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The Changing Face of Addiction Health Care Moving Forward. Arthur Schut Arapahoe House, Inc Colorado Texas Initiative for Program Success and Sustainability Leadership Summit Association of Substance Abuse Programs Austin, Texas January 10, 2011. OR. How to Avoid Being a Dinosaur:

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the changing face of addiction health care moving forward

The Changing Face ofAddiction Health CareMoving Forward

Arthur Schut

Arapahoe House, Inc

Colorado

Texas Initiative for Program Success and Sustainability Leadership Summit

Association of Substance Abuse Programs

Austin, Texas

January 10, 2011

slide2
OR

How to Avoid Being a Dinosaur:

Thoughts related to preventing the potential extinction of stand-alone substance-use illness treatment providers in the course of health reform

goals of breakout
Goals of breakout
  • Brief overview of “Where are we going?”
  • Thoughts on being strategic with the goal of survival – avoid being a dinosaur
  • Practical operational issues
  • You leave with one approach or idea that has practical value
moving forward
Moving Forward
  • There will be some type of universal health coverage and payment mechanism.
  • There will be a health care delivery system that functions in an integrated manner (even if there is no universal health coverage).
  • Primary care providers will be the “hub” of the health care delivery system that is integrated.
moving forward1
Moving Forward
  • We will have to provide an integrated continuum of substance-use illness care that at the minimum: includes essential levels of care; addresses co-occurring conditions; includes an emphasis upon recovery management; and engages meaningfully with primary care and health homes.
moving forward2
Moving Forward
  • Prevention will be viewed as essential to health system outcomes.
  • We will be part of, or intimately connected to, the mainstream health care delivery system or cease to exist.
moving forward3
Moving Forward
  • We must connect clients to health systems.
  • We must connect our services to health systems.
  • We need to be aware of quality and performance measures (e.g., NQF, IOM).
  • It is time for us as a field to do a self-critical inventory, and make major changes.
moving forward4
Moving Forward
  • Significant changes include…
    • Moving back into the medical system
    • The majority of substance-use illness services will be provided through primary care settings (as is currently true for depression and anxiety disorders)
    • Some of us will be the substance-use illness specialty providers for the transformed system
slide9

Trends that are transforming the fieldNew information is altering many old assumptions about treatment by Gary A. Enos, Editor and David Raths, {Addiction Professional - Used and edited with permission}

  • ….the trends we see as having a transformative effect on addiction services … are among the subjects that are informing treatment or challenging treatment orthodoxy.
science fiction may be close to fact
Science fiction may be close to fact
  • The images … healthy and drug-affected brains … bring the promise of more effective treatments to be generated from the various discoveries in the lab.
  • What areas of the brain are associated with craving?
physicians become a significant influence
Physicians become a significant influence
  • “As health care reform moves forward, it will require a proactive approach that includes early detection, screening and interventions”
  • “Physicians have a key role to play in this effort.”

[Larry M. Gentilello, MD, professor of surgery at the University of Texas Southwestern Medical Center, Dallas]

wider implementation of electronic health records
Wider implementation of electronic health records
  • Automation is “among the most important strategic decisions organizations such as ours have to make.” [David T. Smith, New Beginnings in Waverly, Minnesota and St. Cloud State University]
  • … addiction treatment facilities … continue to lag behind both mental health and general health facilities in technology adoption
competencies in multiple services
Competencies in multiple services
  • “There's absolutely no question that providers who aren't able to address multi-service needs are not going to be in service much longer”

[Linda Grove-Paul, MSW, Centerstone of Indiana]

competencies in multiple services1
Competencies in multiple services
  • Both the stand-alone addiction treatment organization and the mental health only agency appear to be moving toward extinction.
tobacco becoming an enemy of recovery
Tobacco becoming an enemy of recovery
  • …. people in treatment for alcohol and drug addiction have better outcomes if they quit tobacco use….
  • Some studies show that more than 50 percent of the deaths in substance abuse treatment populations result from tobacco-related disease.
  • State governments commit funding and pass legislation regarding smoking cessation in addiction treatment facilities
taking treatment services online
Taking treatment services online
  • Patients use a smart phone system with an opt-in GPS tracking feature which monitors their movements and triggers a peer call when they go near high risk situations (marked liquor stores, for example).
  • University of Wisconsin (with support from NIAAA) has launched the Innovations for Recovery Model (http://www.innovationforrecovery.com)
emphasizing diet and exercise
Emphasizing diet and exercise
  • The days when addiction treatment programs would ignore clients' other health habits as long as they weren't drinking or using seem to be numbered. Treatment centers are experiencing a nutrition and fitness boom…
embracing blended treatment approaches
Embracing blended treatment approaches
  • “Since no one behavioral approach has better overall outcomes than others, clients should have a choice of available, effective treatments,”

