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Addiction help: goodbye to the 28-day inpatient program?

The medication that kept Phyllis free from headaches for 12 years eventually forced her to deal with another pain in her life--the anguish of addiction.

When her employer suggested in January that she get help for a drug addiction, she agreed, and is in continuing care at the Aurora Chemical Dependency Program at Reid Hospital and Health Care Services in Richmond.

While she was addicted, Phyllis kept working. Her children were grown and away from the house, and her husband didn't know about her addiction. Her employer did, and was concerned about a change in Phyllis' personality. "I was having some aggressive, angry behavior at work, and that's not me at all," Phyllis says. When her employer confronted Phyllis, she agreed to go for treatment.

She kept her job, and began an intensive outpatient treatment program at Aurora that allowed her to return home every day. Now in continuing care, Phyllis is able to go to a meeting daily if she wants, and can request one-on-one counseling.

Five or 10 years ago, Phyllis probably would have been checked into the hospital for a 28-day inpatient treatment program that was automatically prescribed for those with drug and alcohol addictions. "The 28-day program evolved in Minnesota, which was very liberal in the treatment of alcoholism as a disease rather than a social problem," says Vernon Westrich, the Midwest division vice president of Charter Medical Corp. Charter operates inpatient psychiatric hospitals in Terre Haute, where Westrich is based, as well as South Bend, Fort Wayne, Indianapolis, Lafayette and Hobart. It also has about 20 outpatient centers in Indiana.

The program became known as the Minnesota Model. Under this model, most patients were given the same treatment because that's what most insurance companies would agree to pay for.

"The old philosophy says you got the same treatment--the same thing over and over--until it worked. The belief was that eventually it would take," says Ann Kelley, director of mental health services and an addictions counselor at Hamilton Center in Terre Haute.

Now, the emphasis is on outpatient, and tailoring the treatment to the patient's needs, she says. "It's not a blanket prescription anymore."

"I think 28-day programs are gone for good," says Brian Donley, director at Aurora. The new focus on outpatient care--instigated mostly by insurance companies that want to pay less and companies that want to keep employees at work--forces treatment clinics and hospitals to be more creative in their approach to care.

Phyllis had begun weaning herself off pain medication, and did not require detoxification, which is done on an inpatient basis. "I did OK with the outpatient," she says. "If I had needed more control, I wouldn't have hesitated to tell them, and they would have checked me in."

Outpatient therapy had its advantages for Phyllis. "You come home at night and you're thrown back in the same environment, instead of in a protected environment. You have to come out after a while, and everyone's scared to death to do that."

Experts think outpatient treatment has many advantages for people like Phyllis, as long as family or friends provide support. Continuing care is constant--for as long as a year for some patients.

"Treatment is generally considered to be a yearlong phase," says Westrich. He adds that some medical studies now show that, in the case of alcoholism, the brain undergoes certain changes in that first alcohol-free year.

Robert Krumwied, executive director of Tri-City Mental Health Center in East Chicago, says the only drawback to intensive outpatient care is that some patients do not have a support system. They are often then treated on an inpatient basis.

He concurs that the change in philosophy was spurred in part by insurers. "The insurance companies got wise and discovered that there really wasn't any better outcome" with inpatient versus outpatient treatment. Also, he says, patients in inpatient treatment would get "artificially well," and wouldn't cope as well once they were in their old environments, with all the problems and temptations.

The cost of an outpatient program versus an inpatient one is the biggest advantage for those footing the bill, frequently insurance companies or employers. Costs vary at clinics and hospitals, but all outpatient programs cost significantly less than inpatient.

David Judy, manager of intensive outpatient programs at Chemical Dependency Center at St. Mary's Medical Center in Evansville, says his organization's outpatient program is one-fifth the cost of the inpatient program.

"You can understand why employers would be happy about that," he says. For a company, the cost of treating an employee is much less than the cost of lost work time--or replacing the employee.

With follow-up care extending for a year after the patient's intensive outpatient program, an outpatient program clearly takes more time to complete than the traditional inpatient treatment. But, Judy says, that gives counselors more time with an individual, and more of a chance to see the patient in his or her own environment.

