Transcript Executive leadership track-Improving Patient Outcomes

Improving Patient Outcomes:
“Moving to a Value Based Agenda”
Robert Anderson, LCSW, CASAC, CARC, CRPA
Executive Director, The Counseling Center
Overview
• National Treatment System- How did we get here?
• How is the Treatment landscape changing? Are we “Fixing” healthcare?
• Remaining relevant and solvent?
• The “value agenda”
• Insuring a full Continuum of Care
• Ancillary Services as a means to grow
• Using technology and performance improvement to meet outcomes
• Where does the field go now?
What do you value about Recovery?
How long in the field? Why are you in it?
• "You cant keep it unless you give it away"- sense of giving back
• I might as well do something I know well and am passionate about
• It is my calling!! I want a career…
Now that your here…was it what you expected?
• The money can actually be good- but only if you run it like a business...
• Ever heard, “S/He’s a great clinician, but doesn’t get the business side of
it?”
• So at the end of the day do these values clash?
Business vs. Caring?
Treatment-A Brief Historical View
• 1935 The meeting of Bill W. and Dr. Bob S. (and Dr. Bob's last drink) mark the beginning
of Alcoholics Anonymous (AA).
• 1944 Marty Mann founds the National Committee for Education on Alcoholism (today the
National Council on Alcoholism and Drug Dependence) around the following five
propositions:
• Alcoholism is a disease.
• The alcoholic, therefore, is a sick person.
• The alcoholic can be helped.
• The alcoholic is worth helping.
• Alcoholism is our No. 4 public health problem, and our public responsibility.
• 1950: The Twelve Traditions are formally adopted to govern the group life of
AA and membership surpasses 90,000 as America (and Hollywood) becomes
interested in the subject of alcoholism. Cinema portrayal of alcoholism
includes such noted
films as “Lost Weekend”, “Days of Wine and Roses”, and “Come Back, Little
Sheba”.
• 1952: American Medical Association first defines alcoholism.
• 1958: The first ex-addict-directed therapeutic community - Synanon -- is
founded by Charles Deiderich. It will be widely replicated in the 1960s and
1970s
• 1963-66: Provision for local alcoholism and addiction counseling are
included in federal legislation funding the development of local
comprehensive community mental health centers, anti-poverty
programs, and criminal justice diversion programs. (beginnings of the
public funded models of care)
• 1966: Two federal Appeals Court decisions support the disease
concept of alcoholism. President Johnson appoints first National
Advisory Committee on Alcoholism and becomes the first President to
address the country about alcoholism. He proclaims: "The alcoholic
suffers from a disease which will yield eventually to scientific research
and adequate treatment."
• 1960’s- formative years for residential treatment programs; para-professional, little emphasis
on specialization
• Most other “treatment” in hospitals or psychiatric institutions; and 12 step AA
• Peer driven models based on experiential knowledge
• With the advent of “professional expertise” the models of care have shifted to today’s
programs emphasizing Prevention-Treatment-Recovery; inclusion of multiple disciplines and
ancillary services
• Trend towards use of peers is strangely now coming back towards full circle -”Nothing about
us without us!!!” this is in line with person-centered care models.
• MESSAGE continues to be one of HOPE:
People do recover and change is possible!
Four Components Key to a Successful
Recovery from Addiction
• Health: overcoming or managing one’s disease(s)
• Home: a stable and safe place to live;
• Purpose: meaningful daily activities, such as a job, school, volunteerism,
• Community: relationships and social networks that provide support,
friendship, love, and hope
-SAMHSA Recovery Domains
Insanity in Healthcare?
• Despite treatment’s deep historical roots-In today’s health care system, the
days of business as usual are over.
• Around the world, every health care system is struggling with rising costs and
uneven quality despite the hard work of well-intentioned, well-trained
clinicians.
• Health care leaders and policy makers have tried countless incremental
fixes—attacking fraud, reducing errors, enforcing practice guidelines, making
patients better “consumers,” implementing electronic medical records—but
none have really had much impact.
• Instead of doing the same thing over and over again-It’s time for a
fundamentally new strategy
Value of Care
• How do we increase the value of care? Secure good outcomes but remain
profitable???
• By providing a full “continuum of care”: one that makes sense, is evidence based
and maintains the 4 recovery paradigms. (Health, Home, Purpose, Community)
• The challenge of becoming a value-based organization should not be
underestimated, given the entrenched interests and practices of many decades.
