Thoughts related to preventing the potential
extinction of stand-alone substance use
illness treatment providers
Arapahoe House, Inc
October 21, 2009
Brief overview of my crystal ball regarding
the future including assumptions
What is the end point? Where are we
What do we need to look like? What are
our need operational capabilities?
This is not strategic planning
This is not a comprehensive business plan
This presentation is some thoughts on
being strategic with the goal of
survival – avoid being a dinosaur
Practical operational issues
My goal: you leave with one
approach or idea that has practical
We decided it might inspire some dialogue if we
reported on some of the trends we see as having a
transformative effect on addiction services. The
eight developments analyzed below, listed in no
particular order, are among the subjects that are
informing treatment or challenging treatment
These days, the old messages about “your brain
on drugs” [eggs in a frying pan] have been
replaced with, well, an actual brain. The image of
two flat-screen computer monitors flanking the
office desk of NIDA director Nora D. Volkow, MD,
depicting images of healthy and drug-affected
brains, has become part of the treatment
community's collective psyche, with promise of
more effective treatments to be generated from
the various discoveries in the lab.
As the field learns more, for instance,
about what areas of the brain are
associated with craving, it could be nearing
a point where individuals could be trained
in ways to “turn on and off” parts of their
brain during the precarious early stages of
recovery. (Joe Frascella, NIDA)
“The medical profession is rising from a
prolonged slumber, and is increasingly
recognizing that physicians must be
adequately trained to prevent, recognize
and treat substance use disorders”
“Nearly one out of four patients seen in
health care settings for routine medical
problems would screen positive if
evaluated for addictive or harmful alcohol
use, illicit drug use, or use of prescription
drugs for non-medical reasons”
“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 in
American Reinvestment and Recovery Act of 2009
(ARRA) technology provisions promise to spend
close to $20 billion to make electronic health records
But will that spending reach addiction treatment
facilities, which continue to lag behind both mental
health and general health facilities in technology
adoption? Most of the stimulus legislation's funding
comes from increased Medicare and Medicaid
reimbursements for organizations already using
EHRs rather than grant funding to help with
purchases and implementation.
“For an organization with 100 employees and 30
PCs, the software isn't really affordable.” 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)
The national focus on electronic patient records has
started to resonate with addiction professionals.
“They realize that it is not if, but when they are going
to do it.” (Bill Connors, president and CEO of
Both the stand-alone addiction treatment
organization and the mental health only
agency appear to be moving toward
extinction. With expectations of multiple
needs among clients, and with resource
shortages convincing agencies to chase
after funds wherever they can be located,
the field looks destined to be populated
with organizations offering access to the
full spectrum of human 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,” says Linda Grove-
Paul, MSW, director of addiction and
forensic services at Centerstone of
More research might be required before public
health officials definitively state that people in
treatment for alcohol and drug addiction have
better outcomes if they quit tobacco use at the
same time. But with some studies showing that
more than 50 percent of the deaths in substance
abuse treatment populations result from tobacco-
related disease, the momentum in the field has
clearly shifted toward a concept of wellness that
includes treating tobacco addiction.
As state governments from New Jersey to
Colorado commit funding and pass legislation
regarding smoking cessation in addiction
treatment facilities, all eyes remain on ongoing
progress in the state of New York, which last
year launched the most ambitious initiative to
date. The state Office of Alcoholism and
Substance Abuse Services (OASAS) issued a
directive stating that all 1,550 treatment facilities
in the state had to go completely smoke-free.
The statistics are discouragingly familiar: Of the
nearly 20 million Americans in need of addiction
treatment at any given time, only 25 percent
have access to treatment. And of that group, half
drop out, according to SAMHSA. A growing
number of researchers and entrepreneurs are
seeing promise in Internet-based and mobile
phone technologies to engage patients.
With a five-year grant from NIAAA, the University
of Wisconsin has launched the Innovations for
project to study the impact of online and mobile
This fall patients just leaving residential
treatment programs in Peoria, Illinois and Boston
will begin using a system that offers many
features, including an opt-in GPS tracking
feature that monitors their movements and
triggers a peer call when they go near marked
liquor stores, for example.
