Recently Relias hosted a webinar Recovery Residences to Improve Long-Term Outcomes with presenters from the National Alliance for Recovery Residences (NARR). David M. Sheridan, NARR Board President and Director of the Chandler Lodge Foundation, and Jason Howell, MBA, BS, PRS, Board President Emeritus, NARR and Executive Director of RecoveryPeople, presented on the value of quality recovery residences to long-term recovery.
Many professionals across the country and all types of providers joined the webinar and hundreds more asked for the recording. We were unable to get to all the questions that were asked during the webinar, so we created this blog post to address everything our audience brought up.
For those who would like to watch the recording, here is the link to the recovery residences webinar. Be sure to check for upcoming webinars on topics related to healthcare and human services. We host regular webinars to help support you.
Can you elaborate about the service levels not being a grading system but rather a designation?
In contrast to a rating system (e.g. 1-star vs 5-star), the NARR Levels distinguish between types (categories) of recovery residences, which differ in the kind and intensity of services and supports they provide. One level of support is not better than another, just different. Diversity within the continuum is important, because recovery is a process. Individuals need various types and levels of support at different stages of recovery. Matching an individual with the appropriate level of support is both recovery supportive and cost effective. A bit more on services offered by each level can be found on the NARR site, which offers a good summary table.
How does the recovery house pay for all the building (short and long-term) expenses?
Most often residents share in some, if not all, of the cost by paying monthly fees (e.g. rent). The vast majority of NARR Level 1 and Level 2 residences are self-pay. Level 4 residences, since they are usually licensed treatment providers, often accept insurance and other forms of third party payments. Level 3 residences are funded by either resident fees, third party payments, or a mix of those.
High start-up, operating, and capital expenses can be a significant barrier to creating and sustaining quality recovery residences. There are numerous approaches to addressing these issues; a sustainability plan is crucial to providing a stable and supportive living environment. To lower capital outlay, many providers choose to rent property from a landlord, who values long-term tenants and/or values supporting recovery. Others choose to own and/or maintain the property.
Revenue streams also vary by type of residence. In many states, programs for certain targeted populations such as criminal justice clients, fund recovery residence stays. A growing number of voucher programs and insurance benefit packages are looking at the cost effective nature of recovery housing. California’s Medicaid waiver permits the state to include recovery residence stays in its Medicaid program (although subject to existing prohibitions on using Medicaid funds for room and board.) Other states are exploring that model for their own Medicaid systems.
Is there a systematic way to assess an individual’s recovery capital for the purpose of determining the likelihood of a person achieving successful long term recovery?
William White has developed a Recovery Capital Assessment Tool, which has been adapted by others including George Braucht’s version called Recovery Capital Assessment, Plan and Scale (ReCAPS).
Rather than using such a tool as a predictor of long-term recovery outcomes, a recovery capital assessment may be better used as barometer as to the progress of an individual in their recovery. It is often used as a self-assessment, allowing an individual to reflect on where they are and what they want to focus on in a person-driven recovery action plan.
Recovery housing researcher Dr. Leonard Jason has written about other measures, which are found to have correlation with long-term outcomes, including self-efficacy and psychological sense of community.
Our state has mandated all HUD funded housing must follow Housing First. Do you believe HUD’s Housing First policy (homeless people are housed and allowed to continue using drugs/alcohol) is hurting people in recovery or violating the rights of people in?
Due to federal policy, this is true across all states. While Housing First and recovery housing are often held as diametrically opposed, that view is beginning to change. HUD published a Brief on Recovery Housing in December 2015. This document is a real change for HUD. In the brief, HUD highlights that some recovery housing does align with Housing First principles. Housing Choice is the bridge between the two seemingly opposite housing approaches. If we believe that addiction recovery is a person-driven process, that there are many pathways to recovery, and that abstinence from alcohol and non-prescribed (or illicit) drugs is a valid recovery pathway, then why would we not support someone’s choice to live in a sober, safe and peer supportive living environment? In some cases, recovery housing is the most stabilizing and integrative housing option for an individual at risk for homelessness or of being (re)institutionalized due substance use issues.