[Mark L. Willenbring, Director, Treatment and Recovery Research Division NIAAA]

the quality of care we must provide
The Quality of Care We Must Provide

National Quality Forum (NQF)

National Voluntary Consensus Standards

Institute of Medicine (IOM) of the National Academies

Crossing the Quality Chasm 

The Six Aims of High-Quality Health Care

slide20
NQF
  • National Voluntary Consensus Standards for the Treatment of Substance Use Conditions: Evidence-Based Treatment Practices (2007)
  • “… performance measures for the treatment of substance use conditions.”
nqf standards impact
NQF Standards Impact
  • “… conducted according to the NQF Consensus Development Process, … the 11 endorsed practices and their specifications have legal status as national voluntary consensus standards for the treatment of substance use conditions.”
the six aims of high quality health care iom
The Six Aims of High-Quality Health Care (IOM)
  • Safe - avoiding injuries to patients from the care that is intended to help them.
  • Effective - providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit (avoiding underuse and overuse, respectively).
the six aims of high quality health care iom1
The Six Aims of High-Quality Health Care (IOM)
  • Patient-centered - providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions.
  • Timely - reducing waits and sometimes harmful delays for both those who receive and those who give care.
the six aims of high quality health care iom2
The Six Aims of High-Quality Health Care (IOM)
  • Efficient - avoiding waste, including waste of equipment, supplies, ideas, and energy.
  • Equitable - providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status.
  • SOURCE: IOM, 2001:5–6. [Italics added]
challenges
Challenges
  • For many clients there are “consequences” for not cooperating with treatment
  • Clients now may be pushed to one provider (or group of providers) because it is the only source of services with financial assistance. This will change.
  • Do we have as the foundation of our service delivery model an implicit assumption that most clients have to come to us?
challenges1
Challenges
  • What happens when everyone has the ability to pay with universal coverage?
  • There will be more options for services.
challenges2
Challenges
  • In the new delivery system we will need to be engaging in a different way to assist clients to voluntarily manage their own care
  • Evidence-Based Practices (EBP) need to be implemented with reportablefidelitymeasurement
  • Brief interventions and case management alone are treatment
challenges3
Challenges
  • Enhance Handoffs to and from “the health system/primary care”
  • Organize services around episodes and a full continuum of care, rather than discrete levels of care or locations
  • Increase skill diversity of professional staff to address major co-occurring conditions
improve customer service
Improve Customer Service
  • Our tradition of consumer involvement – persons in recovery – gives us the illusion we know what it is like to be a customer.
  • Need high quality customer service – NIATx process improvement techniques are a very effective tool.
  • “Be a customer”.
improve customer service1
Improve Customer Service
  • Apply for services at your own organization.
  • Be admitted.
  • Ask a customer.
  • Become active in NIATx.
evidence based practices and programs
Evidence-Based Practices and Programs
  • Evidence-based “Practices” as well as “Programs”
  • Incomplete adoption and too little fidelity
  • TIPS, TAPS
  • National Quality Forum (NQF)
  • IOM Crossing the Quality Chasm
evidence based practices and programs1
Evidence-Based Practices and Programs
  • NREPP – National Registry of Evidence-based Programs and Practices
  • Medication assisted treatment
  • Training to, and tracking fidelity of, implementation of EBPs
  • Without FIDELITY there is no evidence-based practice
  • Need executive leadership support for implementation with fidelity measures
human resources qualified professional clinical staff
Human ResourcesQualified professional clinical staff
  • Experience vs. education - No longer a “real” separate choice
  • Need and can find both experience and education in one
  • Payers will not pay for experience absent education
human resources qualified professional clinical staff1
Human ResourcesQualified professional clinical staff
  • Need significant numbers of staff dual-credentialed at a level, and in a way, that is acceptable as a health professional
  • Clinical master’s degree prepared
  • Licensure both as mental health professional and upper level certified addictions counselor
human resources qualified professional clinical staff2
Human ResourcesQualified professional clinical staff
  • A high school diploma and certification as an addictions counselor will not be acceptable as a primary provider nor as a clinical supervisor of services for substance use illness treatment.
  • Bachelor’s or Master’s degree minimum for primary service delivery
meaningful roles for those existing staff without at least a ba bs
Meaningful roles for those existing staff without at least a BA/BS
  • Recovery coach
  • Recovery mentor
  • Addictions tech (psychiatric tech)
  • Detox technician
  • Outreach worker
  • Other?
action from this point forward
Action from this point forward:
  • Hire clinical staff with at least a BA.
