recovery oriented systems of care wyandotte county kansas city, kansas heartland regional alcohol...

RECOVERY ORIENTED SYSTEMS OF CAREWYANDOTTE COUNTYKANSAS CITY, KANSASHEARTLAND REGIONAL ALCOHOL & DRUG ASSESSMENT CENTER

Jim Clarkson

CEO/Via Positiva

Paradigm Shift From An Acute Care Medical Model to A Chronic Disease Management Person Centered Model

An Overview of Recovery Oriented Systems of Care

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Integrated Care: From Silos….

To Synergies….4

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”

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

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.

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

Sanctuary

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

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

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

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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

Local Communiti

es

Providers

Systems

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…

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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.

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Describing Recovery-Oriented Systems

Planning Recovery-Oriented System Change

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I. Conceptual Framework

II. Assessment/GapsIII. Capacity

Building

IV. PlanningV. Development

and Implementation

VI. Evaluation

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.

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

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

TRI Studies Concluded:

Give Your Clients

Names & Phone Numbers of

Free & Low Cost Service Community

Referrals! Costs you close to nothing

Improves treatment outcomes

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)

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)

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)

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???

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.

Wyandotte County Population 157,505

299 Churches

54 Childcare Agencies

87 AA Meetings

17 Transportati

on

6 Housing Agencies

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

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, controls costs and improves quality, is accessible, equitable, and effective. It is a public health asset that improves the lives of Americans and lengthens their lifespan.

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.

Remembering Who We Serve

• Disability Weights

• Internalized Oppression

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

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Type of Mental Disorder % Adults

Anxiety disorder 18.1 .

Major depressive disorder 6.7 .

Substance use disorder 7.0 .

Bipolar disorder 2.6 .

Eating disorders 2.1 .

Schizophrenia .44 .

Any mental disorder 26.2 .

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

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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

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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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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.

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.

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).

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).

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

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Trauma—Adverse Childhood Experience Study

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Internalized Oppression

Core Beliefs of the Addict (Paraphrased P. Carnes)

1) I am a bad, unworthy person2) If people knew me they would not like me.3) If I have to get my needs met I will have to

do it myself.4) I will find something to make me feel better.

>>Internalized “self talk”

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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.

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.

ROSC Opportunities Within the Unfolding Behavioral Health Landscape

Funding Considerations

HOW MANY SA PROVIDERS ARE THERE?

SAMHSA 11,246 NIDA 13,000ONDCP 20,000+

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AND

13,918 McDonalds!

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COMPARED TO

11,168 Starbucks!

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Where we are now: a few relevant facts

Population characteristics Funding trends State agency spending MH/SA providers

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Percentages of Adults with Mental Disorders and/or Medical Conditions

National Comorbidity Survey Replication, 2001-2003 54

Average Monthly $ for Medicaid Beneficiaries w/ & w/o Co-Occurring Physical Conditions (2003)

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$-

$1,000

$2,000

$3,000

$4,000

$5,000

$751

$1,999 $2,739

$4,032

$680

$1,601

$2,627

$4,717

$212

$1,382 $2,052

$3,233

Mental Health Service Users Substance Abuse Service UsersAll Other Medicaid Beneficiaries

Source: Medicaid Analytic eXtract (MAX), 2003Substance Abuse and Mental Health Services Administration. (2010). Mental health and substance abuse services in Medicaid , 2003: Charts and state tables. HHS Publication No. (SMA) 10-XXXX. Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration.

SA Funding Trends – 1986 - 2005

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31% 29%36% 38% 40%

10%21%

15% 15% 14%12%

16%19% 20% 20%

8%

7%7% 6% 7%27%

15%12% 11% 10%

10% 9% 7% 7% 6%

0%

20%

40%

60%

80%

100%

1986$9 Billion

1992$13 Billion

1998$14 Billion

2002$19 Billion

2005$22 Billion

Perc

ent D

istr

ibuti

on

Out-of-Pocket

Private InsuranceOther Private

Medicare

Medicaid

Other Federal

Other State and Local

Source: SAMHSA Spending Estimates, preliminary data

2014 Coverage Expansion

Below 133% FPL ($29,500 family)

Medicaid Expansion To Childless Adults

Coverage for essential MH/SA at parity for benchmark plan

Feds pay 100% for 3 years, then down 90%

Simplified enrollment, express apps: web too

Integrated data with State exchanges: one application

Foster kids up to age 26

133 – 400% FPL ($88,000 family)

