increasing attendance and compliance with incentives maxine stitzer, ph.d. johns hopkins univ som...
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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 on the other hand, use incentives to…
• 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
Reinforcement programs
Reward vs Reinforcement Reward goals
Completing treatment
Get a job
Complete GED
30 days abstinent
Reinforcement goals
Attend treatment session
Submit job application; go to interview
Sign up for GED; attend a class
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
Rate
Rates increased when WIC food vouchers were given to those who had their children immunized
(Hoekstra et al., 1998)
Per
cent
Im
mun
ized
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)
Per
cent
Rec
eivi
ng S
ervi
ces
Six-Month Outcomes
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
INCENTIVES
PE
RC
EN
T
ATTENDED SESSIONS ENTERED TREATMENT
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)
PE
RC
EN
T
Rural Malawi residents (N = 2812) accepted free HIV testingAll participated in a drawing where there could earn $0, $1, $2 or $3 if they returned for HIV test results
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
– Attention control– Motivational interview– Barrier reduction- pay for taxi, bus, parking, etc– Incentives- $20 gift certificate upon ISP completion
Traumatic Brain Injured Sample Percent Signing ISP
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 Prizes Escalate With Consecutive Target Behavior PerformanceConsecutive Target Behavior Performance
Sessions Attended
# PrizeDraws
1
2
4
5
3
Attendance Incentives in an HIV Drop-In Center
(Petry et al., 2001)
Average Attendance per Session
Baseline CM intervention
0.7 7 (range 0-3) (range 2-12)
Prize draws escalate with weeks of consecutiveattendance during a 14 week intervention (n = 43)
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
Per
cent
Se s
sion
s A
tte n
d ed
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)
Ses
sion
s at
tend
ed
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 negativeurine 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
Methadone Maintenance Sample:Percent Stimulant Negative Urines
0
20
40
60
80
100
1 3 5 7 9 11 13 15 17 19 21 23
Study Visit
Per
cen
tag
e o
f st
imu
lan
t n
egat
ive
uri
ne
sam
ple
s
Abstinence IncentiveUsual Care
OR=1.98 (1.4-2.8)
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 atherapeutic 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
Dollar Stores are full of great things!
Incentive prizes don’t need to be costly but do need to be desirable know your audience
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 Evidence-Based Practice (Taylor & Francis, 2012)
Incentive programs are feasible to
implement
And they will make a difference!