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Advancing Recovery Missouri Case Study

About Advancing Recovery Missouri

The Advancing Recovery project aims to develop and implement administrative and clinical system improvements at provider and state levels to promote the use of selected categories of evidence-based practices for addiction treatment. The project is designed for single state agencies and treatment providers to work in close collaboration, as partners, to increase the use of evidence-based administrative and clinical practices (EBPs) in the treatment of addictions.

Advancing Recovery (AR) Missouri is a partnership is between the Missouri Department of Mental Health, Division of Alcohol and Drug Abuse (ADA), and 10 certified, contracted substance abuse treatment providers located throughout Missouri. The Missouri Department of Mental Health, Division of Alcohol and Drug Abuse (ADA) is the single state agency (SSA) responsible for administering federal and state funds appropriated for drug and alcohol prevention and treatment. Terry Morris, Director of Clinical Services, Division of Alcohol, leads the AR Missouri project.

All 23 providers contracted by the state were invited to participate in the partnership. Ten providers accepted and are actively participating in the partnership. These providers serve both Kansas City and St. Louis, the two largest metropolitan areas of Missouri. Two of the participating partnerships are programs for women and their children. These are inner-city based programs with a high admission rate of minority women. One of the programs is located in the inner city and is associated with a homeless shelter. This program serves a high percentage of minority men who are homeless and jobless. Two other of the programs in the partnership have well-developed co-occurring disorder programs and members of this population are eligible to participate. The partnership also includes providers in rural settings.

Project Information

Changes Implemented

Key Successes

In the first year of this partnership, the Advancing Recovery Missouri project worked to remove barriers to the implementation of medication-assisted treatment (MAT) for treating alcoholism. Key successes of Year 1 included an improved screening tool to determine client appropriateness for medication-assisted treatment, increasing awareness of the effectiveness of medication-assisted treatment for alcohol dependence, and most significantly, establishing a funding mechanism for medication, physician, and laboratory services.

No consumers were receiving naltrexone or acamprosate to assist treatment of their alcohol use disorder prior to the Advancing Recovery partnership. Now all consumers are being screened by providers in the partnership. Over 170 consumers have received medications and over 55 continue to take medications as prescribed.


Medication-assisted treatment has been historically underutilized in Missouri's publicly-funded system of care, and previous attempts to increase use of medication-assisted treatment had been unsuccessful. The first category of evidence-based practice (EBP) that the Missouri partnership chose to address was the "use of medications for specific diagnoses."

Client data for 2005 clearly showed that for nine of the ten providers in the partnership, alcohol was most frequently used and abused by their adult clients. Because of this, in Year 1, AR Missouri chose to focus on removing barriers to the use of naltrexone and acamprosate to treat alcohol dependence. This evidence-based practice was judged to offer the greatest potential to benefit the largest percentage of Missouri consumers from all cultures, backgrounds, and socioeconomic levels.

Provider Walk-throughs

As part of the application process for the Advancing Recovery project, the Missouri provider agencies were required to conduct a walk-through of a selected system or process. The walk-through exercise helped the provider change teams gain familiarity with the NIATx model. The process also helped the teams identify the most significant barriers embedded in their systems that prevented use of medication-assisted treatment:

  • The screening process was not set up to evaluate the consumer's appropriateness for medication-assisted treatment.
  • Lack of funds: state contracts reimbursed providers for medications, physician and laboratory services for detoxification, but not for day treatment with residential support or outpatient treatment.
  • Consumers lacked the resources to purchase naltrexone or acamprosate even if the medications were prescribed.

Based on the results of the provider walk-through exercise, the Missouri team planned to focus their change efforts on modifying the screening process so both the SSA and provider could get a better idea of how many clients might be potential candidates for medication-assisted treatment. This information could guide the development of practices and funding approaches for those individuals.

The provider walk-through also showed that the greatest barrier to implementation of medication-assisted treatment was that the state does not fund physician services in all programs. The state did not reimburse providers for medication or laboratory services. These services must be available for the provider to use this evidence-based practice. Adding reimbursement for medication, physician time, and laboratory services would dramatically increase the use of the medication-assisted treatment for alcoholism.

State System Walk-through

The Advancing Recovery application also required the ADA to complete a walk-through of one of the state system's administrative processes. The state walk-through exercise began by focusing on reimbursement mechanisms to fund this evidence-based practice.