  • Inventory existing clinical staff: degree(s); college or university (accredited? really?); program of study/major; eligible for licensure/certification? (substance-use illness; mental health); supervision requirements (what kind, by whom, in what amounts, for what duration).
develop concrete plan with support to assist staff to upgrade
Develop concrete plan with support to assist staff to upgrade:
  • support non-degreed staff to become degreed
  • support BA level staff to obtain MA, MSW, etc.
  • support existing MA level staff to become licensed MH professionals
  • train substance-use illness staff to mental health competence
  • train mental health staff to substance-use illness competence
  • Train all professional staff to work with primary care
develop concrete plan with support to assist staff to upgrade1
Develop concrete plan with support to assist staff to upgrade:
  • flex time for external classes
  • tuition assistance ($$)
  • clinical supervision for licensure and/or certification (internal or hired consultants) ($)
  • multiply supervision over time as develop own licensed/certified professionals
  • salary differentials for licensure and certification ($)
finance
Finance
  • Credential with third party payers
    • organization with payers when possible
    • individual clinicians as necessary
  • Engage clinical staff in pre-authorizations, continuing stay reviews, billing documentation – they usually produce what is billed or reported.
finance1
Finance
  • Analyze business processes particularly as they relate to services delivered which could be billed or are currently billed.
  • Coding services delivered – need to be correct to result in payment
  • Claims-based billing systems
finance2
Finance
  • Electronic tie from services recording to billing [There are advantages to services being recorded in a way that is sufficiently disaggregated that most billing options are open].
  • Bundling and unbundling services at the billing end of the process.
  • Electronic claims processing
finance3
Finance
  • Appeal claim denials
  • Advocate for single case agreements
  • Contracting vs care management
  • Appeal claim denials
information technology
Information Technology
  • IT is part of the essential foundation for service delivery.
  • Sophisticated does not have to be complicated.
  • Develop business processes anticipating Electronic Health Record (EHR).
  • Ability to export to other systems is important.
information technology1
Information Technology
  • Ability of other systems to import information from you is important
  • Single entry data (efficient & reduces errors)
  • Customer friendly information collection (unduplicated is efficient)
information technology2
Information Technology
  • Effective, timely information sharing between clinicians, systems of care, and different provider organizations.
  • Thoroughly inventory both internal and external electronic communication.
information technology3
Information Technology
  • State and payer reporting requirements should be an output, not the design structure.
  • Challenges in conceptualizing data reporting in a way that facilitates an “episode of care”, rather than discrete admissions and discharges (“opens and closes”?)
  • Providers should not allow data reporting to structure clinical services (also see regulation).
e communication without a lot of e
e-Communication without a lot of "e"
  • Initiate business practices that begin to approach electronic communication
  • Closed internal email system
  • Scan and email (closed system)
  • Scan and fax
  • Photocopy and send with the patient
e treatment
e-Treatment
  • Integrated with physical location services
  • Target is to ultimately provide patient electronic access integrated with all clinical services
  • Secure login where clients can complete initial information
e treatment1
e-Treatment
  • Smart phone, text messages, access to part of client’s clinical record, etc.
  • The substance-use illness field could be a leader in the development of e-solutions.
regulation
Regulation
  • Most providers have multiple audits by multiple funders and regulators – at times with conflicting requirements.
  • High degree of variability in regulation.
  • Historically some regulation assumes provider is a paraprofessional requiring significant oversight of a “clinical supervisor” (mental health professional).
regulation1
Regulation
  • Will regulation and documentation requirements change as the delivery system changes?
  • Required documentation often drives the structure of the delivery system.
regulation2
Regulation
  • Requirements to collect way too much information “up front” – how difficult can we make initial engagement and entry into treatment?
  • Regulation by convenience for external record audit – regulatory or payer audit staff suggestions regarding how to make audits easier for them.
regulation3
Regulation
  • How much of what we think is “regulation” is provider self-inflicted?
  • Providers should not allow regulation and auditing to structure clinical services (also see IT).
  • Providers should partner with states to modify regulation – including self-inflicted regulation.
slide55
Do not confuse payer requirements with how you think of clients’ relationships with you as a provider.
  • e.g., client must be “discharged” after 30 (or 45 or 60 or 90) days of no face-to-face contact.
