Recovery oriented systems of care Wyandotte County Kansas City, Kansas Heartland regional alcohol & Drug Assessment

1. Recovery oriented systems of careWyandotte CountyKansas City, KansasHeartland regional alcohol & Drug Assessment center Jim Clarkson CEO/Via Positiva

2. An Overview of Recovery Oriented Systems of Care Paradigm Shift From An Acute Care Medical Model to A Chronic Disease Management Person Centered Model

3. Integrated Care: From Silos….

4. To Synergies….

5. ROSC Model The law of floatation was not discovered by contemplated the sinking of things, but rather than by contemplating the characteristics of those things which floated naturally and intelligently asking why they did so. (Judge Thomas Troward) Box (1987): “All models are wrong, but some are useful”

6. Recovery? “The process by which people are able to live, work, learn, and participate fully in their communities. For some individuals, recovery is the ability to live a fulfilling and productive life, despite a disability. For others, it implies the reduction or the complete remission of symptoms”… --The President’s New Freedom Commission Report

7. Iatrogenic Suffering Suffering caused by the physician, practitioner or other helper, usually unintentional but increasing the amount of distress a person seeking help already has. It is often caused by the practitioner’s bedside manner or barriers placed within a system. The patient bears the brunt of the practitioner’s unfinished or unconscious psychological issues regarding death, vulnerability, mental or other serious illness or the effects from trauma, growing up in a home with alcoholism, drug addiction, domestic violence or the like.

8. Person First • Sanctuary • Value & Therapeutic Alliance Whatever you can do or dream you can, begin it. Boldness has genius, power and magic in it!‘--Goethe

9. Sanctuary Place of safety, oasis, shelter, sacred place (S. Covington)

10. Recovery? “Recovery is a deeply personal process of (re)gaining physical, spiritual, mental and emotional balance. It is a process of healing and restoring wellness during stressful episodes of life”. --Mental Health First Aid

11. Recovery Oriented System of Care • “A recovery oriented system of care identifies and builds upon each individual’s assets, strengths, and areas of health and competence to support achieving a sense of mastery over his or her condition while regaining a meaningful, constructive, sense of membership in the broader community”. –Thomas Kirk, CDMHAS

12. Any problems faced by the individual substance user cannot be seen in isolation from their family, local community and society. - Scottish Advisory Committee on Drug Misuse, 2008. Society Systems Providers Local Communities

13. Toward Communities of Caring • Estimates of People in Recovery (23 million) • Characteristics of People in Recovery. • Creating Environments for Recovery: Recovery Oriented Systems of Care • 22 million meet the definition of Substance Use Disorder today in the US. • A possible “tipping point”… 7,500 (5%) in Wyandotte County to 15,000…

14. Describing Recovery-Oriented Systems Recovery-oriented systems include: • A comprehensive menu of services and supports that can be combined and readily adjusted to meet the individual’s needs and chosen pathway to recovery. • An ongoing process of systems-improvement that incorporates the experiences of those in recovery and their family members. • The coordination of multiple systems, providing responsive, outcomes-driven approaches to care. 14

15. Planning Recovery-Oriented System Change I. Conceptual Framework II. Assessment/Gaps III. Capacity Building VI. Evaluation V. Development and Implementation IV. Planning 15

16. ROSC Providers… • Partners in the recovery process of every person enrolled in the program. • A focal point of powerful social influences…the recovery community, faith-based organizations, community organizations and clinical treatment providers. • A Recovery Hub…a touchstone for non-judgment, caring and wellness for individuals, families and communities.

