Home detox could be the wave of the future

Managed care companies showing interest

A Dallas-area home care agency has launched an ambitious home detox program as a lower-cost alternative to inpatient treatment for people addicted to alcohol or prescription drugs. Although home detoxification services are primarily private pay now, one provider predicts they will soon catch on with managed care and become a national trend.

"Once managed care gets into this, this is going to be the wave of the future," says Maritta Loo, RN, CNA, director of Dallas-Fort Worth Home Health Care.

Loo claims Dallas-Fort Worth Home Health Care’s detox program is the first of its kind in the Dallas-Fort Worth area. At least three other providers around the nation offer similar programs. Staff Builders Homecare & Hospice in Independence, OH, and Recovery Resources in Cleveland now are providing detoxification entirely in patients’ homes. Home Detox, based in San Diego, says it has put 150 patients through home-based drug and alcohol addiction treatment in the past two years.

"They are doing it in a big way in Canada, England, and Australia," says Barbara Keeney, RN, clinical coordinator of the home detox program at Dallas-Fort Worth Home Health Care.

Most patients will pay for the home detox program themselves, Loo says. The agency charges a flat rate of $1,000 for a three-to-four-day program and $1,250 for a five-to-seven-day program. That compares with $4,000 to $6,000 for a similar hospital inpatient detox stay, Loo says. But she is quick to add that not all patients qualify for home detox. Dallas-Fort Worth will not treat people addicted to street drugs, such as heroin, cocaine, or marijuana.

Payers are showing interest, though. "Some local HMOs and PPOs are seriously looking at this," Loo says. "We’ve actively discussed it with some, but [negotiation] is a very lengthy process. We plan to market it to them. It’s still in process; there’s a lot of protocol."

Only one of the managed care organizations insisted on outcomes (three months worth) as a condition for paying, Keeney says. "Our program is very formal, very specific, and we give them a case rate. Managed care organizations love that."

Interest and numbers are there

Loo and Keeney estimate that approximately 15% of the people in the 17-county Dallas-Fort Worth area have serious addictions to alcohol or drugs. "We have a high student population, and that’s calculated in the overall numbers," explains Keeney.

Dallas-Fort Worth Medical Center does not have its own inpatient detox program, however.

A full-service provider of home medical, surgical, and psychiatric nursing since 1985, Dallas-Fort Worth Home Health began its home detox program only this past June. So far, only one patient has successfully completed the program, but Loo and her associates expect to treat 20 to 50 patients before June 1998.

According to Dallas-Fort Worth Medical Center public relations director Sally Bradford, about 20 people have made phone inquiries, mainly the result of local newspaper ads. "We’re starting to average about two calls a week," she says.

Research shows that response to the ads, which so far have cost approximately $3,000, has been divided into two categories, based on when the ads run in the newspaper. Family members of alcoholics and addicts call on weekends, and the addicts call during the week. "Alcoholics tend to read the Monday paper, not the weekend papers. Mondays are when they begin to feel they may have a problem. So we addressed that in our advertising," explains Bradford. "Weekend ads were aimed at families. Monday ads were for the alcoholic."

Other inquiries have come chiefly through referrals from Alexander Graham, MD, an Arlington, TX-based physician who has been treating addictions for more than 20 years. Graham has encouraged the program and assisted in the development of the agency’s assessment tools, such as the critical pathway/treatment plan. (See pathway, inserted in this issue.)

"We get referrals from families, doctors, emergency rooms, and substance abuse cases referred through Dr. Graham’s office," says Keeney.

The seed for the idea was planted by Graham and by Keeney, who says she had been approached by patients and other providers about the feasibility of a home detox program.

Getting the family involved

Loo and Keeney see a market in home detox among mothers who reject inpatient detox programs because they have small children at home. Aside from the convenience, it affords more privacy, they say.

But they also see a more practical reason for such programs. "You’re finding out what’s really going on at home," explains Keeney. "Dysfunctional families can cause a relapse. I feel that’s why we have so many people relapse in the inpatient programs."

Educating families about addiction, a key component of the program, improves the patient’s chances of recovery, Loo argues. "The more the family gets involved, they actually see the process of getting sober. Patients don’t go away for treatment and come back a different person."

The program includes clinical pathways with specific steps for each day of treatment, although Loo and Keeney say some of the pathways are evolving because the program is still new.

Patients are taught about the disease concept of addiction — how the brain changes with drug or alcohol abuse. "This makes them feel less guilty," Keeney says. "It also helps the family to get them involved in the process of education. Otherwise they tend to be left on the periphery."

Once an alcoholic has detoxified, he or she must sign a treatment contract, agreeing to attend Alcoholics Anonymous meetings or meetings with a group addiction counselor regularly. Wives and husbands or significant others are encouraged to attend Al-Anon meetings.

Home services provided are physician supervision, detox medication management, a copy of the book Alcoholics Anonymous, lab costs, family education, 12-step program orientation, educational video tapes, and all daily nursing visits, including follow-up phone calls at one, three, six, and 12 months.

The staff comprises six RNs with extensive psychiatric and substance abuse training, Loo says, but all the home health nurses are given inservices on dealing with addicts and alcoholics.

"It’s 24-hour medical coverage," says Keeney. "Our nurses need to know that if a detox patient calls in the middle of the night and reports a 106-degree temperature that Tylenol doesn’t lower or they’re having chest pains, they should go to the ER."

Valium is the drug of choice for alcohol detox, says Keeney, "because with alcoholics you worry about seizures and cardiac problems. They don’t seize with Valium."

Patients addicted to other benzodiazepine drugs like Xanax and Klonopin, usually prescribed for panic attacks, are weaned off the same drug, Keeney says, although Tegretol, an anticonvulsant, is used in some patients addicted to Klonopin. "Some people on Klonopin are at risk for seizures," she explains.

All detox is carefully monitored by nurses and in between visits by a family member who maintains a medication administration record, which shows dosage time, frequency, and amount.

"You need medical supervision for detox, but you don’t always need to be in the hospital and have round-the-clock nursing," Keeney says.

Nurses initially screen patients over the phone. During a 15-minute conversation, nurses can usually determine if there is family support for home detox. Patients are then referred to Graham, who also is affiliated with other hospitals in the area. He makes a more thorough assessment, including a blood chemistry test to determine, for instance, if there is any liver damage. Nurses take random saliva tests at home to ensure that addicts aren’t using or alcoholics aren’t drinking during treatment.

To even be considered for home detox, patients must be physically and mentally stable and must require physiological detox, Keeney says. "They can’t be suicidal. And we require that someone, either a husband, wife, or significant other is at home. There needs to be supervision in the home to track the detox medication."

Although the program is brand new and payers are slow to react, Keeney says she believes strongly in home detox. "When you think about it, it really is a bargain. It’s a small price to pay for sobriety."