State Exchanges Coverage for essential MH/SA at

parity & prevention @ no co-pays Helps individuals and small

employers with purchasing health insurance

Assist by voucher to pay premiums or cost sharing

Develops consumer friendly tools & plain language on insurance

One application to both exchanges or Medicaid; can do on the web

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Possible SAPT Block Grant Changes Static or Decreased funding Changes in Mission ROSC

Encouragement of integrated planning Redirection of funds towards services

and persons that Medicaid cannot pay for

Major Features of the SA Treatment System

Financing More than three-quarters of funding

comes from public sources Primary source is state and local

funding other than Medicaid Federal block grant is third largest

source of public funding after Medicaid

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Major Features of the SA Treatment System

Providers Majority are standalone

non-profit/government facilities A quarter provide residential

treatment w/an avg size of 32 beds

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Major Features of the SA Treatment System

Services Most often consist of abstinence-

oriented counseling/education delivered by treatment staff with limited professional training

A third of providers have no physician on staff or contract

Limited use of medication

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Major Features of the SA Treatment System

Billing/administration 40% of providers do not accept

private insurance or Medicaid or both

Half have no mgd care contracts 20% have no IT system of any kind;

few have an integrated clinical system

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Effects - Funding

Overall increase in funding Shift toward more federal financing Transition from grant/contract funding to

health plan model

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Effects - Providers

Partnerships Medicalization Integration/diversification (FQHCs, CMHCs) Deinstitutionalization (IMD exclusion)

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Effects – State Administration

Medicaid Authorities Increase in SA service users and spending Greater authority over provider enrollment

& rate setting Need to improve Medicaid SA coverage to

meet 2014 benchmark requirements

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Effects - State Administration

SA Authorities Shift of half or more of service population to

Medicaid Need to mainstream SA providers into

general health care Need for closer integration with Medicaid

and person-centered focus

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Effective Engagement and Accurate Assessment

“Unless people believe it is safe enough to be vulnerable around us, we can never really teach them anything, for they will never let us see themselves as they actually are.”

(paraphrased from Rudolph Dreykurs)

Conclusions Parity, health care reform, and declines in state

general revenue will significantly change the behavioral health service system, particularly the public part of that system and that which deals with substance abuse.

Overall support for these services should expand, while increasing the variety of providers offering such services.

Financing, administration, and delivery of these services will become more similar to general health care, with greater emphasis on outpatient-based programs that integrate services.

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Health Care Reform and New Medicaid Eligibility

Will include non-elderly adults without dependent children

Incomes less than 133% of the federal poverty level

2014 32 Million Newly Insured (6-10 SA, about ½ Medicaid)

15 million will remain uninsured States will have to manage coordination of

benefits and recovery support services.

Opportunities Exercise

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Screening, Brief Intervention and Referral to Treatment (SBIRT)

SBIRT is a comprehensive, integrated, public health approach to the delivery of early intervention and treatment services for persons with substance use disorders, as well as those who are at risk of developing these disorders. Primary care centers, hospital emergency rooms, trauma centers, and other community settings provide opportunities for early intervention with at-risk substance users before more severe consequences occur.

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SBIRT continued

Payer Code Description Fee Schedule:

Commercial Insurance CPT 99408 Alcohol and/or substance abuse structured screening and brief intervention services; 15 to 30 minutes $33.41 CPT 99409 Alcohol and/or substance abuse structured screening and brief intervention services; greater than 30 minutes $65.51

Medicare G0396 Alcohol and/or substance abuse structured screening and brief intervention services; 15 to 30 minutes $29.42 G0397 Alcohol and/or substance abuse structured screening and brief intervention services; greater than 30 minutes $57.69

Medicaid H0049 Alcohol and/or drug screening $24.00 H0050 Alcohol and/or drug service, brief intervention, per 15 minutes $48.00

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Introduction

Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) – Applies to both mental health and substance use disorder (MH/SUD) benefits Interim Final Regulations issued February 2, 2010 (75 Fed. Reg. 5410) – Agencies requested comments — may issue revisions – Most health plans will need to be reviewed and

possibly amended in light of these rules Affordable Care Act of 2010 – Beginning in 2014, applies MHPAEA to most plans

What is Parity

Dictionary – equal or equivalent, at symmetry, not favoring one over another, fairly matched

Parity As A Legal Construct: A group of State Laws Beginning In the mid 1990s – Over Half of

States Have Some Form of Parity Law 1996 Federal Mental Health Parity Act:

Prohibit different annual and lifetime dollar limitsdid not extend to substance use