• Embracing the goal of value at the senior management and board levels is
essential
• Implement ancillary services that can add value and quality
• INSURE PERFORMANCE BASED PROCESSES!!!
Maximizing Value for Patients
• Bottom line: Achieve the best outcomes at the lowest cost …But
How?
• The “value agenda.”
• In 2006, Michael Porter and Elizabeth Teisberg introduced the
value agenda in their book Redefining Health Care.
• Current move is away from a supply-driven health care system
organized around what physicians do and toward a patientcentered system organized around what patients need
Maximizing Value for Patients
• Seeing a shift in focus from the volume and profitability of services provided—
physician visits, hospitalizations, procedures, and tests (labs, toxicology)—to
the patient outcomes achieved (Positive VS Negative).
• Emphasis on replacing today’s fragmented system, in which every local
provider offers a full range of services, to a system in which services for
particular medical conditions are concentrated in health-delivery organizations
and in the right locations to deliver high-value care.
• How does this relate to the addiction industry?
Perform efficiently or
!!!
Addiction System Follow Trends From Primary Care
• The number of hospital beds has declined in the U.S. from 3 beds per 1,000 people in 1999 to
2.6 in 2010.
• Residential addiction beds are following this same pattern-yet growing Outpatient options
• Physician and Program income has remained static over the past decade
• National retailers like Walmart, CVS, and Walgreens are going after the primary care market on
a large scale, by offering in-store clinics that provide basic services at prices as much as 40%
below what physicians’ offices charge.
• In the past, providers would cover losses from Medicare and Medicaid and from uninsured
populations by demanding higher payment rates from commercial insurance plans—often
winning increases of 8% to 10% per year. THOSE DAYS ARE OVER!
What’s to Come?
• Organizations that fail to improve “value”, no matter how prestigious and powerful they seem
today, are likely to encounter growing pressure.
• Health insurers that are slow to embrace and support the value agenda—by failing, for
example, to favor high-value providers—will lose subscribers to those that do.
• Providers that cling to today’s broken system will become “dinosaurs” (look at some former
public system giants that have had recent re-organizations or mergers–…,….)
• Reputations that are based on perception, not actual outcomes, will fade.
• Those organizations—large and small, community and academic—that can master the value
agenda (performance based outcomes) will be rewarded with financial viability and the only
kind of reputation that should matter in health care—excellence in outcomes and pride in the
value they deliver
Insuring Positive Outcomes: How?
• While addiction is a chronic relapsing condition, and recovery is a long term
process-who says treatment can’t be a one time deal… a value system of
care intervention?
• Let’s do it right the first time (and develop that happy consumer!)
• Implement and follow a true full “Continuum of Care” process for your clients
• Partnering and linkage agreements• Don’t fear referring out to experts in other modalities
• If it’s your account- deal with companies that value that and maintain that
relationship
• Discharge planning and integrity in returning clients to you post care
Insuring Positive Outcomes
• The “Continuum of Care” process includes a fully comprehensive
treatment experience that meets the client where they are at; but
also follows them through till the maintenance stage of change
• Ancillary supports help the client succeed! Don’t be afraid to try
new things and enhance treatment plan options
• What does this “Continuum” look like?
The Addiction Treatment Continuum of Care
Detoxification (Residential i.e. Sunrise Detox Center; or Ambulatory)
MAT/RS
In-Patient Rehabilitation
Extended Care
MAT/RS
MAT/RS
Outpatient/ IOP
IOP/Outpatient
MAT/RS
Aftercare /Community Recovery
Aftercare/Community Recovery
MAT/RS
MAT/RS
Integrate external referrals as needed for ‘continuity of care’ and:
Confusing? How do you think the client feels?
The Benefits of Sticking
to the Continuum!
• The Benefits:
• Realistic clinical goal attainment is possible…a concrete plan that a client can see
• Data shows the longer the care episode, the better the outcomes
• Maximization of revenue per treatment episode
• Insurance companies will be measuring recidivism, so it benefits you to insure full
process- we are in this together for the client!!
• A positive outcome experience will still result in a return upon relapse
• The winner-everyone!
Ancillary supports
• Ancillary services have been shown to provide key support to addiction only
services. Examples include
• Recovery Coaching/Peer Services
• Brand new opportunities-Home and Community based services
• Medication Assisted Services
• Co-occurring Services
• Acupuncture, Bio-feedback, Brain training (i.e.neurolinguistic
approaches)
• Let’s look at an example of how some “Ancillary Supports” increase outcomes
and can build your bottom line!
