Encore Recovery Solutions employs an evidence-based model of care that customizes treatment for young adults and families struggling with issues surrounding substance use and co-occurring disorders. Since our goal is to see an improvement in overall outcomes for anyone that happens to suffer from substance use disorders, we thought we would dissect some of the issues related to the implementation of evidence-based practices in treatment.
The term “evidence-based” gets thrown around a great deal these days, but it seems that the definition is widely misunderstood. Per the American Psychological Association (APA) “Evidence-based practice in psychology (EBPP) is the integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences.” EBPP is combining research with the working knowledge and expertise of the practitioner(s), AND considers the input and specifics of the individual patient. For a practice to be considered evidence-based, it must be dynamic and customized for the individual, and it must be processed through the filter of qualified professionals as appropriate for that individual, before being deemed the best approach.
The fact that a certain clinical intervention is backed up by research does not make the use of that practice “evidence-based.” It is only evidence-based if clinical expertise and the specifics of the patient determine that the intervention is indeed the best course of action available. Additionally, a boilerplate approach to treatment wherein there is a general “track” of care, duration-based “phases” of care, or a cycle of standard educational and worksheet based content, falls away from the criterion for EBPP because such practices are not customizable to the patient, and they are not routinely informed by the clinician’s expertise.
Most approaches to treatment utilize a structure that is prescriptive. Intensive Outpatient Programs (IOP) will often use groups set at a frequency of 3-5 days a week, for 3 hours each day, with a duration of treatment lasting a pre-determined number of weeks or sessions (6-10 weeks is common). In such programs, every patient enters treatment with the expectation that their course of care will take a specific amount of time, and they will undergo the exact same process that every other patient will undergo at that facility. Educational content and group processes at programs that utilize this structure are often on a cycle, so if you miss a week of care or stay in a phase for longer than intended, you will repeat information you have already received.
From an operations standpoint, groups provide the highest profit margin, and having a predictable regimen and duration of treatment is the most efficient way to create ease of scheduling, and staffing. It’s an easier path to follow if you are trying to create a business that operates as profitably, efficiently, and routinely as possible, but such rigid structure is clearly not what is best for patients and their concerned others. An additional sticking point we see comes from the fact that most programs cater to insurance companies because their patients rely on insurance benefits to cover their treatment, and insurance companies dictate what treatment should be provided by refusing to reimburse for much beyond the generic structured programming we have discussed.
At Encore Recovery Solutions, we have chosen to focus on building a comprehensive program that is truly evidence-based. Our evaluation process includes an initial interview, a history and physical, psychological evaluation and testing, psychiatric and medication evaluation, nutritional evaluation, and a thorough look at the family system. We have services for young adults that include a variety of heavily researched and proven individual and group based clinical interventions such as Dialectical Behavioral Therapy (DBT), Motivational Interviewing (MI), Somatic Experiencing, and others. We include integrative/holistic therapies such as yoga, nutrition/dietary consulting, and therapeutic massage, and we employ life skills coaches that focus on specific areas such as finances, academics, and employment. Additionally, we offer ongoing clinical services focused specifically on the needs of the family system, an often-overlooked component of a patient’s life and successful recovery.
The variety of services we offer at Encore allows us to create treatment plans that are completely customized. Our initial interview and evaluation process allows us to gain insight into the specific needs, values, and priorities of the patient, and helps our clinical team work with that patient to select services to help them reach their goals, and ultimately achieve sustained recovery. To ensure that our approach is effective, we utilize outcomes measures and tools to gauge therapeutic alignment between patient and clinician from the beginning of treatment, throughout the process, and for an extended period post treatment completion.
The one disadvantage of our model is that it costs more to operate, and most insurance policies do not provide coverage for all the work we do. We attempt to offset costs for our patients and families by billing insurance on an out-of-network basis, and we take the financial circumstances of our patients into consideration when developing individual financial plans. We also take lower profit margins than many other programs to decrease cost to our clients. Still, medical care is not inexpensive, and there is a percentage of the population that may not have the extra out of pocket finances or out of network insurance benefits that would allow them to fully engage with us. We have the goal of increasing access to the services we offer in the future, but our current focus is on providing the highest quality services possible, building a model that we can prove works, and not letting the current practices of insurance companies and the status quo of the industry dictate our methods.
Most programs don’t have the luxury of starting from scratch like we recently did. For other programs, changing a financial model away from in-network insurance reimbursement or state/federal insurance reimbursement isn’t feasible, and it would leave a huge portion of the population without any services. Still, a change is needed if we are going to focus on improving outcomes and providing evidence-based care. The good news is that the field does not need to reinvent the wheel. In our opinion, the communities that we provide care in have all the resources we need.
Strangely, while the Substance Abuse and Mental Health Services Administration (SAMHSA) and the recent Surgeon General’s report on Alcohol, Drugs, and Health fully support customized, integrative, evidenced based, and community oriented care to address the current addiction epidemic in the United States of America, many (most) programs do not follow the heavily researched and proven suggestions of such experts. To be fair, many community based organizations do adhere to the approach suggested by SAMSHA and the Surgeon General’s findings. Sadly, it seems it is the portion of the treatment industry that relies on health insurance reimbursement to fund their care that falls incredibly short of providing effective evidenced based care.
We believe that the solutions to the problems we are highlighting are well within reach. We propose, as an industry, we look back at what has long been called “wrap-around-services,” and Recovery Oriented Systems of Care (ROSC) and begin to work together to make sure the patients we treat are getting all their needs met. As a collective, we should focus more energy on creating community relationships that form a large system of supports and services that are accessible to a wide swath of individuals. We should provide services that fall within our areas of expertise, and we should coordinate with other professionals in our communities that offer solutions that are beyond the scope of our own care.
At Encore Recovery Solutions, one of our mantras is “we cannot possibly solve or address every single problem facing our patients and families, but we believe strongly that our community can.” Even though our in-house services are dynamic and highly customizable, we recognize that developing Recovery Oriented Systems of Care within our community will improve outcomes for our patients and exponentially increase our ability to remain evidence-based. We implore other providers to consider a similar approach to care, and look forward to seeing more and more individuals successfully recover from substance use disorder.