On work trips, these individuals will be able to
use their cell phones to get information about the
closest meeting. They also can take part in
online support groups.
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, with many hiring
executive chefs who have been more
experienced in four-star hotels than in 30-day
There is a fully equipped gym available to
residential and outpatient clients at Bayside
Marin in San Rafael, California.
Anne S. Hatcher, EdD, co-director of the
Center for Addiction Studies at
Metropolitan State College of Denver, says
she integrates nutritional information into
the pharmacology course she teaches, and
an RN at the college combines the two
topics as well.
The lines continue to blur among the
various “schools of thought” on what
constitutes effective treatment.
The 12 Steps and cognitive-behavioral
therapy (CBT) have a lot more in common
than people tend to assume. “So let's not
compare AA with CBT. AA is CBT.” (Brian
“Since no one behavioral approach has
better overall outcomes than others, clients
should have a choice of available, effective
treatments,” Mark L. Willenbring, director
of the Treatment and Recovery Research
Division at NIAAA.
Gary A. Enos is Editor of Addiction Professional
David Raths is a freelance writer based in Pennsylvania
Addiction Professional 2009 July-August;7(4):18-24
Institute of Medicine of the National Academies
Crossing the Quality Chasm
The Six Aims of High-Quality Health Care
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,
Patient-centered—providing care that is
respectful of and responsive to individual
patient preferences, needs, and values
and ensuring that patient values guide all
Timely—reducing waits and sometimes
harmful delays for both those who receive
and those who give care.
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.
1. Care based on continuous healing
relationships. Patients should receive
care whenever they need it and in many
forms, not just face-to-face visits. ….
responsive at all times (24 hours a day,
every day) and that access to care should
be provided over the Internet, by
telephone, and by other means in addition
to face-to-face visits.
2. Customization based on patient
needs and values. The system of care
should be designed to meet the most
common types of needs but have the
capability to respond to individual patient
choices and preferences.
3. The patient as the source of control.
Patients should be given the necessary
information and the opportunity to exercise
the degree of control they choose over
health care decisions that affect them. The
health system should be able to
accommodate differences in patient
preferences and encourage shared
4. Shared knowledge and the free flow
of information. Patients should have
unfettered access to their own medical
information and to clinical knowledge.
Clinicians and patients should
communicate effectively and share
5. Evidence-based decision making.
Patients should receive care based on the
best available scientific knowledge. Care
should not vary illogically from clinician to
clinician or from place to place.
6. Safety as a system property. Patients
should be safe from injury caused by the
care system. Reducing risk and ensuring
safety require greater attention to systems
that help prevent and mitigate errors.
7. The need for transparency. The health
care system should make information
available to patients and their families that
allows them to make informed decisions…
This should include information describing
the system’s performance on safety,
evidence-based practice, and patient
8. Anticipation of needs. The health
system should anticipate patient needs,
rather than simply reacting to events.
9. Continuous decrease in waste. The
health system should not waste resources
or patient time.
10. Cooperation among clinicians.
Clinicians and institutions should actively
collaborate and communicate to ensure an
appropriate exchange of information and
coordination of care.
SOURCE: IOM, 2001:8.
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
Primary care providers will be the “hub” of
the health care delivery system that is
The majority of substance-use illness
services will be provided through primary
care settings (as is currently true for
depression and anxiety disorders).
We are substance-use illness specialty
providers – not primary care providers
We will have to provide a 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 begins, ends, and
engages meaningfully with primary care.
Specialty services funding streams may be rolled
into universal coverage, and the federal
Substance Abuse Prevention & Treatment Block
Grant and state funds may be rolled into a
The judicious assumption is to plan as if all block
grants will be rolled into universal coverage.
We will be part of the mainstream health care
delivery system or cease to exist.
What do we need to look like? What are our
needed operational capacities? Where do we
connect to health systems? How do we connect
to health systems?
It is time for us as a field to do a self-critical
inventory, and make corrections.
As we think about this ASSUME: there is
universal health coverage; substance-use
illness is included as a covered benefit; the
substance-use illness field is integrated
specialty providers; continuing care
management of health is provided in
connection with Primary Care Providers
(PCPs) as a medical home.
What happens when everyone has the ability
to pay with universal coverage?