17. TRI Studies Studies show that clients in SA treatment, who also have problems in other areas of their lives (e.g. medical, employment & psychiatric), have better outcomes when those other problems areas are also addressed • McLellan compared 2 groups of SA clients • Standard group received treatment as usual • Enhanced group received treatment as usual, plus referrals for help with other problems (e.g. medical screening & parenting classes) • Enhanced group had better outcomes at 6 months • Stayed in tx longer & had higher tx satisfaction • Had fewer psychological & physical problems • Had less substance use

18. TRI Studies Specifically, McLellan found: • After 30 days • 39% of Standard group clients still in treatment • 68% of Enhanced group clients still in treatment • After 60 days • 12% of Standard group clients still in treatment • 49% of Enhanced group clients still in treatment • After 6 months (unexpected finding) • 60% of Standard group counselors left job • 20% of Enhanced group counselors left job

19. TRI Studies Concluded: Give Your Clients Names & Phone Numbers of Free & Low Cost Service Community Referrals! • Costs you close to nothing • Improves treatment outcomes

20. What does ROSC really look like? • Statewide & Local Models • Cross system training • Cross system referrals • Usually voucher based (funding follows client) • Partial Performance Incentive • Outcome and data driven • Engagement, Retention & Continuation (NIATx)

21. From Acute Care to Chronic Disease Management • Addiction (severe alcohol and drug dependency) shares many of the defining characteristics of chronic primary illnesses, e.g., 2 diabetes mellitus, hypertension, and asthma. • Characterizing addiction as a chronic illness does not mean that all AOD problems have a prolonged course requiring professional treatment, that full recovery is not possible, or that self management responsibilities are in any way diminished. • Although long characterized as a chronic disorder, addiction has been treated in an essentially acute-care (AC) model of treatment. • The AC model of addiction treatment is characterized by its crisis-linked point of intervention, brief duration, singular focus on symptom suppression (achievement of abstinence), professionally dominated decision-making process, short service relationship, and expectation of full and permanent problem resolution following “graduation.” • The development of the AC model of addiction treatment grew out of the medicalization, professionalization, and commercialization of addiction treatment and the subsequent growth of managed behavioral health care in the United States. (White 2008)

26. Recovery Oriented System of Care "The phrase recovery-oriented systems of care refers to the complete network of indigenous and professional services and relationships that can support the long-term recovery of individuals and families and the creation of values and policies in the larger cultural and policy environment that are supportive of these recovery processes. The “system” in this phrase is not a federal, state, or local agency, but a macro-level organization of the larger cultural and community environment in which long-term recovery is nested." (William White 2008)

27. Sometimes… • Treatment providers think it is an adjunct to improve what they do… • The Recovery and Advocacy community think, finally, we can formally share what we know works… • Faith-based Organizations think, “they are finally seeing the light!” • RSS providers think, finally they can learn from us…we knew we could help substance users all along! • State: How can we pay for this? • MCO’s: What? Measure? UR? Quality? • Consumers: Wow! Seriously???

28. Systems Integration Systems integration is the process of understanding how things influence one another within a whole. In organizations, systems consist of people, structures, and processes that work together to make an organization healthy or unhealthy. Systems Thinking has been defined as an approach to problem solving, by viewing "problems" as parts of an overall system, rather than reacting to specific part, outcomes or events and potentially contributing to further development of unintended consequences. Systems thinking is not one thing but a set of habits or practices within a framework that is based on the belief that the component parts of a system can best be understood in the context of relationships with each other and with other systems, rather than in isolation.

30. Wyandotte County Population 157,505

31. Client Relationship Network • Recovery Support Services Coordinator • Sponsor • Recovery Groups • Spiritual Guide • Clinician • Recovery Coach • SA informed cab driver, childcare provider, job coach, financial coach, legal advisor, housing provider

32. A Good and Modern System A modern mental health and addiction service system provides a continuum of effective treatment and support services that span healthcare, employment, housing and educational sectors. Integration of primary care and behavioral health are essential. As a core component of public health service provision, a modern addictions and mental health service system is accountable,organized, controlscosts and improves quality, is accessible, equitable, and effective. It is a public health asset that improves the lives of Americans and lengthens their lifespan.

33. Recovery Necessity, not Medical Necessity The system should include activities and services that go beyond traditional interventions such as the current acute care residential or outpatient services. Coordination, communication, and linkage with primary care can no longer be optional given the prevalence of co-morbid health, mental health and substance use disorders.