2008 Medicare Improvements for Patients and Providers Act By 1/1/2014 Phases out higher coinsurance for outpatient mental

health care 2008 Federal Mental Health Parity and Addictions Equity Act:

Effective October 3, 2009Regulations Effective As Policies Renew On/After July 1, 2010

2010 Health Reform Law Expands To Broader Population In 2014(SAMHSA)

Goal of Parity

Goal Of Parity Law Is To: Increase Access To Treatment Remove Discriminatory Financial Costs More Equal Treatment For These Medical

Conditions

Details

The Law Stipulates:

Covered group health insurance plans that offer both medical/surgical and mental health/ substance use benefits must offer them at parity

Parity Is Defined To Include:

Financial requirements including deductibles, coinsurance, co-payments, and other cost sharing requirements, as well as annual and lifetime limits on the total amount of coverage.

Treatment limitations include restrictions on the number of visits or days of coverage, or

Other limits on the duration and scope of treatment.

Does Not Preempt Stricter State Laws – Impact on State Regulated Insurance

Essential Health Benefits

The Affordable Care Act ensures Americans have access to quality, affordable health insurance. To achieve this goal, the law ensures health plans offered in the individual and small group markets, both inside and outside of the Affordable Insurance Exchanges (Exchanges), offer a comprehensive package of items and services, known as “essential health benefits.”  Essential health benefits must include items and services within at least the following 10 categories:

Essential Health Benefits

Ambulatory patient services Emergency services Hospitalization Maternity and newborn care Mental health and substance use disorder

services, including behavioral health treatment Prescription drugs Rehabilitative and habilitative services and devices Laboratory services Preventive and wellness services and chronic disease

management, and Pediatric services, including oral and vision care

Regulation

MH/SUD benefits may not be subject to any separate cost sharing requirements or treatment limitations that only apply to such benefits

If a group plan provides for out of network medical/surgical benefits, it must provide for out of network mental health and substance use benefits

Standards for medical necessity determinations and reasons for any denial of benefits relating to MH/SUD must be disclosed upon request

Four Major Dimensions and 10 Principles of ROSC

Principles of Recovery Oriented Systems of Care

Attitude & Aptitude

Attitude & Aptitude

Essential Qualities for Positive Therapeutic Outcomes

1) Factors related to what the client brings to the situation (about 40%)

2) The therapeutic relationship (about 30%)

3) Expectancy and Hope (about 15%)4) An explanatory system that guides the

healing practices (about 15%)

Sooooo…..

“This means that 60% of what accounts for whether or not a person responds to treatment hinges on the people delivering the treatment. If they develop a positive, warm, supportive and empathic relationship, support the development of hope that progress can be made, have a clear rationale for what they are doing that outlines a therapeutic map of recovery, and empower the client to help themselves, there is likely to be improvement.” (Bloom 2009)

Recovery

“A process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential.” (SAMHSA, 2011)

Four Major Dimensions of Recovery

Health Home Purpose Community

Health

Overcoming or managing one’s disease(s) or symptoms—for example, abstaining from use of alcohol, illicit drugs, and non-prescribed medications if one has an addiction problem—and for everyone in recovery, making informed, healthy choices that support physical and emotional wellbeing.

Home

 a stable and safe place to live.

Purpose

Meaningful daily activities, such as a job, school, volunteerism, family caretaking, or creative endeavors, and the independence, income and resources to participate in society.

Community

Relationships and social networks that provide support, friendship, love, and hope.

Hope

Recovery emerges from hope:  The belief that recovery is real provides the essential and motivating message of a better future – that people can and do overcome the internal and external challenges, barriers, and obstacles that confront them.  Hope is internalized and can be fostered by peers, families, providers, allies, and others.  Hope is the catalyst of the recovery process.

Person Centered

Self-determination and self-direction are the foundations for recovery as individuals define their own life goals and design their unique path(s) towards those goals. 

Many Pathways to Recovery

Recovery occurs via many pathways:  Individuals are unique with distinct needs, strengths, preferences, goals, culture, and backgrounds including trauma experiences that affect and determine their pathway(s) to recovery.

Holistic

Recovery is holistic:  Recovery encompasses an individual’s whole life, including mind, body, spirit, and community. 

Supported by Peers and AlliesRecovery is supported by peers and

allies:  Mutual support and mutual aid groups, including the sharing of experiential knowledge and skills, as well as social learning, play an invaluable role in recovery.