  • Letter to client “if we don’t hear from you by xx/xx/xxxx we are going to discharge you.” “Failure to xyz will result in your discharge ….”
  • How many letters like this have you received from your health care provider?
metrics
Metrics
  • Evaluation of business processes
  • Organizing data around business management requirements, rather than external reporting requirements [still need to accommodate external reporting]
  • Performance measurement – process and outcome
  • Reliable accurate data (internal)
metrics1
Metrics
  • Reliable accurate data is more important than a lot of data.
  • Reliable external data is a challenge at the minimum.
  • Benchmarking – where is the thermometer by which we compare our organization’s performance – what is normal?
metrics2
Metrics
  • Fidelity – do we do what we say we do? Need for formal mechanisms to measure
  • Results driven service delivery – what does the customer want as deliverables?
  • Who are the customers? Pay for health outcomes!
metrics3
Metrics
  • Join NIATx process improvement - “mini metrics”
  • Join a benchmarking initiative –Benchmarking for Organizational Excellence in Addiction Treatment initiative, sponsored by SAAS, NIATx and Behavioral Pathway Systems 
  • Using data to make decisions – actually using data.
strengths n ew and d iverse o pportunities
Strengths = New andDiverse Opportunities
  • We are experts at dealing with difficult to reach patients
  • We are experts at engaging patients that are seen as disruptive in other systems
  • We are experts at de-escalation
  • We have affection for people who are addicted, even when they are not at their best
strengths new and diverse opportunities
Strengths = New and Diverse Opportunities
  • We know how to manage a complex illness over a lifetime. We know recovery.
  • We understand what’s going on with the family in relation to the illness.
  • We understand how a range of external systems impact and can support a patient and family e.g., child welfare, employment, law enforcement, corrections, etc
strengths new and diverse opportunities1
Strengths = New and Diverse Opportunities
  • Who are our health system customers?
  • Where can we add value in the places we “touch”
  • What do we do that creates value for primary care and health systems?
  • Is there a thorn in the paw that we can remove?
strengths new and diverse opportunities2
Strengths = New and Diverse Opportunities
  • Inventory - What we SAY we do well
  • Inventory – What DO we do well (outside view needed?)
  • Inventory - Where do we currently “touch” health services? Just “touch” anywhere - primary care, health systems, clinics.
improved p artnership with p rimary c are
Improved Partnership with Primary Care
  • “Fast Forward” – skip ahead to primary care integration
  • Connecting our clients to primary care
  • How many SUD specialty providers know (or ask) if client has a primary care provider?
improved partnership with primary care
Improved Partnership with Primary Care
  • How many SUD specialty providers contact clients’ existing primary care providers at admission?
  • At discharge?
  • How many arrange for a primary care “home” before discharge?
improved partnership with primary care1
Improved Partnership with Primary Care
  • Provide consultation to primary care health professionals (need immediate access)
  • Increase qualifications of professional staff to dual credentialed, professionally licensed
  • Brief patient consult - 15 to 20 minutes sessions
partnership opportunities
Partnership Opportunities
  • Intervening to help patients participate in the management of their illness to shorten hospital stays
  • Partner around shared challenges – healthy babies, outreach, over-utilization, disruptive behavior, prescription medication addiction (pain management challenges), illness management
p artnership o pportunities
Partnership Opportunities
  • Networks with other substance-use illness providers, mental health and behavioral health providers – create a continuum of care
  • Joint efforts/ventures
  • Behavioral health managed care entities, managed service organizations, private payers
partnership opportunities1
Partnership Opportunities
  • Co-locate/integrate in primary care clinics
  • Co-locate/integrate in emergency departments
  • Co-located/integrated services need to be seamless to the client
partnership opportunities2
Partnership Opportunities
  • Emergency departments (EDs) and intoxicated patients
  • Reducing over-utilization of services
  • Managing chronic illnesses
partnership opportunities3
Partnership Opportunities
  • Community health clinics,
  • OB/GYN clinics
  • EAPs
  • HMOs/MCOs/Integrated MCOs e.g., Kaiser Permanente
where to start
Where to start
  • Can all this be done in the next few years?
  • Start with “low hanging fruit” – trite but true
  • Business process
where to start1
Where to start
  • Clinical efficiency
  • IT support
  • Inventory & enhance clinical staff
where to start2
Where to start
  • We must connect clients to health systems.
  • We must connect our services to health systems.
  • We need to be aware of quality and performance measures (e.g., NQF, IOM)
where to start3
Where to start
  • One change at a time – avoid contingent linking.
  • Measure change (quick, brief, & targeted).
  • Adjust – Move Forward.
resources
RESOURCES
  • Benchmarking