34. Remembering Who We Serve • Disability Weights • Internalized Oppression

35. U.S. Adults with a Mental Disorder in Any One Year 9

36. Median Age of Onset One-half of all lifetime cases of mental illness begin by age 14, three-quarters by age 24 • Anxiety Disorders – Age 11 • Eating Disorders – Age 15 • Substance Use Disorders – Age 20 • Schizophrenia – Age 23 • Bipolar – Age 25 • Depression – Age 32 4

37. The Impact of Substance Abuse and Mental Illness • SA/MH can be more disabling than many chronic physical illnesses. For example:  • The disability from moderate depression is similar to the impact from relapsing multiple sclerosis, severe asthma, or chronic hepatitis B. • The disability from severe post-traumatic stress disorder is comparable to the disability from paraplegia. • “Disability” refers to the amount of disruption a health problem causes to a person’s ability to:  • Work • Carry out daily activities • Engage in satisfying relationships 10

38. Disability Weights • Stouthard et. al (1997) published weightings for 53 illnesses of public health importance. • The World Health Organization has compared the relative impact of different illnesses across the world. According to this data, mental disorders rank as the biggest health problem in North American ahead of both cardiovascular disease and cancer.

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40. Integration The integration of primary care, mental health and addiction services must be an integral part of the vision. Mental health and addiction services need to be integrated into health centers and primary care practice settings where most individuals seek health care. In addition, primary care should be available within organizations that provide mental health and addiction services, especially for those individuals with significant behavioral health issues who tend to view these organizations as their health homes. Providing integrated primary care and behavioral health services will allow for cost effective management of co-morbid conditions.

41. Funding and Payment Strategies In the public sector, individuals/families/youth with complex mental and substance use disorders receive services funded by federal, state, county and local funds. These multiple funding sources often result in a maze of eligibility, program and reporting specifications that create funding silos featuring complicated administrative requirements. If services are to be integrated, then dollars must be also intertwined. In the same way that Medicaid will be required to streamline eligibility and enrollment, the good and modern system must either blend or braid funds in support of comprehensive service provision for consumers, youth and families.

42. Exposure to Trauma • 51 – 98% of public mental health clients with severe mental illness, including schizophrenia and bipolar disorder, have been exposed to childhood physical and/or sexual abuse. Most have multiple experiences of trauma (Goodman et al., 1999, Mueser et al., 1998; Cusack et al., 2003).

43. Exposure to Trauma • One in four children and adolescents in the United States experiences at least one potentially traumatic event before the age of 16, and more than 13 % of 17-year-olds—one in eight—have experienced posttraumatic stress disorder (PTSD) at some point in their lives. (National Survey of Adolescents and other studies).

44. Trauma—Adverse Childhood Experience Study • 17,000 Kaiser Permanente Members & Partnership with CDC • 63% at least one category of trauma • 20% at least 3 categories of trauma • 11% emotional abuse • 28% physical abuse • 21% sexual abuse • 19% grew up with someone in the household with MI • 10% physical neglect • 13% saw mother being treated violently • 27% grew up w/someone using Alcohol and/or drugs

45. Trauma—Adverse Childhood Experience Study

46. Internalized Oppression Core Beliefs of the Addict (Paraphrased P. Carnes) • I am a bad, unworthy person • If people knew me they would not like me. • If I have to get my needs met I will have to do it myself. • I will find something to make me feel better. >>Internalized “self talk”

47. Helping Clients Navigate to Success • The companies that truly stand at the intersection of Information Technology and the Humanities will create the opportunities, indeed, the economies of the 21st Century. (Steve Jobs) • The first principle of the Apple Marketing Philosophy is Empathy, an intimate connection with the feelings of the customer: We will truly understand their needs better than any other company. (Mike Markkula) • Network for Improvement of Addiction Treatment’s First Principle: Understand and involve the customer.

48. Navigation The integration of primary care, mental health and addiction services must be an integral part of the vision. Mental health and addiction services need to be integrated into health centers and primary care practice settings where most individuals seek health care. In addition, primary care should be available within organizations that provide mental health and addiction services, especially for those individuals with significant behavioral health issues who tend to view these organizations as their health homes.

49. Funding Considerations ROSC Opportunities Within the Unfolding Behavioral Health Landscape

50. How Many SA Providers Are There? SAMHSA 11,246 NIDA 13,000 ONDCP 20,000+