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

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 • 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 • 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 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 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 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 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

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 • 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 • “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 • 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 • “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 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 • …. 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 • 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 • 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 • “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 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

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 • “… 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) • 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 (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 (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 • 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?

Challenges • What happens when everyone has the ability to pay with universal coverage? • There will be more options for services.

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

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 • 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 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” 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 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 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 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 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 • Recovery coach • Recovery mentor • Addictions tech (psychiatric tech) • Detox technician • Outreach worker • Other?

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: • 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 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 • 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.

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

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

Finance • Appeal claim denials • Advocate for single case agreements • Contracting vs care management • Appeal claim denials

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 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 Technology • Effective, timely information sharing between clinicians, systems of care, and different provider organizations. • Thoroughly inventory both internal and external electronic communication.

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" • 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 • 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-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.

The Changing Face of Addiction Health Care Moving Forward