Transcript Restructuring Services - Florida Alcohol and Drug Abuse Association

Restructuring Services
Creating Clinical Pathways Through
Provider Networks
Presented by…
Bob Holm, Regional Substance Abuse Director, Suncoast Region DCF
Richard Brown, Chief Operating Officer, The Agency for Community Treatment Services
Linda McKinnon, Chief Executive Officer, Central Florida Behavioral Health Network
Bob Holm
Regional Substance Abuse Director
Department of Children & Families
Suncoast Region
Provider Network as Change Agent
DCF supported the creation of
CFBHN as a means to promote
best practices and the
development of clinical
pathways across a designated
geographic area (old District 6).
The Network was developed to address
service and system development throughout
the designated area.
DCF wanted to assure services were
coordinated into a system that could be easily
navigated by the client receiving care,
whether from multiple providers or multiple
levels within a provider agency.
DCF, as the purchaser, requires the
following from the Managing Entity:

Evaluation, integration and re-engineering system of care into a
seamless and easily navigated system at the client level

Uniform promulgation of clinical policies and best practices
throughout the Network

Uniform data collection used to drive quality improvement
initiatives

Resource maximization and cost effectiveness

Increased access to care

Simplification and non-duplication of contracting and oversight
functions to allow for effective use of limited staff and resources
Required Features of DCF CommunityBased Networks and Managing Entities

Community governance and oversight

Shared risk with providers

Comprehensive service delivery and ability to provide integrated
service

Client involvement

Community re-investment

Coordination with collateral systems

Creation of opportunities for planned transition of service
strategies
Tasks Required to Develop System
 Analyze and plan for individual service needs
 Strategies for service delivery
 Evaluation of service implementation
 Review of services and revision as required
 A formal information sharing process
Evolution not Revolution
 CFBHN began working with providers to
collaborate on clinical improvement activities
occurring at individual agencies
 Network services strategies were developed
for HIV, children’s issues, family intervention,
etc.
 During 2002-2004, CFBHN began working on
developing systems of care across provider
agencies: TANF, co-occurring, elder services,
etc.
In 2004, management of all substance abuse
prevention, treatment and aftercare funding was
transitioned to the Network.

The Network was required to ensure the development of
network-wide, county specific system of care plans and
that services were provided as specified in the plans
through the contract period

The Network was required to increase access to acute
care services for substance abuse

The Network was required to maximize resources
available for substance abuse treatment

The Network was required to provide science-based
prevention strategies to target populations
DCF’s Goals for the Network
 Enhance community prevention
strategies
 Increase access to acute care services
for substance abuse
 Maximize resources available for
substance abuse treatment
2004 Contract Deliverables Related to
the Goals
--Prevention-Assist, develop and resource community
coalitions throughout each area of the
Network.
2004 Contract Deliverables Related to
the Goals
--Acute Care--
The Managing Entity will review the current
detoxification system in Hillsborough in Hillsborough
& Pinellas counties and will make written
recommendations concerning the possibility of
reducing the number of residential and adding
outpatient detoxification as an alternative.
2004 Contract Deliverables Related to
the Goals
--Treatment-The Managing Entity will be responsible for
managing and reporting the substance abuse
wait list. A baseline for number of days waiting
and average number of people waiting will be
established by December 31, 2004.
2005 Contract Requirement
Specific to Acute Care
--Outpatient Detoxification--
By October 31, 2005, the provider (CFBHN)
will fully implement the Department
approved recommendations for the Region’s
detoxification system. These
recommendations were provided by the
provider (CFBHN) as one of the 2004
contract deliverables.
Linda McKinnon
Chief Executive Officer
Central Florida Behavioral Health Network
The Process
Manatee Glens, a Network provider, had
been providing outpatient detoxification
services for several years
Manatee Glens’ program was developed in
response to limited detoxification availability
in Manatee County; there were 3 beds and
the unmet needs were growing
Research indicated there is no long-term significant difference in
outcomes for clients detoxified in an inpatient and
an outpatient environment.
Significant advantages were identified for those who are properly
triaged to the level of care appropriate to the clinical need.






