Stepped Care Models
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Stepped care models are minimally intensive care models for treating conditions or changing behaviors. Patients are initially typically provided with an easy-to-disseminate, low-cost, minimally intensive intervention. If this does not produce remission of undesirable symptoms or sufficient behavior change, patients are provided with a slightly more intensive and more costly intervention. This continues until patients receive an intervention that produces the desired outcome. Ideally, each patient receives the least resource-intensive yet most effective treatment they need. Stepped care models require repeated assessments to determine if a treatment is effective (and can be stepped down), too burdensome (and should be stepped down), ineffective (and must be stepped up), when another treatment becomes available and more likely to produce better effects (requiring deimplementation of the current treatment and initiation of the new treatment), or inappropriate/unlikely to produce effects (and must be stepped down or discontinued altogether).
Stepped care models involve the systematic process of care for an individual through stages of treatment meant to address the severity of their condition(s). Stepped care models can take many forms at various steps, such as bibliotherapy, computerized services, medications, and in-person treatment (e.g., cognitive behavioral therapy, a medical procedure).
There is a necessity for resource-efficient psychiatric, behavioral, and medical care. Frequently, individuals encounter insufficiently available care options (Jacobi et al. 2017; Carels et al. 2009). Many individuals do not have the financial means, transportation, or time to get the care they need, they do not have access to high-quality care, or the initial care they receive is insufficient to cause meaningful remission of symptoms; rather than pursue adequate care, they discontinue services or experience crisis requiring higher acuity treatment. Such patterns of care utilization are frequently seen in smoking cessation, psychotherapy for depression or severe mental illness, and weight management.
Stepped care models seek to solve these problems by being a resource-efficient form of care that is accessible, cost-effective, and innovative. Stepped care models have shown clinical and medical benefit for numerous populations and treatment needs. For example, stepped care approaches for weight loss have produced better outcomes or similar weight losses (with lower costs) when compared to standard treatments (Waring et al. 2014). Stepped care approaches have also been found to be effective for the treatment of substance use disorders, including reduced overall drug use (Kidorf et al. 2007).
Stepped care programs may use weekly monitoring and initial assessment data to determine whether a patient needs to step up or down in the stepped care model. Patients may be evaluated for the severity and type of disorder they have, and the patient’s preferences are also considered when deciding whether to go into the lowest level of care or higher (Waring et al. 2014; Carels et al. 2009). After treatment initiation, a follow-up assessment of regular symptom monitoring helps the clinician to determine if the original treatment should be transitioned to more intensive treatments, less intensive treatments, or if the treatment should be kept the same, according to how the patient is responding to treatment (Carels et al. 2009).
An example of the stepped model program developed for chronic pain includes pain self-management strategies and cognitive behavioral therapy (CBT). A clinical trial targeted musculoskeletal pain in veterans. In this case, the stepped care model kept participants engaged by including constant contact (biweekly) to check engagement in treatment. Participants were also taught self-management strategies on how to deal with their pain, such as goal setting, positive self-talk, and other relaxation techniques (Bair et al. 2015). Results found that a combination of analgesics, self-management strategies, and CBT effectively reduced the effects of pain on veterans’ day-to-day lives (Bair et al. 2015).
The stepped care model has also been effective for weight management. In one program using motivation interviewing (MI), a therapeutic technique used to increase motivation for changes in behavior (Carels et al. 2007), participants met for 45–60 min weekly for MI until they reached their weight loss goal. Participants who were in the stepped care condition lost significantly more weight in comparison to non-stepped care participants. Participants in the stepped care condition also self-reported increased physical activity (Carels et al. 2007). In the context of weight management, the stepped care model may be useful in increasing participation and motivation in weight loss programs.
Stepped care models can be incredibly impactful if adopted. The affordability, accessibility, effectiveness, resource efficiency, and immediacy of care of this model could lead to higher rates of individuals in need receiving treatment without undue stress on the healthcare system.
References and Further Readings
- Bair, M. J., Ang, D., Wu, J., Outcault, D. S., Sargent, C., Kempf, C., Froman, A., Schmid, A., Damush, T., Yu, Z., Davis, W. L., & Kroenke, K. (2015). Evaluation of stepped care for chronic pain (ESCAPE) in veterans of the Iraq and Afghanistan conflicts: A randomized clinical trial. JAMA Internal Medicine, 175(5), 682–689. https://doi.org/10.1001/jamainternmed.2015.97.CrossRefPubMedGoogle Scholar
- Carels, R. A., Darby, L., Cacciapaglia, H. M., Konrad, K., Coit, C., Harper, J., Kaplar, E. M., Young, K., Baylen, A. C., & Versland, A. (2007). Using motivational interviewing as a supplement to obesity treatment: A stepped-care approach. Health Psychology, 26(3), 369–374. https://doi.org/10.1037/0278-622.214.171.1249.CrossRefPubMedGoogle Scholar
- Carels, R. A., Wott, C. B., Young, K. M., Gumble, A., Darby, L. A., Oehlhof, M. W., Harper, J., & Koball, A. (2009). Successful weight loss with self-help: A stepped-care approach. Journal of Behavioral Medicine, 32(6), 503–509. https://doi.org/10.1007/s10865-009-9221-8.CrossRefPubMedPubMedCentralGoogle Scholar
- Jacobi, C., Beintner, I., Fittig, E., Trockel, M., Braks, K., Schade-Brittinger, C., & Dempfle, A. (2017). Web-based aftercare for women with bulimia nervosa following inpatient treatment: Randomized controlled efficacy trial. Journal of Medical Internet Research, 19(9). https://doi.org/10.2196/jmir.7668.CrossRefGoogle Scholar
- Waring, M. E., Schneider, K. L., Appelhans, B. M., Busch, A. M., Whited, M. C., Rodrigues, S., Lemon, S. C., & Pagoto, S. L. (2014). Early-treatment weight loss predicts 6-month weight loss in women with obesity and depression: Implications for stepped care. Journal of Psychosomatic Research, 76(5), 394–399. https://doi.org/10.1016/j.jpsychores.2014.03.004.CrossRefPubMedPubMedCentralGoogle Scholar