• Motivator and Cheerleader
• Ally and Confidant
• Truth-Teller
• Role Model and Mentor
Recovery Coach
Roles
• Problem Solver
• Resource Broker
• Advocate
• Community organizer
(Adapted from William White)
• Lifestyle consultant
• Friend and companion
• An equal
Do some of these roles and functions sound
familiar?”
A ONE SIDED APPROACH ??
NYS is doing a great job in creating awareness about and implementing peer
services- but who is inadvertently left out?
-A Medicaid
driven philosophy….1115 waiver for home and community based
services
-APG rates for recovery coaching
-Grants and funding models including service vouchers i.e. RTS
-All fantastic….but do you see a demographical pattern?
 What about the Non-Medicaid insured individuals
suffering with addiction/mental health issues?
Census Notes:
-2013:
- Approx. 20,000,000 People In NYS
- 5,303,375 on Medicaid
- 3,231,599 from NYC
- So roughly 25% of public accesses insurance through Medicaid
- The data also shows that only 10% of New Yorkers that need
addiction services, access addiction services on any given day
That says to me: 75% of the public uses private insurance and 90% of the
addicted population needs prevention, treatment and recovery services.
How are we reaching this population????
And if we reach them, what can we realistically offer???
Off the rolls….and then what?
 Traditional NY residential treatment programs:
 Range longer in treatment stays than the rest of the country
 The NYS model incorporates funding for ‘Intensive residential”;
traditionally was 18-24 months in the continuum of care; now
more like 3-12 months
 One consistent philosophical principle in these programs is
“become a responsible individual” with: structure, hard working;
become an honest, tax paying person
 Unless there is a continuing disability; most clients once they step
down are geared for economic and vocational enhancement
 Some mandates still require: HSD and employment before lifting
supervision…
We gear people into a “life” of recovery; how do they then access
recovery services once off Medicaid?
 Create a clinical product clients will commit to and pay for
 Become marketable to Medicaid M/C and commercial
insurance providers-expand your client base
 Show them how use of “coaches” and recovery based
services can:
 Improve outcomes
 Reduce recidivism
 Promote overall health and wellness
 Reduce their losses, and improve profit margins
 Essential concept: NOT A REPLACEMENT FOR TREATMENT; BUT AN
ANCILLARY SERVICE
One Approach to Building Recovery Services (that also sustain your
bottom line)
 As we grow within insurance networks, emphasis on peers
 Home and Community Based Services model opportunity
• While designated ideally for OMH/OASAS Medicaid HARP populations the
framework can be used to outline recovery services for your programs
• For the peer network, identify areas of this model you can focus on and train
to expand conventional service models
• Insurance providers and program administrators “LOVE” cost effectiveness
One Approach to Building Recovery
Services (that also sustain your bottom line)
 Be cognizant of the diverse populations programs can
potentially treat; don’t assume all are Medicaid
only or vice versa-market to your audience
 Provide certified coaches with staffing opportunities
• For both internal and externally related business processes
Potential Private Inroads Based on HCBS
To remain relevant “Executive Management” must:
• Think 10 years ahead and have clear vision (no longer 3-5 years)
• Know that recovery services is a paradigm that the federal and
state entities are encouraging
• Identify ways to improve performance, at less cost
• Identify services that will become billable and increase efficacy
 HCBS Service Components model• Focal areas for this payment based initiative (ideally for
HARP enrollees) include:
1) Rehabilitation Counseling- including
• recovery activities and interventions that support and restore
social and interpersonal skills necessary to increase or maintain
community tenure,
• enhance interpersonal skills,
• establish support networks,
• increase community awareness,
• develop coping strategies and effective functioning in the
individual’s social environment such as home, work, and school
• These include:
Home and Community Based Services
3) Personal autonomy:
1) Learning to manage stress, unexpected daily events and
disruptions, mental health symptoms, relapse triggers and cravings
with confidence;
2) develop and pursue leisure and recreational interests, manage free
time comfortably;
3) transportation navigation
(can you see the potential for hybrid roles utilizing coaches??)
HCBS
4) Health:
1) Developing constructive and comfortable interactions
with health-care professionals, Relapse Prevention
Planning ( Individual Recovery Plan); managing
chronic medical conditions, mental health symptoms
and medications;
2) Establishing good health routines and practices
(potential to add cost effective “peers coaches” to a
Multi Disciplinary treatment team? Can it increase
outcomes?)