OPD is less costly
The client’s life is not disrupted
The client does not undergo abrupt transition from
protected inpatient setting to the community
OPD services are available for a longer period of time,
allowing for a longer engagement period
More clients can be served
Wait time is reduced
CFBHN completed a review of publicly funded
inpatient detoxification facilities and the OPD
program in place.
Monthly provider meetings were
conducted to discuss the
development of OPD programs,
review current inpatient medical detoxification,
complete literature reviews and recommend
strategies.
The agreed upon definition for
inpatient medical detoxification:
Medically monitored detoxification and
stabilization for adults, 18 years of age and
older, who are dependent on drugs and/or
alcohol and are admitted by physician’s
order.
Criteria for admission requires that the
client cannot safely detoxify in an
outpatient setting and meet ASAM
placement criteria.
The following inpatient detoxification
standards were catalogued for all
facilities:











Admission criteria
Medical monitoring and stabilization
Co-occurring disorder capabilities
Discharge criteria
Secure/non-secure environments
Licensed bed capacity
Funding
Average length of stay
Length of stay by substance
Current cost to operate/cost per bed to operate
Involuntary admissions by category
Outpatient Detoxification Program
SAMHSA TIP 19 defines outpatient detoxification as a
modified medical model: a social model that contains
routine access to medical services in order to manage
the medical and psychiatric complications of a patient’s
withdrawal.
Manatee Glens’ OPD services were catalogued by:
- Number of slots
- Length of stay
- Staffing pattern/medical availability
- Group composition
- Cost per slot
- Completion rate
The Committee agreed to a set of
standards for outpatient detoxification
services.
• Uniform assessment and admission criteria
• Length of stay to be 10-14 days, depending on
•
•
•
•
•
referral source
Medication protocols and IDP funding
Housing
Staffing
Hours of operation
Methodology for collection of outcomes
Challenges Identified
• Concern that additional OPD slots may not decrease
need for medical detoxification beds
• Concern regarding stakeholder/community reaction to a
reduction in beds
• 60% of clients admitted identified as having co-occurring
disorders that require medications and the limited
availability of IDP funds for substance abuse
• Lack of availability for temporary housing for clients who
are homeless
Benefits Identified
• OPD slots are significantly less expensive
• Less disruptive
• Higher potential for engagement in treatment
• Ability to “practice” new behaviors at home and work while in program
• Increased numbers served
• Actual provider experience of successfully providing outpatient
detoxification services
• Ability for clinical members of provider teams to meet regularly to
facilitate program development, share best practices and problem solve
challenges
• Ability to ensure evaluation component is developed to provide objective
information and guide future decision making
Network Consensus
• Reduce inpatient beds from 35 to 20 per
provider (ALOS – 6 days)
• Add 25 outpatient slots per provider
(ALOS – 12 days)
• Result is 46 additional clients served by
each provider
2005 – The Rubber Hits the Road
• ACTS establishes outpatient detoxification services in
October 2005
• Committee, comprised of detoxification providers,
CFBHN staff and Suncoast Region Substance Abuse
Director, established to assist in evaluation
• Committee recognized that the collaboration provided
a unique opportunity to gather information about OPD
programs and how utilization of OPD might affect the
system of care
Committee determined scope of information
to be analyzed during initial stages of
development:
• Impact of OPD service availability on wait
list for residential services
• Impact of OPD service availability on
residential detoxification system
• Type of client and program that contribute
to successful outcomes
Evaluation Component
● Providers agreed to a set of written guidelines for data collection and the
consistent utilization of specific instruments
● Committee identified the measure of success in completion of OPD
● Primary goal – medical stability (defined as stable vital signs)