Relationship and Social Network

Recovery is supported through relationship and social networks:  An important factor in the recovery process is the presence and involvement of people who believe in the person’s ability to recover; who offer hope, support, and encouragement; and who also suggest strategies and resources for change.

Recovery is culturally-based and influenced

Culture and cultural background in all of its diverse representations including values, traditions, and beliefs are keys in determining a person’s journey and unique pathway to recovery.

Addresses Trauma

The experience of trauma (such as physical or sexual abuse, domestic violence, war, disaster, and others) is often a precursor to or associated with alcohol and drug use, mental health problems, and related issues. 

Services and supports should be trauma-informed to foster safety (physical and emotional) and trust, as well as promote choice, empowerment, and collaboration.

Strengths and Responsibility Recovery involves individual, family,

and community strengths and responsibility:  Individuals, families, and communities have strengths and resources that serve as a foundation for recovery.

Respect

Recovery is based on respect:  Community, systems, and societal acceptance and appreciation for people affected by mental health and substance use problems – including protecting their rights and eliminating discrimination – are crucial in achieving recovery.

Ensure genuine, free, and independent client choice…

Ingredients Within Successful Recovery Oriented Systems of Care

Using ROSC as a Framework.Recovery Oriented Systems of Care is a

framework for coordinating multiple systems, services and supports that are person centered and designed to readily adjust to meet the needs of the individual’s needs and chosen path to recovery.

Harnesses and Aligns Community Healing and Resiliency Factors

ROSC harnesses and coordinates the healing power of clinical treatment providers, the recovery community, the faith-based community and an array of recovery support service providers.

Choice

Ensure genuine, free, and independent client choice for substance abuse clinical treatment and recovery support services appropriate to the level of care needed by the client. Choice is defined as a client being able to choose from among two or more providers qualified to render the services needed by the client, among them at least one provider to which the client has no religious objection.

Strong Leadership/Central Model

Strong mission driven leadership. Ensures each client receives an

assessment for the appropriate level of clinical and recovery support services and is then provided a genuine, free, and independent choice among eligible providers.

Voucher Based Payment

Allow eligible clients to use their vouchers to pay for assessment and other clinical treatment and recovery support services from a broad network of eligible providers. The network of eligible providers should include provider organizations that have not previously received public funding. Eligible service providers for the voucher program may include the following: public and private, nonprofit, proprietary organizations, including faith-based and community-based organizations.

Outreach and Training of FBOs Ensure that faith-based organizations

otherwise eligible to participate in this program are not discriminated against on the basis of their religious character or affiliation.

Incentivize for Outcomes

Maintain accountability by creating an incentive system for positive outcomes and taking active steps to prevent waste, fraud and abuse.

Community Structure

Advisory Council Monthly Provider Meetings and Data

Sharing.

Leverage Existing Funding and Resources

Expand clinical treatment and recovery support services by leveraging use of all Federal, State and Local Funding.

Investigate and coordinate funding for those seeking services.

Healthcare Navigation/Peer Supports.

Other Keys to Success

Clear Credentialing Requirements and Process. Set of trainings for FBOs and Recovery Support

Services Providers. Use of GPRA/NOMS and other measures for

outcomes. Mobile assessments and assertive outreach. EBPs such as Motivational Interviewing, CRA,

CRAFT, 12 Step Facilitation Therapy & Education, Trauma Informed Care, Matrix Model.

EBP to Introduce EBPs--NIATx.

Preparation: Process ImprovementNIATx (www.niatx.net)

Since 2003 Partnership between Robert Wood Johnson Foundations Paths To Recovery, The Substance Abuse and Mental Health Services Administration (SAMHSA) and the National Institute on Drug Abuse.

There are agencies in all 50 states using NIATx process improvement principles along with 25 State Substance Abuse Authorities. Free Provider Tool Kit.

NIATx Aims

Reduce Waiting Time Reduce No-Shows Increase Admissions Increase Continuation

Each of these activities has had a marked improvement in agency bottom lines (Business Case Series 3/07).

NIATx Principles

Understand and involve the customer

Fix key problems that keep the CEO up at night

Pick a powerful change leader Get ideas from outside the

organization or field Use rapid-cycle testing to establish

effective changes (Plan-Do-Study-Act)

NIATx Results

34.8% reduction in waiting times

33.0% reduction in no shows

21.5% Increased Admissions

22.3% Increase in continuation

Walk Through

Staff members experience the treatment process just as a customer does. The goal is to see and feel the agency from the customer’s perspective. Taking this perspective of services—from the first call for help, to the intake process, and through final discharge—is the most useful way to understand how the customer feels and to discover how to make improvements that will serve the customer better.

