Transcript Increasing Attendance and Compliance with Incentives

Increasing Attendance and
Compliance With Incentives
Maxine Stitzer, Ph.D.
Johns Hopkins Univ SOM
Improving Care Conference
Johns Hopkins Center for Behavior and
Health
September 25, 2013
Presentation Outline
• Motivational Incentives: Definition and goals
• Utility in service access, entry and utilization
• Application feasibility issues
Motivational Incentives =
Contingency Management
• Definition: Positive reinforcement delivered for desired
behaviors to increase frequency of those behaviors
– Can be social (attention; praise) or tangible reinforcers
• What’s the goal?
– Counter ambivalence and barriers to service access
– Guide people to better health and well-being by
encouraging healthful and pro-social behaviors
Motivational Incentives
positive reinforcement to promote desirable behavior change
Reward programs
Acknowledges people for achieving a major goal or
completing significant progress
• Rewards usually given to the “best” and most
motivated people
• They don’t change the behavior of those
struggling with drug use and/or treatment
compliance
Reinforcement programs
Reinforcement programs on the other hand, use
incentives to…
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Break down goals into very small steps
Reinforce each step along the way
Make it easy to learn & earn
Give reinforcements early and often
Include the most troubled and difficult to reach
most troubled & difficult to reach patients
Reward vs Reinforcement
Reward goals
Reinforcement goals
Completing treatment
Attend treatment session
Get a job
Submit job application; go to interview
Complete GED
Sign up for GED; attend a class
30 days abstinent
One negative urine
Incentives in Substance Abuse
Treatment: Efficacy Review
• Service access and entry
• Repeated service utilization
• Drug use cessation and relapse prevention
Service Access and Entry
Getting people into the door
Immunization Rates
100
80
60
40
20
0
YES
NO
Rates increased when WIC food vouchers were
given to those who had their children immunized
(Hoekstra et al., 1998)
Vouchers for Free Methadone
Treatment
(Sorensen et al., 2005)
• Opioid abusers (N = 126) receiving care
in a hospital
• Randomly assigned to 4 conditions
–
–
–
–
Usual care referral
Case management for 6 months
Voucher for 6-months free methadone Tx
Combined voucher and case management
Vouchers for Free Methadone
Treatment (Sorensen et al., 2006)
Six-Month Outcomes
100
80
60
40
20
0
Usual Care
Case Mgt
Vouchers
Combined
Tx
Vouchers for Treatment Re-entry
(Kidorf et al., Addiction, 2009)
• Incentives offered to needle exchange users
(N = 188) for attending “treatment
readiness” groups
– $10 cash; $10 MacDonald; $3 bus pass per
group attended
• If they entered Tx, $50 was paid to the
program to cover initial fees
Vouchers for Treatment Entry
(Kidorf et al., Addiction, 2009
ATTENDED SESSIONS
ENTERED TREATMENT
60
40
20
0
YES
NO
INCENTIVES
Care Continuity: Residential to OP
(Aquavita et al., JSAT, 2013)
• Tested 3 methods of transition from 28-day
residential to outpatient aftercare treatment
(N = 260)
– Usual care
– Client incentive
– Residential in-reach
Care Continuity Interventions
• Usual care
– Select program; fax referral; make appt (optional)
• Client Incentive
– $25 to show up; $75 more for continued attendance
• Residential in-reach
– In-person meeting with OP counselor; sign contract;
next day appt
Residential-To-Outpatient
Transition Rates
84%*
74%*
Service Entry Summary
• Vouchers for free treatment have worked
• Direct payment to patients for entry not as
effective as “warm hand-off”
Services Follow-Through
Receipt of HIV Test Results
(Thornton R, Am. Econ Rev, 2008)
Rural Malawi residents (N = 2812) accepted free HIV testing
All participated in a drawing where there could earn $0, $1,
$2 or $3 if they returned for HIV test results
100
80
60
40
20
0
YES
NO
INCENTIVES
Incentives for Treatment Entry
Follow-Through
(Corrigan et al., 2005)
• Substance users with traumatic brain injury (N = 195)
with intake completed at an OP treatment program
• Outcome = return to sign an individual service plan
(ISP) within 30 days
• Randomly assigned via phone delivered intervention
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–
–
–
Attention control
Motivational interview
Barrier reduction- pay for taxi, bus, parking, etc
Incentives- $20 gift certificate upon ISP completion
Percent Returning in 30 days
Traumatic Brain Injured Sample
Percent Signing ISP
100
80
60
40
20
0
Attention
MI
BR
Study Condition
Incentive
Services Follow-Through
• Financial or transportation incentives can
motivate people to follow up with the next step
– Return for test results
– Complete treatment ISP
Attendance Incentives:
Encouraging People to Stay
Prizes Escalate With
Consecutive Target Behavior Performance
5
4
3
2
1
Sessions Attended
# Prize
Draws
Attendance Incentives in an
HIV Drop-In Center
(Petry et al., 2001)
Prize draws escalate with weeks of consecutive
attendance during a 14 week intervention (n = 43)
Average Attendance per Session
Baseline
0.7
(range 0-3)
CM intervention
7
(range 2-12)
Attendance: Group Therapy for
