Restructuring Services

1. Restructuring Services Creating Clinical Pathways Through Provider Networks Presented by… Bob Holm, Regional Substance Abuse Director, Suncoast Region DCF Richard Brown, Chief Operating Officer, The Agency for Community Treatment Services Linda McKinnon, Chief Executive Officer, Central Florida Behavioral Health Network

2. Bob Holm Regional Substance Abuse Director Department of Children & Families Suncoast Region

3. Provider Network as Change Agent DCF supported the creation of CFBHN as a means to promote best practices and the development of clinical pathways across a designated geographic area (old District 6).

4. The Network was developed to address service and system development throughout the designated area. DCF wanted to assure services were coordinated into a system that could be easily navigated by the client receiving care, whether from multiple providers or multiple levels within a provider agency.

5. DCF, as the purchaser, requires the following from the Managing Entity: • Evaluation, integration and re-engineering system of care into a seamless and easily navigated system at the client level • Uniform promulgation of clinical policies and best practices throughout the Network • Uniform data collection used to drive quality improvement initiatives • Resource maximization and cost effectiveness • Increased access to care • Simplification and non-duplication of contracting and oversight functions to allow for effective use of limited staff and resources

6. Required Features of DCF Community-Based Networks and Managing Entities • Community governance and oversight • Shared risk with providers • Comprehensive service delivery and ability to provide integrated service • Client involvement • Community re-investment • Coordination with collateral systems • Creation of opportunities for planned transition of service strategies

7. Tasks Required to Develop System • Analyze and plan for individual service needs • Strategies for service delivery • Evaluation of service implementation • Review of services and revision as required • A formal information sharing process

8. Evolution not Revolution • CFBHN began working with providers to collaborate on clinical improvement activities occurring at individual agencies • Network services strategies were developed for HIV, children’s issues, family intervention, etc. • During 2002-2004, CFBHN began working on developing systems of care across provider agencies: TANF, co-occurring, elder services, etc.

9. In 2004, management of all substance abuse prevention, treatment and aftercare funding was transitioned to the Network. • The Network was required to ensure the development of network-wide, county specific system of care plans and that services were provided as specified in the plans through the contract period • The Network was required to increase access to acute care services for substance abuse • The Network was required to maximize resources available for substance abuse treatment • The Network was required to provide science-based prevention strategies to target populations

10. DCF’s Goals for the Network • Enhance community prevention strategies • Increase access to acute care services for substance abuse • Maximize resources available for substance abuse treatment

11. 2004 Contract Deliverables Related to the Goals --Prevention-- Assist, develop and resource community coalitions throughout each area of the Network.

12. 2004 Contract Deliverables Related to the Goals --Acute Care-- The Managing Entity will review the current detoxification system in Hillsborough in Hillsborough & Pinellas counties and will make written recommendations concerning the possibility of reducing the number of residential and adding outpatient detoxification as an alternative.

13. 2004 Contract Deliverables Related to the Goals --Treatment-- The Managing Entity will be responsible for managing and reporting the substance abuse wait list. A baseline for number of days waiting and average number of people waiting will be established by December 31, 2004.

14. 2005 Contract RequirementSpecific to Acute Care --Outpatient Detoxification-- By October 31, 2005, the provider (CFBHN) will fully implement the Department approved recommendations for the Region’s detoxification system. These recommendations were provided by the provider (CFBHN) as one of the 2004 contract deliverables.

15. Linda McKinnon Chief Executive Officer Central Florida Behavioral Health Network

16. The Process Manatee Glens, a Network provider, had been providing outpatient detoxification services for several years Manatee Glens’ program was developed in response to limited detoxification availability in Manatee County; there were 3 beds and the unmet needs were growing

17. Research indicated there is no long-term significant difference in outcomes for clients detoxified in an inpatient and an outpatient environment. Significant advantages were identified for those who are properly triaged to the level of care appropriate to the clinical need. • OPD is less costly • The client’s life is not disrupted • The client does not undergo abrupt transition from protected inpatient setting to the community • OPD services are available for a longer period of time, allowing for a longer engagement period • More clients can be served • Wait time is reduced

18. CFBHN completed a review of publicly funded inpatient detoxification facilities and the OPD program in place. Monthly provider meetings were conducted to discuss the development of OPD programs, review current inpatient medical detoxification, complete literature reviews and recommend strategies.

19. The agreed upon definition for inpatient medical detoxification: Medically monitored detoxification and stabilization for adults, 18 years of age and older, who are dependent on drugs and/or alcohol and are admitted by physician’s order. Criteria for admission requires that the client cannot safely detoxify in an outpatient setting and meet ASAM placement criteria.

