Why we ALL need recovery

Originally published in Alcoholism and Drug Abuse Weekly (September 5, 2011)

If you think we in healthcare are not in a world of
major change, stop here and read no further. That
would be a clinical matter, atypical denial or delusions.
Turn the page.

Over the past few years, change has become a
constant as we scurry to prepare for such realities as
the Affordable Care Act and to continue the integration
of behavioral and physical health care. This is
happening so fast that even other major changes such
as the implementation of parity or the building of
recovery-focused care are running to “keep up” or be
lost in an ever-morphing environment. Providers often
feel threatened as policymakers seek to do what is
“right” within increasing new rules (and less funding)
and the need to address now outdated regulations in
the new world order of “science,” “medicines,” and
“best practice,” surrounded by simultaneous mandates
for documented efficiencies and effectiveness.

Amidst all this and the fear that goes along with it,
let’s stop and let one guiding insight unify our vision,
the principles of which can calm us all: Recovery.

An illness is best treated by understanding its
causes, its pathological development and its cure. Each
phase is equally critical to a full understanding and
remediation of the illness. The ultimate measure of this
fuller knowledge is improved future prevention,
intervention, remission and recovery outcomes from
the illness. With this understanding, each part of the
illness’s trajectory can be quantified and measured
directly (e.g. its prevalence and the benefits of care to
individuals, families and local communities); and more
indirectly to payers, policy makers and society in
general (e.g. societal costs and cost offsets). In short,
how “much” does prevention and restored wellness
offset costs of the effects of the illness?

To be accountable, we must not, then, aim for
“topical care” or care so generalized that it cannot
effectively impact an illness’s path or potential
trajectory. We must understand that all illnesses have a
full trajectory addressed through the spectrum of
prevention-intervention-treatment, surrounded by
restored wellness and/or recovery. Addressing one part
of that trajectory, while hopefully positively impacting
the other parts, will never completely eliminate the
illness trajectory itself nor the need for a full
continuum of care. Given the mandate for efficiency
and accountabilities, each and all phases must then
document measurement based care, i.e. compliance to
accepted best practice and progress in that practice
and its achieved outcome, i.e. wellness and/or recovery,
or at least the possibility for recovery. All else is topical.

We seem to have a tough question. Given financial
limits, generalized or topical care for many or specialty
care for few? Here, Christensen, Grossman and Hwang
offer their thoughts in The Innovator’s Prescription
(McGraw Hill, 2009) with a proposal that finds a sound
middle ground to reduce costs and offer personalized
care. They propose “precision” in lower cost settings, i.e.
better screenings, diagnostics, treatment, and training
in lower cost environments, often with lower cost but
very skilled workers.

This lower-cost healthcare will be connected to
each community and its resources. It is designed not to
replace existing models or find cheaper care but is to
augment what is clinically precise and improve its
outcome and workforce. Better care for more people
measured through improved access, retention and
recovery — at a lower cost per capita. Remember, there
are an estimated 23.5 million Americans age 12 and older
needing substance use disorder treatment (SAMHSA,
2010/2011); we currently offer a specialized treatment
capacity for only for about 10 percent of them!

A recovery focus offers this vision — and a safety
net for all of us; payers, providers and policymakers
included. It assures a measure upon which we might all
agree as an “outcome” worth achieving. Indeed, we will
need to define “recovery” for the individual, now and
again over time, and each definition should be
accompanied by precise medical and psychosocial
markers that document care provided for the best
outcome possible. Something like the American Society
of Addiction Medicine’s “phases” of care — with
relevant recovery measures added for each phase.
Using such measurement based care with recovery
measures (e.g. White 2008: infrastructure: workforce,
linkage to recovery supports; process: screening,
assertive outreach, ongoing follow-up; outcome:
personal health, living, community, et al; IRETA 2011 –
Recovery Oriented Methadone Guidelines), we can offer
accountable, efficient personalized care by practicing
precision care augmented through an expanded and
skilled workforce that can better achieve and sustain
individual clinical outcomes. We all have so much to do.

Recovery can be the common denominator in all of
the change around us. Its increased (measured) presence or continued absence will be the ultimate indicator
of the success or failure in what is happening today. A
recovery focus unifies and stabilizes change while holding on
to our ideals, humanity and science. That is why we ALL need
recovery.

Michael T. Flaherty, Ph.D., is the founder of and Senior
Consultant to IRETA in Pittsburgh, PA.