Methadone Patients
(Sigmon & Stitzer, 2005)
• Patients were assigned to attend orientation
(N = 44) or cocaine (N = 58) groups 2X per
week for 12 wks
• Prize draws could be earned on an escalating
schedule for attendance; max earnings =
$170
Cocaine Group Attendance in
Methadone Maintenance
Transition
Clients
Consistent
Clients
100
80
60
40
20
0
No Incentives Incentives
Attendance in OP Treatment
(Petry et al., 2012)
• Participants (N = 215) were cocaine abusers
urine negative at entry to outpatient
psychosocial counseling treatment
• Randomly assigned
– Usual care
– Escalating prize draws over 12 weeks; max
earnings = $250
Attendance in OP Treatment
$250 in prize draws
(Petry et al., 2012)
Sessions attended
20
15
10
5
0
Usual Care
Incentive
Care Continuity Study: Client Incentive
Increased OP Attendance First 30 Days
*
Incentives for Session
Attendance
Positive incentives have clearly been
useful for increasing rates of attendance
in substance abuse treatment settings and
could be effectively used in health care
settings
Abstinence Incentives:
Initiating and Sustaining Drug
Abstinence
Majority of research has used drug
abstinence during treatment as target
by reinforcing drug negative
urine tests
Voucher Reinforcement
for abstinence initiation and
maintenance in cocaine abusers
• Principle of alternative reinforcement:
– Benefits of abstinence are long-term
– Making abstinence today a more attractive option
• Points earned for cocaine negative urine results
– Escalating schedule of point earnings
– Trade in points for goods
– $1000 available over 3 months
Voucher Incentives for Outpatient
Drug-free Treatment of Cocaine Abusers
Higgins et al. Am. J. Psychiatry, 1993
Cocaine negative urines
Percentage of stimulant negative
urine samples
Methadone Maintenance Sample:
Percent Stimulant Negative Urines
100
Abstinence Incentive
Usual Care
80
60
40
20
OR=1.98 (1.4-2.8)
0
1
3
5
7
9
11 13
15 17 19 21 23
Study Visit
Abstinence Incentives
• Promotes initial abstinence when drug use is on-going
• Promotes increased duration of drug-free treatment
participation after drug use stops (relapse prevention)
• Positive impact on long-term outcomes
– Longer during-treatment abstinence translates into better
long-term outcome (Higgins et al., 2000)
Cross-Substance Generality
Cocaine
Opioids
Methamphetamine
Alcohol
Marijuana
Nicotine (Tobacco smoking)
Summary
• Positive incentives in the form of vouchers
or prize draws can be therapeutically helpful
in several ways to promote:
– services access and entry
– continued involvement in services
– abstinence and relapse prevention
Potential Application in
Health Care
• Access specialty services
– e.g. vaccinations; prenatal and pediatric care
• Keep follow-up medical appointments
• Address drug use as a barrier
• Take prescribed medicines
• Promote healthy lifestyle change
Incentives can help overcome
barriers and move patients along a
motivational continuum
• What’s in it for them? People like immediate
gratification
• Long-term benefits to health are theoretical, largely
intangible and in the future
• Incentives bring benefits forward in time and make
them tangible
Can you do it?
Traditional barriers to
implementation are coming down
• Attitudes
• Cost/financing
• Training resources
Why pay people to do what they should
be doing anyway?
Because they aren’t doing it!
Incentives are a practical fix to a
therapeutic conundrum
They change the therapeutic dynamic for
difficult patients toward acknowledging and
celebrating success rather than blaming or
dwelling on failure
Does everyone need incentives?
• Principle of “justice” suggests incentives
should be given to everyone but• Incentives have best application for those who
struggle with adherence despite lower-intensity
interventions such as appointment reminders
Financing
• Ideally, incentives would be built into the
budget and offset by health care cost savings
• Meanwhile, there are some work-arounds
– Community donations (women and children)
– Staff donations of goods and/or money
– Small grants or agency-funded pilot projects
Incentive prizes don’t
need to be costly but do
need to be desirable
know your audience
Dollar Stores are full of great things!
Ask patients
what they want!
Implementation Needs Planning
• Who will be offered incentives?
• How will program be structured?
– How much and for how long?
• Who will manage and coordinate the program?
• How will incentives be purchased and financed?
• Where can staff get training and advice?
• How will impact be evaluated?
Training Resources
• NIDA CTN Blending Products provide principles
and tools for structuring an incentive program
– Identifying effective reinforcers
– Constructing fishbowls
– Escalating schedules
• Expert consultants are also available through CTN
and Addiction Technology Transfer Centers (ATTC)
Training Resources
• NIDA Blending Products
– PAMI
– MI PRESTO (includes CD)
– www.ctndisseminationlibrary.org
• Petry Manual
– Contingency Management for Substance Abuse
Treatment. A guide to Implementing This EvidenceBased Practice (Taylor & Francis, 2012)
Incentive programs
are feasible to
implement
And they will make
a difference!