Motivational Interviewing

Model describes how people change Helps people change their behavior

and improve their motivation to change

Identifies fears and difficulties and helps to resolve these issues

Motivational Interviewing

Client-centered approach Meets the client where they are at Self-determination Self-autonomy Non-judgmental

Motivational Interviewing Counselor

Respect individual differences Tolerance for disagreement and

ambivalence Patience with gradual changes Caring and interest in client Not the expert, but a partner Willing to negotiate with the client Open to ideas from client Supports what the client wants to do

The Peer Recovery Support Specialist

PEER RECOVERY SUPPORT SERVICES (PRSS)

Services to help individuals and families initiate, stabilize, and sustain recovery•Non-professional and non-clinical•Distinct from mutual aid support, such as 12 Step•Provide links to professional treatment and indigenous communities of support•Provided by peers with “lived experience” of addiction and recovery

WHY DO PRSS WORK?

Focus on establishing trust and building relationship•Start with a person’s strengths and Recovery Capital•Promote recovery choices and goals through a self-directed Recovery Plan•Utilize recovery community resources and strengths•Provide entry to healthcare system and services•Elevate recovery as an expectation

BENEFITS OF PRSS

Effective outreach and engagement•Manages recovery from a chronic condition perspective•Stage-appropriate•Cost-effective•Reduce relapse•Promote recovery reengagement•Facilitate reentry and reduce recidivism•Reduce emergency room visits•Create stronger and accountable communities

WHEN ARE PRSS DELIVERED?Across the full continuum of the recovery process:• Prior to treatment• During treatment• Post treatment• In lieu of treatment•Peer services are designed and delivered to be responsive and appropriate to all stages of recovery

WHERE ARE PRSS DELIVERED?Recovery community centers•Faith and community-based organizations•Emergency departments and primary care settings•Addiction and mental health agencies•Criminal justice systems•HIV/AIDs and other health and social service centers•Children, youth, and family service agencies•Recovery residences and Oxford Houses

WHERE ELSE AND IN THE FUTURE?Emergency departments•Primary care practices•Patient-centered health homes•Federally Qualified Health Centers•Accountable Care Organizations•Community-based alternatives to jails and prisons•Schools & colleges•Veterans’ centers

WHO IS PAYING FOR PRSS?

State, County, and Municipal service contracts•SAPT Block Grants•Federal and State grants and discretionary funds•Other Federal funding: TANF, US Department of Justice, VA•Medicaid•Managed Care•Foundation support•Community support

PEER RECOVERY COACH

Personal guide and mentor for individuals seeking to achieve or sustain long-term recovery from addiction, regardless of pathway to recovery•Connector to instrumental recovery-supportive resources, including housing, employment, and other services•Liaison to formal and informal community supports, resources, and recovery-supporting activities

MUCH MORE THAN RECOVERY COACHES

Peer telephone continuing support•Peer-facilitated educational and support groups•Peer-connected and –navigated health and community supports•Peer-operated recovery residences•Peer-operated recovery community centers

RECOVERY COMMUNITY CENTERS Positioning as a community institution (like a Senior Center) •Provides public and visible space for recovery to flourish in

community: Recovery on Main Street •Serves as a “community organizing engine” for civic

engagement, leadership development, and advocacy •Operates as a “hub” for PRSS and recovery-related

activities •Includes participation of family members and allies in

recovery community culture, services, and programs •Provides volunteer and service opportunities for

community members •Positions the recovery community to interface as a key

stakeholder with the greater community

ACA

ACA Enrollment •Outreach to the recovery community •Uninsured people living in recovery

residences, participating in recovery community centers (estimated over 50% are uninsured)

•Community members reentering from incarceration

•Strategic communication and tailored messaging

ACA Enrollment

Navigator contracts to recovery community organizations or advocacy organizations to conduct education, outreach and enrollment of hard to reach individuals with mental illness. June 7, 2013 deadline.

•Creating venues and events to conduct enrollment activities

•Connecting enrollees to health care services

•Keeping people in the health system once enrolled

Policy and Practice

Recovery Oriented Systems of Care Within the

Current Behavioral Health Landscape.

