Detox begins at home, one agency is betting

Texas provider says it’s found a niche market

Hoping to jump ahead of the managed care bandwagon instead of on it, hospital-based Dallas-Ft. Worth Home Health Care has launched an ambitious home detox program as a lower-cost alternative to inpatient treatment for people addicted to alcohol or prescription drugs.

Claiming this is the first program of its kind in the Dallas-Ft. Worth area, director Maritta Loo, RN, CNA, thinks home detoxification services will soon become a national trend. "Once managed care gets into this, this is going to be the wave of the future," she predicts.

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-Ft. Worth Home Health Care.

Between 10% and 15% of the population is estimated to have some form of alcohol or drug dependency, according to figures provided by Kaiser Permanente. Loo and Keeney estimate that approximately 15% of the people in the 17-county Dallas-Ft. Worth area have serious addictions. "We have a high student population, and that’s calculated in the overall numbers," explains Keeney.

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

Dallas-Ft. Worth Home Health is Joint Commission-accredited and employs about 60 people. Home health nurses and aides make about 45,000 visits a year. The daily patient census is between 100 and 125. A full-service provider of home medical, surgical, and psychiatric nursing since 1985, the agency began its home detox program only this past June. So far, one patient has successfully completed the program, but Loo and her associates project treating 20 to 50 patients the first year.

According to Dallas-Ft. 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.

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 a critical pathway/ treatment plan.

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

The agency declined to disclose other start-up costs for the program, saying only that it had spent money on brochures created through the hospital’s public relations office. "We had some energy to expand our product base. When we began looking at it seriously, it became clinically feasible," explains Stephen Nesbitt, a CPA who serves as home health financial manager. "We redirected resources in-house, including a lot of education of our nurses. That’s still ongoing."

The seed of 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.

Pitching the idea to payers

Loo says most patients will pay for the home detox program themselves, but adds, "Payers are interested. Some local HMOs and PPOs are seriously looking at this. We’ve actively discussed it with some, but it [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) 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."

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

But Loo and Keeney 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 detoxed, he or she must sign a treatment contract, agreeing to attend Alcoholics Anonymous meetings or meetings with a group addiction counselor regularly. Spouses or significant others are encouraged to attend Al-Anon meetings.

Dallas-Ft. Worth Home Health 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 Ft. Worth will not treat people addicted to so-called street drugs like heroin or cocaine.

All staff are given inservices

Home services covered are physician supervision, detox medication management, a copy of the book Alcoholics Anonymous, lab costs, family education, 12-step program orientation, educational videos, and 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 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 by the significant other between visits. The significant other 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, it can usually be determined 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 give random saliva tests at home to ensure 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 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."