5) Social Skills:
1) Engaging with people respectfully, appropriate eye
contact, conversation skills, listening skills and
advocacy skills
HCBS cont’d
6) Wellness:
 Meal planning, healthy shopping and meal
preparation, nutrition awareness, exercise options
(maybe peer coaches in nursing homes, Intensive Residential
Programs and other healthcare settings as behavioral aides)
7) Personal care:
 Grooming, maintaining the living environment,
managing finances and other independent living
skills
Business model options
Options: How else might we adapt these HCBS service
components to help promote efficiency and cost compliance
measures throughout your overall business model?
What about:
• Using trained coaches in residential or other settings? Night staff? Escorts?
• “Transportation” is now reimbursable with HARP-with mentors/coaches?
• Outreach and Engagement
Why not design your business model to include these options which are
already approved as a service enhancement?
Cost effective staffing development for “cross trained” workforce
Not for profits must learn to “sell your product” to Insurance Plans.
How do we know Ancillary Services can help?
Ancillary Services Impact: Recovery Coaching and Detoxification
Services
BASICS Recovery Coach Project:
Reporting Period - November 1, 2010 – July 15, 2012 (17 months)
• The project was designed to provide Recovery Coaching to patients enrolled in the
two local NYC community based hospitals.
• Project Manager, 4 Recovery Coaches (2 of which were bi-lingual). Two
placed at each detoxification site.
• During the 17 month reporting period, there were a total of 1366 patients enrolled into
1366 enrolled during this reporting period, 588 (44%) were referred to and admitted to a
care post detoxification.
•
(reminder-new emphasis on pay for performance contracting and how lowering recidivism improves your
Outcomes
• 1366 patients were enrolled
• 588 (44%) were referred and admitted to a higher level of care post detoxification
• 2012 data indicates that only 13.25% of discharged detoxification service clients even made
contact to outpatient providers (New York State Behavioral Health Organizations 2012
Summary )
Total # of Clients
# Returned to Detox
# Moved to Next Level of Care
# in Next Level 30 Days or
# Left AMA From Detox
1366
104
588
345
314
Rehabilitation
Outpatient
Residential
Crisis Center
361
124
78
25
61%
21%
13%
4%
30 Day Retention with continuing care
• Progress and activities carried out with this historically high AMA population
• The project showed significant progress and achievements in the area of next level of care - 30 day retention.
• The data indicated an average of 59% of patients remaining in the next level of care for 30 days or more.
• Recovery coaches focused on• The Recovery Coach’s conducted weekly follow up by both telephone and face to face visits.
• Focused on motivational techniques inclusive of milestone monetary incentives.
• Reported patient feedback :
• “Felt like someone really understands me”.
• “Helped getting through the day”
• “The support was important”
• “The escort helped in getting me to where I needed to go”
Variable
N
%
Male
Female
154
186
45.3%
54.7%
EDUCATION
8th Grade or Less
Some High School
GED/HS Diploma
Beyond High School
Missing
12
97
98
46
1
4.7%
38.2%
38.6%
18.0%
0.4%
AGE (Mean, SD): 37.9
(12.2)
AGE GROUPS
18-24
25-34
35-44
45-54
≥ 55
45
96
74
95
29
13.2%
28.2%
21.8%
27.9%
8.5%
GENDER
Recovery Coaching
Ancillary Services: a
micro level review
Table 1: Demographics of Recovery Support
Participants at Enrollment (n= 340)
Recovery Support Outcomes at
6-Month Follow-up- Odyssey House ROCS
Table 2: Change in Outcome Measures at 6-Month Follow-up (n=189)
GPRA Measures
Intake
6-Month Follow-up
Rate of Change
24.7%
42.7%
73.0%
98.7%
100.0%
1.4%
Stability in Housing
55.5%
62.0%
5.7%
Experienced Depression
27.4%
16.1%
-41.2%
Experienced Anxiety
27.5%
16.6%
-39.6%
Trouble understanding,
concentrating, or remembering
16.5%
7.8%
-52.7%
Trouble controlling violent behavior
6.7%
2.1%
-68.7%
Employment/ Education
Social Connectedness
Treatment Outcomes with Recovery Support Participants
vs. Non Participants
Table 3: Treatment Retention and Completion for ROCS participants versus non-participants enrolled at an outpatient program
Measure
Length of Stay
(Days)
Completion Rate
(% of clients that
complete outpatient
program)
ROCS Cohort (n=145)*
Comparison Group**
(n=332)
Difference
Difference Rate
141
83
58 days
69.9%
38.4%
21.1%
17.3%
82.9%
* Only clients that have been discharged are included in this data. Clients still in treatment were excluded.
