Opioid deaths, addiction, and misuse of prescription drugs continue to be significant issues for communities across the country. The good news is that we are making progress. Besides additional support from the White House, payers are stepping up coverage for support and treatment. While we can celebrate our progress thus far, we need to be cognizant that we still have a long way to go. One of the major barriers inhibiting success remains a disjointed continuum of care for SUD patients. When patients experience fragmented care, especially in transitions of care, they are more likely to abandon treatment.[1]

Any change in treatment settings, staff or peers increases the risk that a SUD patient will drop out of treatment.[2]

When most chronic care patients transition from one care setting to another, such as a skilled nursing facility to home health, their doctor, specialists, and other care providers work closely together to ensure a smooth handoff. But that’s often not the case for SUD patients as they move from intervention to inpatient or detox, and then on to a Partial Hospitalization Program (PHP), an intensive outpatient treatment (IOP) center, or ongoing recovery at home. These transitions, when not handled appropriately, pose significant danger for SUD patients.

The following are three opportunities to elevate the effectiveness of transitions of care and reduce dropouts.

Create a more effective referral process.

This means providers at an inpatient facility need to ensure referrals are complete and that patients have followed through after being referred to a PHP or IOP. The best way to do this is with electronic referrals. Unlike faxed referrals, electronic referrals provide a digital pathway through which providers can share information and close the loop on each referral. Referral-based analytics can provide insights that help identify potential gaps in care and opportunities for process improvement. Electronic referrals also help providers identify the best treatment center or recovery program for each patient while ensuring they are in-network. This removes barriers that could complicate the transition and lead the patient to drop out.

Prioritize patient engagement.

Keeping patients engaged with providers, family, peers, and other caregivers is one of the most effective ways to reduce dropout rates during transitions of care. This is especially true when the patient moves from an inpatient treatment or detox center to a PHP or IOP. Patients are highly vulnerable as they begin to step back into their previous lives where they may face the same pressures that led them to a life of addiction. In other words, they’re getting real-life experience putting what they’ve learned during treatment to work. Having a support system that follows them from one stage of treatment and recovery to the next is essential. Leveraging technology such as smartphone apps is a great way to maintain communication and continue building a relationship of trust and support.

Provide patients with tools that stay with them from inpatient to outpatient to recovery and beyond.

The same smartphone apps that help keep caregivers and patients engaged during transitions of care can also act as a 24/7 support, treatment, and recovery resource. Research shows that SUD patients that use mobile phone interventions are less likely to experience relapse and more likely to achieve long-term success.[3] These apps should include tools like motivational videos, journaling, daily surveys, and appointment reminders. They should also include a feature patients can use to request help quickly when they’re facing a situation likely to cause relapse.

Treat the patient’s healthcare journey as an extended episode of care and use a recovery solution that integrates with a full platform of SUD care tools, including intervention, treatment, and recovery. The solution should offer provider care management functionality, predictive relapse risk indicators, and analytics. This allows for a more comprehensive picture of the patient’s journey and delivers better coordination of care from intervention to inpatient treatment and detox, PHP, IOP, and ongoing recovery at home.

The Proof

CHESS Health offers eRecovery, a solution encompassing the patient-facing Connections App linked to the caregiver Companion App. eRecovery enables continuous communication between patients, peers, and the care team to reduce isolation, promote trust and compassion, and reinforce skills needed for long-term recovery.

CHESS Health offers clinically validated results published in publications like JAMA Psychiatry, and Journal of Dual Diagnosis.[4]

  • 31% fewer patients relapsed
  • 50% reduction in severity of relapse
  • 71% reduction in re-hospitalizations
  • 20% more likely to complete treatment
Enhancing Care Continuity throughout the Continuum for SUD Patients

Gaps in care are deadly for SUD patients and are a key cause of relapse. Transitions from inpatient to PHP to IOP to at-home recovery present the greatest risks for dropouts.

If we are ever to truly win the war on addiction, we must treat SUD patients as we do other chronic care patients. We can do this by ensuring patient engagement is ongoing, that patients have support tools that stay with them through each transition—especially from inpatient to outpatient treatment—and use platform-based tools that help providers deliver a more effective, holistic journey to sobriety.

[1] https://aspe.hhs.gov/system/files/pdf/260791/BestSUD.pdf

[2] https://www.ncbi.nlm.nih.gov/books/NBK64088/

[3] https://www.chess.health/evidence/

[4] https://www.chess.health/wp-content/uploads/2018/11/che-ss-eRecovery-EM181017.pdf