The HUD brief also encourages local continuums of care to consider recovery housing, and permits Continuum of Care funds to be used for that purpose. However, there are no federal funds specifically allocated towards recovery housing at this time.
Some argue that current funding policy, or the implementation of policy, raises barriers to genuine housing choice for persons in recovery from substance use disorders, which is a violation of federal fair housing law.
I think this would be most useful for city life. Is there data to support a rural setting such as a reservation or a less populated state like Montana?
Recovery residences can be traced back to the mid-1800s. Rural recovery residences have existed for a long time and continue to exist today. Like most addiction services (prevention, treatment and recovery support services), we tend to see a greater concentration in urban and suburban areas. Significant gaps in the continuum exist in rural, tribal and other under-served areas. A comprehensive census does not exist, so it is difficult to know where rural recovery residences can be found.
In general, rural residences provide higher or more comprehensive levels of support than other options because there are fewer support resources in the surrounding area. They may also be more closely linked with a faith-based community, treatment center or other supplemental support community. Ohio recently invested state dollars in recovery housing and has seen the growth of recovery housing in rural parts of their state.
What kind of services are provided to Level 2 recovery residence?
At a minimum, a Level 2 recovery residence provides a sober, safe living environment coupled with peer recovery support through the use of social model recovery philosophy and structure. In contrast to a Level 1, a Level 2 has an owner/operator appointed house manager. Some Level 2s offer more formalized recovery support services and life skills development, but not to the degree found in Level 3s or 4s.
Is the State of WV involved with NARR yet?
NARR has not received any inquires or interest from West Virginia’s SSA yet, although a handful of recovery residence providers have expressed interest in recent years. That interest hasn’t been strong enough to create a provider base sufficient to sustain an affiliate organization. Through a SAMHSA contract, NARR currently has resources to support emerging state affiliates. Inquires can be sent to firstname.lastname@example.org. The state’s addiction agency, or West Virginians interested in starting a NARR affiliate, are encouraged to apply for this assistance.
Can you please elaborate on your statement “as long as the client is serving the community”? Would this be considered a requirement to maintain residency in the recovery house, and what would be standard for a client being removed?
All recovery residences are based on the social model recovery. In these residences, residents are both recipients and sources of recovery support. Residents are expected to be active participants in developing and sustaining a recovery supportive culture and family-like community. Cultural norms are often codified in “house rules.” If a resident negatively impacts the health and safety of the household, the community may vote them out, their lease may not be renewed or they may be evicted. Examples of when a resident would be asked to move out are if they are using illicit drugs, engaged in criminal behavior or are a direct threat to others or property.
Would the standards developed have effect on individuals with criminal backgrounds, and how would that be considered?
The NARR standards do not directly address criminal background checks. Note, the recovery residence movement has largely been a peer recovery movement. Recovery residences generally do not discriminate against residents with felony convictions, given the prevalence of addiction amongst individuals convicted of nonviolent drug offences. Recovery residences are more likely to assess where a resident or staff person is in their stage of recovery. Within recovery residences, documenting one’s criminal background would have more to do with linking them with the appropriate resources or support.
So, if you had a model (e.g., a token economy to promote psychosocial achievement toward recovery) then it wouldn’t be a NARR residence?
Assuming “token economy” is referring to direct monetary rewards, there is nothing in the NARR standard that would preclude the use of such a mechanism, as long it was done in a legal and ethical manner. There are concerns around providing residents something of value as a means of inducing them to enroll into services that they don’t need or to exploit financial benefits. Consult legal counsel before implementing such a program. A NARR state affiliate would scrutinize the program using the NARR Code of Ethics as part of the certification and/or grievance process.
