both physicians are hospitals. Although the idea has some basic themes, the details still need to be worked out. For example, some ACO models include hospitals; some don’t.

An ACO needs to be big enough so that any cost saving can be tied to quality improvements and not year-to-year fluctuations in care, he said. That means it should have a population of at least 5,000 Medicare beneficiaries or 15,000 beneficiaries with private insurance. Patients would retain the right to choose their physicians, so the ACO relies on patients’ natural physician-

selection patterns. Research has shown that more than 80% of patients assigned to a physician affiliated with a theoretical ACO would still be with members of that same organization a year later.

Galewitz, Phil. Kaiser Health News. (2009). What Area Accountable Care Organizations? Retrieved at December 30, 2010.http://mylocalhealthguide.com/what-are-accountable-care-organizations/

Cys, Jane. American Medical News. (2009) Accountable Care Organizations: A New Idea for Managing Medicare. Retrieved on December 30, 2010. http://www.ama-assn.org/amednews/2009/08/31/gvsa0831.htm