Through collaboration with providers, the project planned to fund the services for the selected evidence-based practice by reducing residential support services, where clinically appropriate to do so, but without reducing the intensity of treatment. This would be accomplished by stabilizing consumers more rapidly through medication-assisted treatment, and thereby smoothing the progress of their transition to day treatment or intensive outpatient treatment.

A second strategy that the ADA and providers agreed upon was to refer all alcohol-dependent individuals for medication-assisted treatment wherever clinically appropriate, based on criteria to be developed by the Department of Mental Health's Medical Director. The project's first provider change exercise was devoted to testing this change.

Technical Assistance

Advancing Recovery Missouri received guidance from two NIATx coaches—a state coach and payer/provider coach. The coaches facilitated change projects and helped the project develop a sense of community. Face-to-face meetings, regular phone conferences, and the Advancing Recovery Missouri Web site, created with assistance from Matthew Hile at the University of Missouri, also helped with community building. Data tracking and sharing was a great motivator.


Year 1 Results

  • The Advancing Recovery Missouri project created a centralized purchasing process, working with a state hospital that has a contract to purchase naltrexone. The ten participating providers were able to purchase the medication directly from the state hospital at a state contract price, 70 percent below retail.
  • Amended state contracts now allow all contracted providers to be reimbursed for physician or nurse practitioner services to assess consumers and prescribe and manage consumer treatment with naltrexone or acamprosate. Amendments also allowed for contracted providers to be reimbursed for purchase of naltrexone or acamprosate.
  • The project provided training for clinical staff and medical staff to increase knowledge and competence in using medications to assist substance abuse treatment.
  • The state's clinical utilization review unit added medication-assisted treatment to the criteria for extending length of stay or exceeding the customary service authorization.
  • Storing and dispensing the medication presented a challenge for providers that had never dispensed medication before. Some providers were able to manage that through their own pharmacies. Others contracted with a local facility or pharmacy to dispense the medication. Yet other programs used a community health clinic for their prescribing services and in the process, began to develop relationships with medical and pharmacy resources.
  • Because the Missouri Medicaid formulary includes naltrexone, clients with Medicaid could obtain the medication easily at a pharmacy. While these clients represent only a small percentage of the population that ADA serves, the ease with which they could obtain the medication assisted their recovery.
  • The ten contracted providers are now using protocols to screen all consumers admitted for alcohol treatment services for medication-assisted treatment. At the end of Year 1, more than 170 consumers had been prescribed either naltrexone or acamprosate. More than 55 consumers are now receiving medications to assist in their treatment of an alcohol use disorder. Before the Advancing Recovery partnership, no consumers were receiving either medication.
  • At the provider level, focus groups of consumers, clinical staff, and medical staff have been interviewed and had an opportunity to ask questions and give feedback about the benefits and risks of medication-assisted treatment and the process consumers and staff members go through to implement this evidence-based practice.
  • At the state level, the steering committee has met with individuals and professionals within the 12-Step community to solicit feedback on how best to implement this evidence-based practice. This includes presentations to the state-wide advisory committee of the Missouri Division of Alcohol and Drug Abuse. This group is composed of a cross-section of stakeholders from around the state of Missouri and includes consumers, providers, and members of health care, social services, and law enforcement agencies.
  • The contract modifications developed during Advancing Recovery are being spread to include all contracted providers. The centralized purchasing plan for naltrexone is also being made available to all contracted providers. Provider members of the steering committee are meeting with executive directors and clinical staff from all contracted programs to review their experiences and lessons learned during Year 1 of Advancing Recovery. This will include access to the project's Web site and accumulated information and forms.

Lessons Learned

In the first year of Advancing Recovery Missouri, the partnership has learned a lot about implementing new practices. Advancing Recovery has the state and the ten providers thinking about a process that helps implement change in the systems. Key lessons include:

  • It takes champions at all levels to promote change.
  • Agencies that had a champion for medication-assisted treatment in clinical leadership as well as among counselors had greater success.
  • Staff and client education also helped with implementation of medication-assisted treatment. Removing biases and correcting wrong assumptions about medication-assisted treatment is crucial.
  • Naltrexone can be helpful in the recovery of a number of our consumers.
  • Clients responded to success stories about other patients' positive experiences with medication-assisted treatment.

Last updated 02/14/2011

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