● Secondary goal – linkage and engagement to treatment
● Codes established to identify discharge status
● All providers used the URICA (University of Rhode Island Change
Assessment Tool) to measure state of change and treatment readiness
● Additional elements collected for analysis include:
-
Referral source
Drug test results
Vital signs
CIWA/COWS results
- URKIA pre- & post-test results
- Discharge reason
- Length of stay
Data Analysis
Data was collected from clients
discharged between October 1, 2005
and February 26, 2006.
Data included State data reporting elements.
Statistics
# served in OPD during evaluation period
Average age
60% Males
209
37
40% Females
Primary substance used at admission:
Alcohol
Crack
50%
28%
Primary referral source:
Self
Residential detoxification (where available)
Other
Length of stay:
10.68
OPD Wait List
Highest month average (May ’05) = 6.93 days
Average at last month of study (Feb ’06) = 1.05 days
Successful discharge:
Manatee Glens
ACTS (new program)
87%
65%
54%
41%
5%
Results
• Client needs and outcomes will vary by system of care available in
community
• 30 – 50% of clients were medically stable at admission so this
criteria for successful discharge should be evaluated
• Clients with higher URICA scores at pre-test are more likely to leave
prior to completion of treatment
• 50% of clients had positive changes
• OPD services are a viable alternative to achieve medical stability,
gain understanding of substance abuse issues, increased motivation
for change, readiness for treatment and decreased wait lists, which
allow for greater access to care
Recommendations
• To maximize resources most effectively a full continuum of care for both
voluntary and involuntary clients be made available, including inpatient and
outpatient detoxification to achieve medical stability and coordination of care
• Strategies to develop temporary housing opportunities will decrease a
communities’ reliance on inpatient and residential detoxification services
• Strategies for transportation will decrease the need for inpatient
detoxification services
• Readiness for change assessments should be utilized by OPD programs as a
clinical indicator and to improve retention
• Evaluate requirements of current OPD programs and assess opportunities for
development of individualized components for detoxification services
(medical, motivational, recovery, peer services, individual and group
counseling)
acts
The Agency for Community Treatment Services
Richard Brown
Chief Operating Officer
The Agency
for Community Treatment Services
Challenges To Goals
Examine the potential of incorporating Outpatient
Detoxification Services in Hillsborough County’s
System of care as a means to:
Increase accessibility to care, and
Improve engagement in continuing care services
Operationalize Recovery Principles For Consumers
at acts’s points of access to care
Inventory of the presenting “Dots”
(factors driving consideration within
the acts organization)
• Agency experienced success in the re-engineering of Adult
•
•
•
•
•
•
treatment services through CCISC Implementation.
Financially depleting Detox (AARF) Operation.
Potential for community “uprising”
Licensure/Administrative impasses/barriers to the realization of
recovery support orientation.
Successful implementation of freestanding Room & Board operation.
Achievement of the necessary array of “front-end” services but
evidencing a desperate need for “seamless” re-alignment, and
Protections through shared “liability” in support of the transition
Internal Machinations
• Support of Research design & activities,
• Financial Analysis,
• System design activities for re-structuring operations: programmatic,
•
•
•
•
•
•
•
transportation, food service, etc.
Data/Billing/Clinical Records, etc. conforming adjustments,
Physical plant alterations,
Articulation of the adopted service delivery model,
Policy/board endorsement,
Personnel alignments,
Training & Orientation to adjustment to organizational culture,
Establishment of an internal mechanism to catch drift & refine
adherence/performance within the model.
Service Components of the
Adopted Model for Access to Care
• Recovery Support Specialists to initiate consumer engagement and
•
•
•
•
drive acts’ commitment to seamless, continuous care,
Daily recovery support treatment readiness walk in capacity colocated and integrated with outpatient detoxification services.