20. The following inpatient detoxification standards were catalogued for all facilities: • Admission criteria • Medical monitoring and stabilization • Co-occurring disorder capabilities • Discharge criteria • Secure/non-secure environments • Licensed bed capacity • Funding • Average length of stay • Length of stay by substance • Current cost to operate/cost per bed to operate • Involuntary admissions by category

21. Outpatient Detoxification Program SAMHSA TIP 19 defines outpatient detoxification as a modified medical model: a social model that contains routine access to medical services in order to manage the medical and psychiatric complications of a patient’s withdrawal. Manatee Glens’ OPD services were catalogued by: - Number of slots - Length of stay - Staffing pattern/medical availability - Group composition - Cost per slot - Completion rate

22. The Committee agreed to a set of standards for outpatient detoxification services. • Uniform assessment and admission criteria • Length of stay to be 10-14 days, depending on referral source • Medication protocols and IDP funding • Housing • Staffing • Hours of operation • Methodology for collection of outcomes

23. Challenges Identified • Concern that additional OPD slots may not decrease need for medical detoxification beds • Concern regarding stakeholder/community reaction to a reduction in beds • 60% of clients admitted identified as having co-occurring disorders that require medications and the limited availability of IDP funds for substance abuse • Lack of availability for temporary housing for clients who are homeless

24. Benefits Identified • OPD slots are significantly less expensive • Less disruptive • Higher potential for engagement in treatment • Ability to “practice” new behaviors at home and work while in program • Increased numbers served • Actual provider experience of successfully providing outpatient detoxification services • Ability for clinical members of provider teams to meet regularly to facilitate program development, share best practices and problem solve challenges • Ability to ensure evaluation component is developed to provide objective information and guide future decision making

25. Network Consensus • Reduce inpatient beds from 35 to 20 per provider (ALOS – 6 days) • Add 25 outpatient slots per provider (ALOS – 12 days) • Result is 46 additional clients served by each provider

26. 2005 – The Rubber Hits the Road • ACTS establishes outpatient detoxification services in October 2005 • Committee, comprised of detoxification providers, CFBHN staff and Suncoast Region Substance Abuse Director, established to assist in evaluation • Committee recognized that the collaboration provided a unique opportunity to gather information about OPD programs and how utilization of OPD might affect the system of care

27. Committee determined scope of information to be analyzed during initial stages of development: • Impact of OPD service availability on wait list for residential services • Impact of OPD service availability on residential detoxification system • Type of client and program that contribute to successful outcomes

28. Evaluation Component • Providers agreed to a set of written guidelines for data collection and the consistent utilization of specific instruments • Committee identified the measure of success in completion of OPD • Primary goal – medical stability (defined as stable vital signs) • Secondary goal – linkage and engagement to treatment • Codes established to identify discharge status • All providers used the URICA (University of Rhode Island Change Assessment Tool) to measure state of change and treatment readiness • Additional elements collected for analysis include: - Referral source - URKIA pre- & post-test results - Drug test results - Discharge reason - Vital signs - Length of stay - CIWA/COWS results

29. Data Analysis Data was collected from clients discharged between October 1, 2005 and February 26, 2006. Data included State data reporting elements.

30. Statistics # served in OPD during evaluation period 209 Average age 37 60% Males 40% Females Primary substance used at admission: Alcohol 50% Crack 28% Primary referral source: Self 54% Residential detoxification (where available) 41% Other 5% Length of stay: 10.68 OPD Wait List Highest month average (May ’05) = 6.93 days Average at last month of study (Feb ’06) = 1.05 days Successful discharge: Manatee Glens 87% ACTS (new program) 65%

31. Results • Client needs and outcomes will vary by system of care available in community • 30 – 50% of clients were medically stable at admission so this criteria for successful discharge should be evaluated • Clients with higher URICA scores at pre-test are more likely to leave prior to completion of treatment • 50% of clients had positive changes • OPD services are a viable alternative to achieve medical stability, gain understanding of substance abuse issues, increased motivation for change, readiness for treatment and decreased wait lists, which allow for greater access to care

32. Recommendations • To maximize resources most effectively a full continuum of care for both voluntary and involuntary clients be made available, including inpatient and outpatient detoxification to achieve medical stability and coordination of care • Strategies to develop temporary housing opportunities will decrease a communities’ reliance on inpatient and residential detoxification services • Strategies for transportation will decrease the need for inpatient detoxification services • Readiness for change assessments should be utilized by OPD programs as a clinical indicator and to improve retention • Evaluate requirements of current OPD programs and assess opportunities for development of individualized components for detoxification services (medical, motivational, recovery, peer services, individual and group counseling)