Introduction

Core values Mission and vision Recovery oriented approach The True North

General Articles

Credentialing of Providers Termination Conflict of Interest Confidentiality Rates

Recovery Support Services; Descriptions and Definitions

Recovery Support Service Coordination (Case Management)

Recovery Support Service Coordinator Position (RSSC)

Recovery Support Service Mobile Coordinator Position (RSSMC)

Service Definitions for Recovery Support Services with Eligibility Standards and Documentation Requirements

ChildcareTransportationFamily SupportGroup/Peer SupportHousing ServicesHousing Case

Management Reimbursement

Gap FundGap Case Management

ReimbursementJob Development

MentoringLife SkillsPhysical Fitness &

WellbeingSpiritual SupportPastoral GuidanceTraditional HealingIntensive Recovery

SupportAftercare

Procedures for Recovery Support Services Vouchers

RSS Coordinator RSS Provider

Clinical Treatment Agency Model Program Content

Service Philosophy Basic Services Required Required Service Mix

Roles & Responsibilities of Clinical Supervision

Required minimally once per month Face to Face/Individual or group Motivational and reflective Distinct from administrative supervision Includes self-care plan and professional

growth plan

Provider Operating Requirements & Procedures (1) Voucher Eligibility, Referral and Management Voucher Oversight Voucher Life and Cap Web Training Requirement Evidence of Appropriate Business Licenses Licensure, Certification, Credentials, or Other Staff

Qualification Program Compliance with Health & Safety

Regulations Organizational Governance Religious Activity & Charitable Choice

Provider Operating Requirements & Procedures (2)

New Services Staff Changes Program Operating Standards Program Rules Code of Ethics Protection of Individuals Support Service Program Responsibility Support Service Governance Support Services

Provider Operating Requirements & Procedures (3) Quality Assurance Conflict of Interest GPRA

Personnel or Volunteer Policies

Confidentiality and Individual Records

Policies and Procedures

Program Structure

FACTORS FOR RECOVERY

Recovery-Oriented Systems of Care Recovery Advocacy Movement Mental Health Parity and Addiction Equity Act Affordable Care Act Managed Care Expansion Criminal Justice and Drug Policy Reform Movement

Association for Recovery Community Organizations

82 member organizations (33 states) with local, state, and national focusAssistance to recovery community organizationsNational Alliance for Medication-Assisted Recovery (NAMA-Recovery)Building capacity to operate; develop leadership; advocate and deliver peer recovery support

WHY IS IT IMPORTANT? WHAT DOES IT MEAN? Addiction is costly in terms of finances, physical and

mental health, family functioning, employment, and legal involvement.

Recovery is associated with dramatic improvements in all areas of life – better health/ finances/family life/civic engagement/ employment coupled with dramatic decreases in public health and safety risks.

Life keeps getting better as recovery progresses. Policies, services, and funding are needed to help

more people initiate and sustain recovery, and for additional research to identify effective and cost-effective recovery-promoting policies and services.

ESSENTIAL INGREDIENTS FOR SUSTAINED RECOVERY

HEALTH AND WELLNESS•Safe and affordable place to live•Steady employment and job readiness•Education and vocational skills•Life and recovery skills•Health and wellness•Sober social support networks•Sense of belonging and purpose•Connection to family and community

ESSENTIAL INGREDIENTS FOR SUSTAINED RECOVERY

Safe and affordable recovery housing (substance free)•Some need sober group living situations•Recovery housing for single mothers and children•Housing discrimination against people in recovery with criminal justice history•Recovery housing: NIMBY issues

EMPLOYMENT, EDUCATION AND CIVIC ENGAGEMENT

Recovery Jobs: Recovery-oriented employers and employment programs•Job readiness and preparation•Opportunities to volunteer and build work histories•Leadership development: volunteer and career ladders•Recovery GED programs, high schools and colleges

EMPLOYMENT, EDUCATION AND CIVIC ENGAGEMENT

Recovery GED programs, high schools and colleges•Community college programs for people in recovery•Employment discrimination against people in recovery with criminal justice history•Restrictions on voting rights for people with criminal justice history

OTHER INGREDIENTS

Legal assistance•Expunging criminal records•Financial assistance: debt, taxes, basic budgeting, etc.•Obtaining driver’s licenses•Dealing with revoked professional and business licenses•Regaining custody of children•Relationship and parenting skills

RECOVERY AND WELLNESS FOCUS

Shifting from a crisis-oriented, professionally-directed, acute-care approach with its emphasis on isolated treatment episodes…. To a person-directed, recovery management approach that provides long-term supports and recognizes the many pathways to health and wellness.