A 20 bed secure addictions receiving facility for acute care
detoxification & medical stabilization,
A co-located, 10 bed recovery support structured, Room & Board
capability for AARF step down consumers positioned to continued
and engage in care and
A transportation component (to support consumers access to
community based recovery and supportive services and acts’
Outpatient detoxification & Recovery Access Services).
acts
The Agency for Community Treatment Services
Michele Smith
Program Administrator
Juvenile Assessment Receiving Facility (JARF) & Adult
Addictions Receiving Facility (AARF)
The Agency
for Community Treatment Services
Programmatic Re-Structuring
• Acute care bed space reduced
• Transitional program added to AARF
( 10 bed capacity)
• Reduction in required nursing staff
• Added transportation & case management
services
• Utilize existing facility layout/dorm
configuration for re-structuring
Existing Facility Configuration
• Two large dorms (1 male, 1 female) on
one hall
• Two smaller dorms on a separate hall for
flexible gender placement
• All dorms on secure area of unit.
• No physical barriers between hallways
Facility Challenges
• Equal acute care gender bed capacity
• Reduced flexibility for gender placement
• Single point of egress
• Increased security and safety risks
• Restricted privileges for non-acute clients
Benefits of Restructuring
• Streamline acute care service delivery
• Improved diversion of OPD eligible clients
• Transitional placements to focus on client
individual needs/aftercare planning
• Allow clients time to progress in stages of
change, begin to internalize recovery
concepts
Benefits (continued)
• Client access to ancillary services
through transportation and case
management
• Direct linkage to OPD/ Recovery Support
• Reduces recidivism to acute care services
by bridging the gap to follow up care
• Reduced cost to client
Consequences
• Community perception to reduction in acute care
•
•
•
•
beds
Restricted availability for voluntary admissions
Adjustment to realignment of Nursing Staff
Staff resistance to change
Difficulty achieving parity between male/female
census
Challenges
• Incorporating different levels of care into the
•
•
•
•
•
AARF paradigm
Educating and cross training of staff
Implementing and assimilating new protocols
and recovery concepts
Realigning relationships with our own and other
community service providers
Establishing expanded role in the community
Strengthening team infrastructure
July 2006
AARF
35
30
25
20
15
10
5
0
Clients
Beds
1- 3- 5- 7- 9- 11- 13- 15- 17- 19- 21- 23- 25- 27- 29- 31Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul
July 2006
STTP
20
15
Clients
10
Beds
5
0
1- 3- 5- 7- 9- 11- 13- 15- 17- 19- 21- 23- 25- 27- 29- 31Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul
acts
The Agency for Community Treatment Services
Camille Francis, LCSW
Program Supervisor
Outpatient Detox, Med Clinic, &
Recovery Support
OUTPATIENT DETOX SERVICES
1.
2.
3.
4.
5.
6.
7.
OPD Curriculum
Health Education
Vital signs
Nutrition Class w/ Lunch
Recovery Support Group
Family Support Group
Med Clinic
OPD Curriculum
1. 10 – 14 days
2. Introduction to the following topics
1.
2.
3.
4.
5.
6.
7.
Understanding Addiction
Dealing with Triggers and Cravings
Motivation to Change
Emotional Well Being
Anger Management
Social Well Being
Self-help Education
Recovery Support Curriculum
1. Six Week Curriculum
2. Topics include
1.
2.
3.
4.
5.
6.
Orientation
Engagement Groups
Coping Skills Groups
Relapse Prevention Groups
Change Assessments
Review
PROGRAM MIND SHIFT
• Billing
• Responsibilities
• Program Format
• Direct Service Provider
• Protocol
BOTTOM LINE
• Increased numbers served
• Higher potential for engagement in treatment
• Less disruptive
• Ability to “practice” new behaviors at home and work while in program
• Actual provider experience of successfully providing outpatient
detoxification services
• Ability for clinical members of provider teams to meet regularly to
facilitate program development, share best practices and problem solve
challenges
• OPD slots are significantly less expensive
• Win Win Situation
ACTS TREATMENT SERVICES FLOW CHART
Community
Residential
Treatment
Assessments
Outpatient
Detox
Recovery
Support
Medication
Management
Clinic
Nonresidential
Treatment
After Care