There will be more options for services.
Do we have as the foundation of our service
delivery model an implicit assumption that
most clients have to come to us?
For many clients there are “consequences” for
not cooperating. We are currently skilled in
engaging those clients.
In the new delivery system we will need to be
engaging in a different way to assist clients to
voluntarily manage their own care.
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
Evidence-Based Practices (EBP)
need to be implemented with fidelity
measurement and internal audits
Brief interventions and case
management alone are treatment
Study and enhance Handoffs to and
from the “health system/primary care”
Study and enhance Handoffs within
an episode of specialty care
Organize services around episodes
and a full continuum of care, rather
than discrete levels of care or
Incorporate recovery management as an
essential part of the treatment process
Eliminate idiosyncratic language,
acronyms, and other “addiction field speak”
Ensure clinical record keeping that
integrates with a primary health record,
focused on essential items, gathers
minimum information necessary to provide
high quality services.
Do we really need to know/collect that
Do we use this information?
Do we really need a “complete psycho-social”
Do we really ever use this information to treat
How much of the information do we use
and its utility, compared to how much time
and effort it takes to collect the information.
Is collecting all this an evidence-based
Does this assist clients to engage in
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”
Apply for services at your own
Ask a customer
Become active in NIATx
Evidence-based “Practices” as well as
Incomplete adoption and too little fidelity
National Quality Forum (NQF)
IOM Crossing the Quality Chasm
NREPP – National Registry of Evidence-based
Programs and Practices
Medication assisted treatment
Training to, and tracking fidelity of, implementation of
Without FIDELITY there is no evidence-based
Need executive leadership support for
implementation with fidelity measures
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
Need at least dual-credentialed at a level,
and in a way, that is acceptable as a health
Clinical master’s degree prepared
Licensure both as mental health
professional and upper level certified
A high school diploma and certification as
an addictions counselor will not be
acceptable as a primary deliverer nor as a
supervisor of clinical services for
substance use illness.
Bachelor’s or Master’s degree minimum for
primary service delivery
Addictions tech (psychiatric tech)
Need real training with fidelity measurement
of developed competencies – at ALL
education levels (1 or 2 workshops doth
not competency make)
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
illness; mental health); supervision
requirements (what kind, by whom, in what
amounts, for what duration)
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
train substance-use illness staff to mental health
train mental health staff to substance-use illness
Train all professional staff to work with primary care
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
salary differentials for licensure and certification
organization with payers when possible,
and individual clinicians as necessary
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
Engage clinical staff in pre-authorizations, continuing
stay reviews, billing documentation – they usually
produce what is billed or reported
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
Bundling and unbundling services at the
billing end of the process
Electronic claims processing
Appeal claim denials
Appeal claim denials
Appeal claim denials
IT is part of the essential foundation for
Sophisticated does not have to be
complicated (find private sector talent)
Develop business processes anticipating
Electronic Health Record (EHR)
Ability to export to other systems is
Ability of other systems to import information
from you is important
EHR Systems “talking to each other” not likely
any time soon (2020?) – needs uniform national
standards to happen
Single entry data (efficient & reduces errors)
Customer friendly information collection
(unduplicated is efficient)
Effective, timely information sharing
between clinicians, systems of care, and
different provider organizations.
Thoroughly inventory both internal and
external electronic communication.
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)
Initiate business practices that begin to
approach electronic communication
Closed internal email system
Scan and email (closed system)
Scan and fax
Photo copy and send with the patient
Integrated with physical location services
Target is to ultimately provide patient
electronic access integrated with all clinical
Secure login where clients can complete
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.
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)
Some of the assumptions about
substance-use disorder treatment staff are
accurate – some are not.
Will regulation and documentation
requirements change as the delivery
Required documentation often drives the
structure of the delivery system.
Requirements to collect way too much
information “up front” – how difficult can we
make initial engagement and entry into
Regulation by convenience for external
record audit – regulatory or payer audit
staff suggestions regarding how to make
audits easier for them.
How much of what we think is “regulation”
is provider self-inflicted?
