EXTENDED CASE MONITORING FOR ALCOHOLICS--HEALTH COSTS

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The fundamental goal of this line of research is to find approaches to managing the treatment of patients with alcohol problems that produce the best possible long-term outcomes for patients at the lowest possible cost to society. We feel it is critical to evaluate alcohol treatments from a long-term perspective since alcoholism is a recurrent disorder whose social, health, and economic effects are often delayed. Clinical strategies that produce short-term effects on drinking outcome measures may or may not have substantial long-term impact on outcome measures such as health care or other costs which are of substantial social interest. In this project, we will study the effectiveness of a program of followup monitoring and referral on the clinical outcome and long-term health care use of alcohol patients enrolled in an HMO. Patients will be randomized into extended case monitoring vs. standard treatment. The extended case monitoring program is designed to augment the effectiveness of existing addictions treatment services, not to replace them. The intervention will help ensure that patients stay in contact with the health care system during a period immediately after treatment when the risk of relapse is especially high, and also, at a lower level of intensity, for a followup period of two years during which risk of relapse remains elevated. The case monitoring and referral intervention is designed to be a low-cost protocol that can be delivered by personnel with minimal clinical training and therefore low cost per patient per year. The Case Monitors who deliver the intervention will not themselves do any treatment, but rather assess and refer patients, where appropriate, to existing treatment services. The rationale for the intervention design is based upon protocols used successfully in other mental health fields, prior research in addictions, the literature on social support, and models for relapse. This proactive system for maintaining contact with patients and their families is intended to remedy a defect in the present system of delivering treatment to alcohol abusers, in which treatment services are provided to patients on the basis of their demand at points of acute crisis rather than their actual level of need. Under the current delivery system, many patients who could benefit from clinical intervention fail to seek services until their situation has deteriorated substantially. Earlier re-entry into treatment should improve average outcome levels and over the long run reduce health care costs by minimizing the need for high levels of care to deal with severe crises.