SAAS, NIATx, and Behavioral Pathway Systems are partnering to sponsor an addiction-specific national benchmarking initiative: Benchmarking for Organizational Excellence in Addiction Treatment

A thermometer would not be a very helpful measure of your health if you didn’t know that 98.6° were normal. Similarly, in the absence of a relevant context, your organization’s measures of performance are of limited value.  The Addiction Benchmarking Initiative provides that vital context as well as a vehicle for ongoing organizational improvement.

resources1
RESOURCES
  • Benchmarking

Benchmarking for Organizational Excellence in Addiction Treatment

Behavioral Pathway Systems

877-330-9870 (Toll-Free)

info@bpsys.org

www.bpsys.org

  • If at least 10 agencies from your state participate, your reports will also include state-wide norms in addition to national norms.
slide78

Moving Forward: Preparing for the Future of Addiction Services

Implementing Healthcare Reform: First Steps to Transforming Your Organization, A Practical Guide for Leaders

http://www.saasnet.org/PDF/Implementing_Healthcare_Reform-First_Steps.pdf

slide79

NIATx – Network for the Improvement of Addiction Treatment

www.NIATx.org

  • NREPP – National Registry of Evidence-based Programs and Practices

http://www.nrepp.samhsa.gov/

  • CSAT Inventory of Effective Substance Abuse Treatment Practices

http://csat.samhsa.gov/treatment.aspx

  • Dennis McCarthy The Realities of Evidence-Based Practices for Addiction Treatment

http://www.attcnetwork.org/find/news/attcnews/epubs/v1i2_article04.asp

slide80

National Quality Forum

http://www.qualityforum.org/

National Quality Forum (2007). National Voluntary Consensus Standards for the Treatment of Substance Use Conditions: Evidence-Based Treatment Practices. Washington, DC: National Quality Forum.

http://www.qualityforum.org/Publications/2007/09/National_Voluntary_Consensus_Standards_for_the_Treatment_of_Substance_Use_Conditions__Evidence-Based_Treatment_Practices.aspx

http://www.qualityforum.org/Publications/2005/10/Evidence-Based_Treatment_Practices_for_Substance_Use_Disorders.aspx

slide81

Institute of Medicine of the National Academies

Improving the Quality of Health Care for Mental and Substance-Use Conditions: Quality Chasm Series

http://www.iom.edu

Institute of Medicine (2001). Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press.

Institute of Medicine (2006). Improving the Quality of Health Care for Mental and Substance-Use Disorders: Quality Chasm Series. Washington, DC: National Academy Press.

http://www.iom.edu/Reports/2005/Improving-the-Quality-of-Health-Care-for-Mental-and-Substance-Use-Conditions-Quality-Chasm-Series.aspx

slide82

Bridging the Gap Between Practice and Research

http://www.iom.edu

Institute of Medicine (1998). Bridging the Gap Between Practice and Research: Forging Partnerships with Community-Based Drug and Alcohol Treatment. Washington, DC: National

http://www.iom.edu/Reports/2003/Bridging-the-Gap-Between-Practice-and-Research-Forging-Partnerships-with-Community-Based-Drug-and-Alcohol-Treatment.aspx

contact information
Contact Information

Arthur Schut

Arapahoe House

8801 Lipan Street

Thornton, CO 80260

aschut@ahinc.org