Keeping clients engaged in treatment is an ongoing challenge for providers, but Community Medical Services, an Arizona-based national operator of opioid treatment programs in nine states, is finding success by enticing patients to strive for rewards.
Contingency management is a positive behavior technique used to reinforce positive behaviors by implementing a reward system for patients. Prizes can earned for completing recovery-related activities, such as attending counseling and group sessions. Prizes range from small snacks to vouchers for job interview-appropriate clothing at local thrift shops.
Haley Horton, regional director of operations in southern and western Arizona for CMS, and Michael White, MCJ, the organization’s director of community programs, say they had promising early returns after implementing contingency management initiatives in their programs last fall. They will present on their experiences at the upcoming virtual National Conference on Addiction Disorders. Ahead of their appearance at NCAD, Horton and White spoke with Addiction Professional about how contingency management became part of the CMS model, the difference it made with patients prior to the COVID-19 pandemic, and the importance of understanding the costs involved.
Editor’s note: This interview has been edited for length and clarity.
How did contingency management become part of the CMS model?
White: The reason Community Medical Services looked at this idea was that SAMHSA and two representatives from each state went to an all-hands SOR [State Opioid Response] grant meeting last year. … The first day of that convening was 100% about contingency management, and it was basically SAMHSA and the researchers that had been studying this for two decades informing and educating the state about contingency management, their ability to use it, and also reimbursing providers for it. That was the initial conversation that happened last August, so we knew it was a thing that SAMHSA was pushing and states were being encouraged to adopt.
Being reimbursed for contingency management was something we hadn’t heard about. We definitely were looking at different ways to increase engagement and decrease AWOL rates or discharge rates. Anything we can adopt or implement to affect those numbers, we would take a look at and see if a year later those outcomes made sense and did what we wanted to do.
Horton: We are largely Medicaid-funded in our Arizona market, and this idea of providing reinforcement or prizes to reinforce good behavior is something we’ve never had funding for. Certainly, a company could choose to pay for some of these things out of pocket, but it can become costly if you don’t have a structure around it. When the opportunity came up for us to work with our Medicaid payers and SAMHSA on a grant for this particular purpose, we jumped on it to see if we could implement it in our opioid treatment model, which there hasn’t been a lot of research on so far. A lot of what’s been researched so far has been on stimulant use. That’s how we got started, looking at whether there was a way for us to implement it internally and do we have client behaviors that we want to see reinforced or rewarded.
Have you gotten any sort of feel yet for the difference this is making in terms of improving outcomes?
Horton: A little bit, and then COVID hit, unfortunately. We were given this opportunity last October, and implemented a contingency management program by way of prizes for attending counseling sessions and group counseling sessions in a rural market where, historically speaking, follow-through with treatment was incredibly low. We started the project down there, and we had staff who were jazzed about being able to reward clients for participating in group. They started passing out tickets, and clients who attended sessions would get tickets that could be immediately exchanged for a prize, or they could save it up for a larger prize item. We saw attendance go from zero to about eight people in a very short period of time.
To start this out, our staff took a moment to survey clients. What would get you to participate in groups and counseling sessions? They said, “Reward us with something we can’t buy with our limited income or food stamps.” What are those things? Resoundingly, they came back with things like charging bases for phones, good laundry detergent, good creamer for coffee—things that if you have a little bit of money, you don’t want to spend it on those things necessarily. We purchased those items and created a value system for what tickets were worth. One ticket could get snacks or a soda, which were highly desired. Five tickets might get you a bottle of liquid Tide laundry detergent. That’s how it started—with us asking specific patient populations what they would be interested in—and we immediately saw attendance jump. And the better part was how many people continued to participate in some of these sessions or groups to continue to earn prizes. What we’re tracking now is the outcomes of those particular clients. Did it improve their employability or their stability in the services we’re providing, like medication treatment and medication management for opioid use disorder?
Then, COVID hit, which put a bit of a damper in our plans, but we’re ready start back up as soon as Arizona COVID rates start to decrease again.
Is there anything you’ve learned along the way with implementing this that you wish you had known when you started?
Horton: Aside from predicting the pandemic?
White: I think it would be the total money reimbursement money annually per client. That’s still a heavily debated conversation. SAMHSA says it’s one number, the state says it’s another number, the researchers think it should be a very large number. That’s an important step.
Horton: Funding the program in general. Do we have a problem that needs solving? Do we have a behavior that needs changing? If the answer is yes, is this a fundable project that is sustainable financially? Some companies might be willing to sustain paying out of their bottom line for prizes. And not all prizes or tokens have to cost money. Sometimes, you can establish a partnership with a thrift store to receive a voucher for interview clothing and things like that. That is considered contingency management as well. So, it’s figuring out the funding for this and if you can get some sense of what it costs to make a behavioral change… Like Mike said, it’s highly debatable as to what is the dollar figure that is permissible and that the researchers say is acceptable for making a change. We’ve heard thousands of dollars per person, per year to make a change. We’ve seen that isn’t necessarily true in our framework.