Christine Pochert, marketing director at Charter Hospital of South Bend, says that while inpatient care is still valuable until a patient is free of drugs or alcohol, outpatient is a successful way to treat addictions. "You get the person out of the situation where they're using and abusing and look at it from a distance," she says. "We're just all being more flexible."

"The big trend now is to go for the least restrictive and most cost effective" way to treat addictions, says Scott Lewellen, program coordinator of Counterpoint Center at CPC Valle Vista Hospital in Greenwood.

Although he was at first skeptical of the outpatient approach to treatment, Lewellen now believes that if done properly, and with the family involved, it can be successful. "It's really crucial to involve the family. Overall, I'd say it's a success."

Outpatient treatment traditionally had been "kind of a stepchild" to addictions treatment, says Mike Kowalenko, manager of Lindenview at Parkview Memorial Hospital in Fort Wayne. Before the outpatient trend caught on, most insurance policies covered standard inpatient recovery, and didn't recognize outpatient therapy. Treatment for drug and alcohol addiction is becoming "a lot more service-oriented," he adds.

There is more focus on family support during recovery, and counselors immediately address the factors in patients' lives that make them abuse drugs or alcohol. "When they leave, there's not that abrupt transition" to reality, he says.

The move on the part of clinics and hospitals from inpatient to outpatient treatment truly is a "dramatic change," Hamilton Center's Kelly says. Although the Minnesota Model has not been abandoned, the emphasis now is on "relapse prevention," she says, and that's where outpatient care can help best, because counselors can identify the so-called triggers in a patient's life that cause the person to begin abusing drugs or alcohol. "We're trying to look at what kind of factors play in a role in their using."

Still, there are many experts who are doubtful that outpatient is the only way to go. Some patients still need the intense, protected environment of inpatient care, they believe. People who abuse drugs or alcohol may not be as easy to categorize and treat when counselors see them three or four times a week.

Westrich of Charter Medical Corp. says inpatient treatment remains the choice for patients who need detoxification. Detox is imperative in treating addiction to certain drugs, while other substances require no detox treatment, he says.

"Variables begin to compound the issue," adds Robert Permut, medical director at Behavioral Care Center at Methodist Hospital in Indianapolis. Some patients are addicted to more than one substance, patients are in varying stages of addiction, and a particular treatment for drug abuse may not be as effective for alcohol dependency, he says. "I think it's going to take some side-by-side research" to prove that outpatient is better that inpatient care.

Likewise, Aurora's Donley says patients have different levels of need, and some need inpatient care. The question is when these patients should make the transition to outpatient. In the mind of the payer, the need for inpatient care may be only medical. "The person may be medically stable," but patients are not always emotionally ready for the pressures of everyday life when they've only been clean for a week. "We're seeing a real tough time for some of our patients who go home."

Those newly drug- or alcohol-free patients are "put in an environment they can't cope with," Donley says, "like going on a diet and going into a chocolate shop. It's just not a good idea."

The payers dictate what kind of treatment a patient will receive, he says, because the bills are costly enough that most patients can't afford it on their own, and hospitals can't afford to absorb unreimbursed costs of treatment.

"I think there will always be conflict between the payer and doctor as to when a person is ready to go out, and unfortunately, payers hold the bigger stick," Donley says.

As a result, most hospitals and clinics have become much more flexible. Methodist in Indianapolis has developed a continuum of care, so that patients are treated during all stages of addiction, from inpatient detoxification to after-care and support meeting and counseling.

Fairbanks Hospital in Indianapolis also offers such a continuum of care. It offers inpatient treatment as well as outpatient programs, but also has a program known as intensive day treatment. According to Fairbanks, the highly structured program is for patients who are not yet ready for outpatient programs, but who have stable and supportive living situations that make inpatient treatment unnecessary. Fairbanks also offers after-care services, as well as adult education groups for people who have experienced limited consequences of alcohol and drug use but may not need more intensive treatment.

Since the 28-day inpatient stay as a one-size-fits-all treatment seems destined for history books, outpatient treatment will have to prove successful for all patients in the future. Says Donley, "We've had to get more creative. I think the basic concept is sound, that not everybody needs 28 days, and we need to fine-tune and adjust it."
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Title Annotation:Hospitals & Clinics
Author:Martel, Judy
Publication:Indiana Business Magazine
Date:Nov 1, 1993
Words:1672
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