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

                Arthur Schut
            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
 Discussion/Questions
 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
  (EHRs) ubiquitous.
 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
  Sequest Technologies)
 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
 Recovery Model
 project to study the impact of online and mobile
 phone tools.
 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
  residential programs.
 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
 clinical decisions.

 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
 decision making.
 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
 information now?

 Do we use this information?

 Do we really need a “complete psycho-social”

 Do we really ever use this information to treat
 the patient?
 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

 Be admitted

 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
 addictions counselor
 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
 Recovery coach

 Recovery mentor

 Addictions tech (psychiatric tech)
 Detox tech

 Outreach worker

 Other?

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
 licensure/certification? (substance-use
 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
 licensed/certified professionals

 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
 service delivery

 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
  initial information
 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
 system changes?

 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
 see IT)

 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
 using data.
 Inventory - What we SAY we do well

 Inventory – What DO we do well (outside
 view needed?)

 Inventory - Where do we currently “touch”
 health services. Just “touch” anywhere -
 Primary care, health systems, clinics.
 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
 care provider?

 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

 Joint efforts/ventures

 Behavioral health managed care entities,
 managed service organizations, private
 General health care providers

 Integrated MCOs– e.g., Kaiser

 “Fast Forward” – skip ahead to primary
 care “integration”
 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
 healthy babies

 Intervening to help patients participate in
 the management of their illness to shorten
 hospital stays
 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

 Hospital Departments

 Reducing over-utilization of services
 Public health clinics,

 OB/GYN clinics

 EAPs

 HMOs

 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

 Be one

 Endorse some – send them business
 Can all this be done in the next year?

 Start with “low hanging fruit” – trite but true

 Business process
 Clinical efficiency

 IT support

 Inventory clinical staff
 One change at a time – avoid contingent

 Measure change (quick, brief, & targeted)

 Adjust – Move on.
 Benchmarking

 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.
 Benchmarking

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
                     877-330-9870 (Toll-Free)
 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
   Addiction Treatment
National Quality Forum (2007). National Voluntary Consensus
   Standards for the Treatment of Substance Use Conditions:
   Evidence-Based Treatment Practices. Washington, DC: National
   Quality Forum.
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
   Academy Press.
Institute of Medicine (2006). Improving the Quality of Health Care for
   Mental and Substance-Use Disorders: Quality Chasm Series.
   Washington, DC: National Academy Press.
Institute of Medicine (1998). Bridging the Gap Between Practice and
   Research: Forging Partnerships with Community-Based Drug
   and Alcohol Treatment. Washington, DC: National

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