33. acts The Agency for Community Treatment Services Richard Brown Chief Operating Officer The Agency for Community Treatment Services

34. Challenges To Goals Examine the potential of incorporating Outpatient Detoxification Services in Hillsborough County’s System of care as a means to: • Increase accessibility to care, and • Improve engagement in continuing care services Operationalize Recovery Principles For Consumers at acts’s points of access to care

35. Inventory of the presenting “Dots” (factors driving consideration within the acts organization) • Agency experienced success in the re-engineering of Adult treatment services through CCISC Implementation. • Financially depleting Detox (AARF) Operation. • Potential for community “uprising” • Licensure/Administrative impasses/barriers to the realization of recovery support orientation. • Successful implementation of freestanding Room & Board operation. • Achievement of the necessary array of “front-end” services but evidencing a desperate need for “seamless” re-alignment, and • Protections through shared “liability” in support of the transition

36. Internal Machinations • Support of Research design & activities, • Financial Analysis, • System design activities for re-structuring operations: programmatic, transportation, food service, etc. • Data/Billing/Clinical Records, etc. conforming adjustments, • Physical plant alterations, • Articulation of the adopted service delivery model, • Policy/board endorsement, • Personnel alignments, • Training & Orientation to adjustment to organizational culture, • Establishment of an internal mechanism to catch drift & refine adherence/performance within the model.

37. Service Components of the Adopted Model for Access to Care • Recovery Support Specialists to initiate consumer engagement and drive acts’ commitment to seamless, continuous care, • Daily recovery support treatment readiness walk in capacity co-located and integrated with outpatient detoxification services. • A 20 bed secure addictions receiving facility for acute care detoxification & medical stabilization, • A co-located, 10 bed recovery support structured, Room & Board capability for AARF step down consumers positioned to continued and engage in care and • A transportation component (to support consumers access to community based recovery and supportive services and acts’ Outpatient detoxification & Recovery Access Services).

38. acts The Agency for Community Treatment Services Michele Smith Program Administrator Juvenile Assessment Receiving Facility (JARF) & Adult Addictions Receiving Facility (AARF) The Agency for Community Treatment Services

39. Programmatic Re-Structuring • Acute care bed space reduced • Transitional program added to AARF ( 10 bed capacity) • Reduction in required nursing staff • Added transportation & case management services • Utilize existing facility layout/dorm configuration for re-structuring

40. Existing Facility Configuration • Two large dorms (1 male, 1 female) on one hall • Two smaller dorms on a separate hall for flexible gender placement • All dorms on secure area of unit. • No physical barriers between hallways

41. Facility Challenges • Equal acute care gender bed capacity • Reduced flexibility for gender placement • Single point of egress • Increased security and safety risks • Restricted privileges for non-acute clients

42. Benefits of Restructuring • Streamline acute care service delivery • Improved diversion of OPD eligible clients • Transitional placements to focus on client individual needs/aftercare planning • Allow clients time to progress in stages of change, begin to internalize recovery concepts

43. Benefits (continued) • Client access to ancillary services through transportation and case management • Direct linkage to OPD/ Recovery Support • Reduces recidivism to acute care services by bridging the gap to follow up care • Reduced cost to client

44. Consequences • Community perception to reduction in acute care beds • Restricted availability for voluntary admissions • Adjustment to realignment of Nursing Staff • Staff resistance to change • Difficulty achieving parity between male/female census

45. Challenges • Incorporating different levels of care into the AARF paradigm • Educating and cross training of staff • Implementing and assimilating new protocols and recovery concepts • Realigning relationships with our own and other community service providers • Establishing expanded role in the community • Strengthening team infrastructure

46. July 2006

47. July 2006

48. actsThe Agency for Community Treatment Services Camille Francis, LCSW Program Supervisor Outpatient Detox, Med Clinic, & Recovery Support

49. OUTPATIENT DETOX SERVICES • OPD Curriculum • Health Education • Vital signs • Nutrition Class w/ Lunch • Recovery Support Group • Family Support Group • Med Clinic

50. OPD Curriculum • 10 – 14 days • Introduction to the following topics • Understanding Addiction • Dealing with Triggers and Cravings • Motivation to Change • Emotional Well Being • Anger Management • Social Well Being • Self-help Education