ROSC

Build on the strengths and resilience of individuals, families and communities as individuals take responsibility for their long-term recovery, health and wellness.•Make services and resources available that people can use to meet their needs•Offer a variety of supports that work for and with each person to restore their lives (an ongoing process)

Mobilization

Mobilizing all of the resources in our communities to:•Change discriminatory public policies in the areas of health care, jobs, education and housing to eliminate barriers and support the ability of people to get into and sustain their recovery for the long haul.•Develop networks and systems that work together to treat addiction as a public health problem

Mobilization

Mobilizing all of the resources in our communities to:•Accord people in or seeking recovery dignity and respect•Engage people to seek help in the health system•Help more people find and sustain their recovery for the long-term•Build the capacity of communities, organizations and institutions to support recovery

Making Systems Work

Public education and awareness about addiction prevention and the many pathways to recovery•Greater focus on what happens BEFORE and AFTER primary treatment•Transition from professionally-directed treatment plans to individually-developed recovery plans – recovery self-management•Greater emphasis on the physical, social and cultural environment where people live their daily lives•Integration of primary care, prevention, professional treatment and recovery support•Recovery community representation at all policy and decision making levels

Compensation Continuum for Performance-based Payments

A shift toward increased collaboration and outcome-based payment Requires several steps to achieve full integration

This modular set of performance-based contracting options align with a provider’s risk readiness

Compensation Continuum

(Level of Financial Risk)Small % of financial

riskLarge % of financial

riskModerate % of financial

risk

Limited Integration Full IntegrationModerate Integration

Fee-for-

service

Performance- based Contracting

• Physician• Hospital

Patient-centered Medical Home

Bundled and

Episodic Payment

s

Shared Saving

s

Shared Risk Capitation

Capitation +

Performance- based

Contracting

Reimbursement MethodologiesDefinition Pro’s Cons

Separate payment to a health-care provider for each unbundled medical

service rendered to a patient

Payments match services Complete utilization data Provides audit trail

May incentivize over-utilization May discourage efficiencies Doesn’t address

quality/performance directly

Providers are rewarded for meeting pre-established targets for delivery

of health-care services

Incentivizes positive outcomes Supports improvement in quality

measures May encourage efficiency

May direct provider attention only to impacted measures

May be difficult to evaluate causality

A flat payment for bundled group of procedures and/or services

Controls cost per episode of care Decreases UM oversight

Increased provider risk Incentivizes shifting treatment to

other settings/codes

A flat payment for bundled group of procedures and/or services

Aggregates claims by diagnostic category instead of lumping all diagnoses into one case rate

May result in premature discharge or under treatment

May incentivize making cases more complicated

A set payment for each enrolled person assigned to a provider or

group of providers, whether or not that person seeks care, per period of

time

Predictable and stable costs Reduces billing

May promote under-treatment or selection incentives

Fee for Service (FFS)

Performance-Based Contracting

Case Rate

Diagnostic Related Group (DRG)

Capitation

These are the fundamental avenues of focus for improving care and outcomes, and enhancing employee health

Achieving the Triple AimImproved Population Health, Quality and Affordability

Performance-based contracting and other more sophisticated reimbursement approaches as providers’ sophistication matures

Facilitates provider quality and accountability

Payment Reform

Consumer Tools/Transparency

Centers of ExcellenceBenefit tiering/high

performing networksHelps members make

informed choices

Employee Responsibility/

Incentives

Sophisticated AnalyticsIntra-provider incentivesElectronic Health Records

that allow Provider Interoperability

Consumer support toolsFacilitates total

population management

Population Analysis

Triple Aim

Direction from Health and Human Services/Center for Medicare/Medicaid Services

HHS and CMS are facilitating the following strategies as a major focus of Health care reform:

Public Reporting: engaging consumers and others stakeholders

Health Information Technology: enabling improvement

Value-Based Payment: rewarding achievement

Clinically-Integrated Delivery Systems: achieving patient-centered, coordinated care

The Department of Health and Human Services in setting the stage for health care reform has commissioned the National Quality Forum to aid in the development of a national measurement strategy.

NQF will be convening a behavioral health workgroup to examine and assimilate measures.