Providers should not allow regulation and
auditing to structure clinical services (also
Providers should partner with states to
modify regulation – including self-inflicted
e.g., client must be “discharged” after 30 (or 45
or 60) 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 primary health care provider? How
about your other health specialist provider?
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
Reliable accurate data (internal)
Reliable accurate data is more important
than a lot of data
Reliable external data is a challenge at the
Benchmarking – where is the thermometer
by which we compare our organization’s
performance – what is normal?
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?
Join NIATx process improvement - “mini
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
Inventory - What we SAY we do well
Inventory – What DO we do well (outside
Inventory - Where do we currently “touch”
health services. Just “touch” anywhere -
Primary care, health systems, clinics.
How and where do we engage clients and
touch the general health care system?
Where can we add value in the places we
What do we do that creates value for
primary care and health systems? Is there
a thorn in the paw that we can remove?
We are experts at dealing with difficult to reach
We are experts at engaging patients that are
seen as disruptive in other systems
We are experts at de-escalation
We have affection for the addicted when they are
not at their best.
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
Who are our health system customers?
Connecting our clients to primary care
Who manages continuing care?
Substance-use illness specialists or
primary care providers?
How many SUD specialty providers
contact clients’ existing primary care
providers at admission?
How many contact clients’ existing primary
care providers at discharge?
How many know if client has a primary
How many arrange for a primary care
“home” before discharge?
Networks with other substance-use illness
providers, mental health and behavioral
health providers – create a continuum of
Behavioral health managed care entities,
managed service organizations, private
General health care providers
Integrated MCOs– e.g., Kaiser
“Fast Forward” – skip ahead to primary
Use organizational & services connections
to primary care & health systems
Increase diversity of professional staff to
address major co-occurring conditions
Managing my own illness?
Managing my own recovery?
Where and how is the patient engaged
with the provider in the management of
their own illness and recovery.
Problem Gambling Services
HIV/AIDS management and prevention
Mothers managing their health to produce
Intervening to help patients participate in
the management of their illness to shorten
In what health care settings do substance-
use conditions co-occur?
Partner around shared challenges –
healthy babies, outreach, over-utilization,
disruptive behavior, prescription
medication addiction (pain management
Primary care clinics – private, hospital or
health system owned.
Co-locate in primary care clinics
Co-locate in emergency departments
Co-located services need to be seamless
to the client
Enhanced management of EDs
[Intoxicated individual in ED $xxx.xx per
H1N1 – seasonal flu in EDs – what is our
EDs and intoxicated clients
EDs and seasonal flu or H1N1
Reducing over-utilization of services
Public health clinics,
Provide consultation to primary care health
professionals (need immediate access)
Brief patient consult - 15 to 20 minutes
sessions instead of the 50-60 minute hour?
Preferred provider arrangements
Endorse some – send them business
Can all this be done in the next year?
Start with “low hanging fruit” – trite but true
Inventory clinical staff
One change at a time – avoid contingent
Measure change (quick, brief, & targeted)
Adjust – Move on.
SAAS, NIATx, and Behavioral Pathway Systems are partnering to
sponsor an addiction-specific national benchmarking initiative:
Benchmarking for Organizational Excellence in Addiction
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.
If at least 10 agencies from your state participate, your reports will also
include state-wide norms in addition to national norms.
Benchmarking for Organizational Excellence in Addiction Treatment
Behavioral Pathway Systems
NIATx – Network for the Improvement of Addiction Treatment
NREPP – National Registry of Evidence-based Programs and
Dennis McCarthy The Realities of Evidence-Based Practices for
National Quality Forum (2007). National Voluntary Consensus
Standards for the Treatment of Substance Use Conditions:
Evidence-Based Treatment Practices. Washington, DC: National
Improving the Quality of Health Care for Mental and Substance-Use
Conditions: Quality Chasm Series
Institute of Medicine (2001). Crossing the Quality Chasm: A New
Health System for the 21st Century. Washington, DC: National
Institute of Medicine (2006). Improving the Quality of Health Care for
Mental and Substance-Use Disorders: Quality Chasm Series.
Washington, DC: National Academy Press.
Institute of Medicine (1998). Bridging the Gap Between Practice and
Research: Forging Partnerships with Community-Based Drug
and Alcohol Treatment. Washington, DC: National