Overall, the need to identify what is and what is not a recovery residence was a driving factor behind the development of the NARR standard. To be considered a recovery residence, a provider or program needs to meet a wide range of standards. The social model of recovery and the cultivation of a psychological sense of community focuses on rewarding individuals and/or offering individuals the opportunity to have rewarding and meaningful experiences. If residents are not getting something out of the experience, they disengage and the therapeutic culture collapses. In this sense, there is an economy of exchange, but this may not fit within the definition of “token economy.” Other kinds of rewards include more relaxed house rules as residents progress in their recoveries.
That being said and when opportunities arise, resident leaders are recruited as a House Manager or other staff members. In turn, they typically receive discounted rent and/or a salary in exchange for fulfilling their staffing roles and responsibilities. But, these opportunities are not programmatically available to all residents.
What about those individuals who need medication-assisted treatment?
Recovery is a person-drive process, and there are many pathways to recovery. For those with an opioid use disorder. Many choose medication-assisted treatment (MAT); just as many choose not to use MAT. Medication alone is not a best practice, and recovery residences can play a vital role in an individual’s recovery journey regardless of their choice around MAT. Provider policies differ greatly. Some residence providers will not accept individuals taking certain prescribed medications, including those employed in MAT. Others may impose additional requirements on such residents, including provisions for safekeeping of medications.
NARR is currently developing an educational resource for providers on how to operationalize safe and supportive recovery housing when residents are using MAT.
Which recovery residence models of Type IV are in NREPP?
Various models can be found within each NARR Level of Support. Examples of Level 4s, which are listed in NREPP include Correctional Therapeutic Community (CTC) and Modified Therapeutic Community (MTC).
Is there a comprehensive list of recovery housing in Texas?
Like in most states, a comprehensive list of recovery housing does not exist in Texas. In large part, this is due to a lack of funding needed to conduct this research. TROHN, NARR’s Texas affiliate, maintains a list of residences complying with NARR standards, and which are subject to TROHN’s oversight. For more information, please visit the TROHN website. A directory of Oxford Houses in Texas is accessible on the Oxford House website.
How might I begin the process of opening/starting a recovery residence if I’m a LPC and LCAS?
Best of luck with your recovery residence startup. Feel free to use the NARR Standards as a roadmap. Since you are a clinician, you may want to check with your state laws around providing clinical services within a recovery residence setting. In some states, that can require the facility to be licensed as well. if you are in a state with a NARR affiliate organization, you should also contact that organization. Contact information is available on the NARR website. Just click on the state on the national map on the NARR home page.
In regards to HUD, is this specific to a certain state? And would they be able to move with the HUD after completion of the recovery home/ program?
HUD is a federal agency, which makes various funding streams available to states and individual providers. Each funding program has different policies and restrictions.
Given the opioid epidemic nationally, is funding increasing or decreasing for recovery residences?
There are some shining state examples, like Ohio, which is investing millions of state dollars into recovery housing in response to the opioid epidemic. Massachusetts has made a significant investment in developing and supporting its network of NARR-compliant Level 2 recovery residences. Other than these and a few other small programs, there has not been a significant increase in dollars allocated to recovery housing, yet.
Due to funding policies, we have not seen federal dollars directly support recovery housing. The Comprehensive Addiction Recovery Act was historic, but it did not come with funding. The 21st Century Cures Act carries $1 billion in federal dollars, but it cannot be used toward recovery housing vouchers. That being said, there is a huge opportunity for states to invest CURES dollars into recovery housing infrastructure: training, technical assistance and NARR affiliate development. This was actually a recommendation from the National Council. Georgia is an example of a state that awarded CURES funds to a NARR state affiliate.
SAMHSA has awarded NARR a 1-year, $150,000 contract to provide SSA’s and emerging NARR affiliates with technical assistance.
Note from Relias: We have staff training, data analytics and many other resources to assist providers with dealing with the opioid epidemic and use funding more effectively.
Special thanks to our webinar presenters who helped with this blog post.
Jason Howell, MBA, BS, PRS
Executive Director, RecoveryPeople Board President Emeritus, National Alliance for Recovery Residences (NARR)
David M. Sheridan
Board President, National Alliance for Recovery Residences. Director, the Chandler Lodge Foundation
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