** Comparison group includes all adult outpatient clients who did not enroll in the ROCS program, but were eligible to enroll.
Ancillary Categories
 HCBS types:
 Psychosocial Rehabilitation (PSR)
Pre-vocational Services
 Community Psychiatric Support and Treatment (CPST)
Transitional Employment
 Habilitation/Residential Support Services
 Peer Supports may be used in conjunction with other HCBS services.
 Family Support and Training
 Mobile Crisis Intervention
 Short-term Crisis Respite
/ Intensive Crisis Respite
 Education Support Services
 Empowerment Services - Peer Supports
Non-Medical Transportation
Ancillary Services (cont’d)
 Other traditional and new types:
 Peer coaching/mentoring
 Smoking Cessation
 Acupuncture
 Mental health primary
 Podiatry and Dental (currently in NY residential system- Article 28)
 HIV prevention
 EEG Bio-Feedback
 Neuro-feedback (Brain mapping for many disorders)
 Vibro-Acoustic Bed (Passive Neuro-Stimulation)
Full Continuum or Partial Care:
A study on “Evaluation of full vs. partial continuum of care in the treatment substance abusers in
Washington State”
•
Evaluated:
• The full continuum (FC), in which clients receive approximately three weeks of inpatient
treatment prior to outpatient care, and
• The partial continuum (PC), in which clients are admitted directly to outpatient treatment.
• Data on treatment process/proximal outcomes, such as psychological distress and
readiness to change, were assessed at 8 weeks post intake, and data on treatment services
received were obtained at 2, 4, 8, and 12 weeks.
• Multidimensional outcomes, including alcohol and drug use as well as a number of
psychosocial functioning outcomes, were assessed at 3 and 9 months post intake.
• And the Survey Says!!!
•
Read More: http://informahealthcare.com/doi/abs/10.1081/ADA-120002976
Washington study results
• Results indicated that clients:
•
in the FC had greater alcohol, drug, and legal problem severity at intake than those in
the PC (makes sense based on level of care needs)
• Medical and employment problem severity was greater in the PC
• Clients in the FC received more treatment services in the first 2 weeks than those in the
PC, but there were no differences at subsequent points.
• Outcome analyses at 3 and 9 months indicated that clients in the FC had greater
improvements in alcohol, drug, and psychiatric severity than those in the PC.
• Matching analyses indicated that clients with greater substance-use severity at baseline
improved to a greater degree in the FC as compared to the PC.
• Read More: http://informahealthcare.com/doi/abs/10.1081/ADA-120002976
Benefits of the Continuum Approach and Utilizing Ancillary Services
•
Data driven clinical decisions are used to determine and help with business areas:
• Allocation of marketing/outreach $$
• Resources to apply to clinical program
• Administrative processes to enhance performance (is the cost worth it?-cost benefit analysis)
•
So, an effective use of a “continuum of care” process built around ancillaries can also lead to:
• Protection against premature AMAs (the client knows what the plan is)
• A savings in operation money (i.e. such as Marketing $$, reduced clinical costs)
• Return-referral security in working with established partners
• Ancillary Support Services lead to happy and successful consumers with better outcomes.
• A happy consumer !!! Remember your best referral is through word of mouth when you have
treated someone successfully
Making healthy business decisions-Where does my
program go now…?
•
Just as the Value System research stated up to 10 years ago- healthcare (and this includes addiction) has
movied to a performance based process
•
You will remain in business if:
• You can excel in your area, but INTEGRATE services and provide research based care and quality outcomes
• As M/C entities now prefer one stop shops; you might need to partner and link with other providers to treat the
client mutually (through the continuum of care) and offer ancillary supports that enhance the process
• Partner with companies that respect your referral and return them to your care when it becomes your role in the
continuum
• While we don’t sell “widgets” we are still in business….and more and more it comes down to this:
• Payers do not want to purchase treatment; they want to purchase positive outcomes
• And at the end of the day…
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Yorktown Heights, NY 10598
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