Performance-Based Contracting – At A Glance

Demonstrated use of Evidence-Based Practices (EBP)• Qualifies as High-Volume provider• Participates in periodic meetings with clinical operations staff to review

data• Submits claims electronically

Sample FacilityParticipationRequirements

Sample Metrics

• Facility will earn escalator based sharing of savings if performance is within targeted range

• Facility will earn performance bonus for achievement of quality metrics

Sample Performance

Incentives

• Reduction in Average Length of Stay• Reduction in 30 day Readmission rate to any inpatient LOC• Improved results on ambulatory follow-up rates (7 days post inpatient

discharge)

Incentivizing provider performance leads to better outcomes for consumers

Outcomes, Options and Transformations

Recovery Oriented Systems of Care Within the Current Healthcare Landscape

Quality Measures

If addiction is a chronic illness requiring sustained monitoring, support, and early re-intervention,can the current acute-care model of addiction treatment provide such continuity of support overan extended period of time?

Quality Measures

a recovery-focused organizational culture; adequate capitalization, funding

diversification, availability of funding streams that enable sustained

support, and financial stewardship; stability of organizational ownership; administrative and clinical leadership and

workforce stability; recovery representation at policy and clinical

decision-making levels;

Quality Measures

Recovery-focused performance measures include three dimensions of systems evaluation: 1) measures of infrastructure stability and adaptive capacity, 2) recovery-focused service process measures, and 3) long-term recovery outcome measures.

Infrastructure stability and adaptive capacity reflect the capacity of an organization to undergo systems-transformation processes (e.g., from an AC to an RM model of care) and the capacity of an organization to fulfill its commitment to continuity of contact and support over time for individuals and families seeking long-term recovery.

Recovery-oriented service process measures (e.g., early identification, engagement, retention, etc.) are intermediary outcomes that are linked to the final goal of long-term individual and family recovery.

Long-term recovery outcome measures represent the major fruits of recovery, defined here as the resolution of alcohol and other drug problems, the progressive achievement of global (physical, emotional, relational) health, and citizenship (life meaning and purpose, self-development, social stability, social contribution, and elimination of threats to public safety).

WHAT DOES LONG TERM RECOVERY LOOK LIKE? LIFE IN RECOVERY SURVEYAlexandre Laudet, PhD

Understanding the experiences of people in recovery should inform this opportunity.•Build recovery-oriented communities where the services and supports that people identify that they need are available – when they are needed.•First nationwide survey of people in recovery from alcohol and other drug problems.•3,228 participated.•44 items representing experiences and indices of functioning in work, finances, legal, family, social, and citizenship domains “in active addiction” and “since you entered recovery.”

Outcomes and Successful ROSC IAIA Access to Recovery Data Philadelphia Connecticut

Institute of American Indian Arts 90% of students indicated that the

Healing Circle Program improved their college experience. Students said that the program was conducive to learning, creative expression and human wellness.

There was a 100% drop in suicide attempts from 3 per semester to 0 during the 2 year term of the Healing Circle Program.

Incident reports related to alcohol or drug use dropped 95% during the Healing Circle Program.

Access to Recovery

At six months post intake, 80.4% were abstinent from substance use.

At six months post intake, 46.5% reported being stably housed.

At six months post intake, 49.8% reported being employed.

At six months post intake, 90.8% were socially connected (attended self help groups or had someone to whom to turn in times of trouble).

At six months post intake, 96.0% reported no involvement in the criminal justice system.

Connecticut

Short-term housing; • Transportation; • Faith-based services; • Basic needs (food, clothing, etc.); • Case management; • Childcare; and • Vocational and educational services.

Connecticut Peer Services

Telephone recovery support; • Family/community education; • Family support groups; • All-recovery groups; • Volunteer training; • Recovery training; • Peer-operated transportation company;

Connecticut Partners

Department of Corrections•Judicial BranchDepartment of Children and Families•Department of Social Services•Primary Healthcare Sites (Hospital ED & FQHC Sites)•DMHAS-funded Outreach & Engagement Urban Initiatives

Connecticut

Wisconsin

Wisconsin

Wisconsin

Data Management System

Allow clients to choose and change network providers;• the capture of all client information, including GPRA outcome data;• the generation and monitoring of vouchers; and,• individual providers billing services rendered to the ATR client.

New Mexico

A Recovery Oriented System of Care in Wyandotte County

Moving Forward!

Getting Started…

Planning Recovery-Oriented System Change

184

184

I. Conceptual Framework

II. AssessmentIII. Capacity

Building

IV. PlanningV. Development

and Implementation

VI. Evaluation

A Meeting of Key Stakeholders and Interested Community Members

Next steps… Grants? Coalition? Action Plan? Learning Collaborative? Further Training?

Thank you!

Jim Clarkson(505) 944-5284

Jim.Clarkson@Prodigy.Net

Final Quiz!