restructuring services

Restructuring ServicesRestructuring Services

Creating Clinical Pathways Creating Clinical Pathways Through Provider NetworksThrough Provider Networks

Presented by…

Bob Holm, Regional Substance Abuse Director, Suncoast Region DCFRichard Brown, Chief Operating Officer, The Agency for Community Treatment ServicesLinda McKinnon, Chief Executive Officer, Central Florida Behavioral Health Network

Bob Holm

Regional Substance Abuse DirectorDepartment 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 Community-Based 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.


--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.


--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 RequirementSpecific 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 OfficerCentral 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 andan outpatient environment.

Significant advantages were identified for those who are Significant advantages were identified for those who are properly triaged to the level of care appropriate to the properly triaged to the level of care appropriate to the clinical need.clinical need. OPD is less costlyOPD is less costly

The client’s life is not disruptedThe client’s life is not disrupted The client does not undergo abrupt transition The client does not undergo abrupt transition

from protected inpatient setting to the from protected inpatient setting to the communitycommunity

OPD services are available for a longer period OPD services are available for a longer period of time, allowing for a longer engagement of time, allowing for a longer engagement periodperiod

More clients can be servedMore clients can be served Wait time is reducedWait time is reduced

CFBHN completed a review of publicly funded inpatient detoxification facilities and the OPD program in place.

Monthly provider meetings wereconducted to discuss thedevelopment 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 - URKIA pre- & post-test results- Drug test results - Discharge reason- Vital signs - Length of stay- CIWA/COWS results

Data Analysis

Data was collected from clientsdischarged between October 1, 2005and February 26, 2006.

Data included State data reporting elements.

Statistics

# served in OPD during evaluation period 209Average age 37

60% Males 40% Females

Primary substance used at admission: Alcohol 50%Crack 28%

Primary referral source: Self 54%Residential detoxification (where available) 41%Other 5%

Length of stay: 10.68

OPD Wait List Highest month average (May ’05) = 6.93 daysAverage at last month of study (Feb ’06) = 1.05 days

Successful discharge: Manatee Glens 87%ACTS (new program) 65%

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)

Richard Brown

Chief Operating OfficerThe Agency

for Community Treatment Services

actsThe Agency for Community Treatment Services

Challenges To GoalsChallenges To Goals

Examine the potential of incorporating Examine the potential of incorporating Outpatient Detoxification Services in Outpatient Detoxification Services in Hillsborough County’s System of care as a Hillsborough County’s System of care as a means to:means to:

Increase accessibility to care, andIncrease accessibility to care, andImprove engagement in continuing care Improve engagement in continuing care

servicesservices

Operationalize Recovery Principles For Operationalize Recovery Principles For Consumers at acts’s points of access to careConsumers at acts’s points of access to care

Inventory of the presenting Inventory of the presenting “Dots” (factors driving “Dots” (factors driving consideration within the acts consideration within the acts organization)organization)• Agency experienced success in the re-engineering of Adult Agency experienced success in the re-engineering of Adult

treatment services through CCISC Implementation.treatment services through CCISC Implementation.• Financially depleting Detox (AARF) Operation.Financially depleting Detox (AARF) Operation.• Potential for community “uprising”Potential for community “uprising”• Licensure/Administrative impasses/barriers to the Licensure/Administrative impasses/barriers to the

realization of recovery support orientation.realization of recovery support orientation.• Successful implementation of freestanding Room & Board Successful implementation of freestanding Room & Board

operation.operation.• Achievement of the necessary array of “front-end” services Achievement of the necessary array of “front-end” services

but evidencing a desperate need for “seamless” re-but evidencing a desperate need for “seamless” re-alignment, andalignment, and

• Protections through shared “liability” in support of the Protections through shared “liability” in support of the transitiontransition

Internal MachinationsInternal Machinations

• Support of Research design & activities,Support of Research design & activities,• Financial Analysis,Financial Analysis,• System design activities for re-structuring operations: System design activities for re-structuring operations:

programmatic, transportation, food service, etc.programmatic, transportation, food service, etc.• Data/Billing/Clinical Records, etc. conforming adjustments,Data/Billing/Clinical Records, etc. conforming adjustments,• Physical plant alterations,Physical plant alterations,• Articulation of the adopted service delivery model,Articulation of the adopted service delivery model,• Policy/board endorsement,Policy/board endorsement,• Personnel alignments,Personnel alignments,• Training & Orientation to adjustment to organizational Training & Orientation to adjustment to organizational

culture,culture,• Establishment of an internal mechanism to catch drift & Establishment of an internal mechanism to catch drift &

refine adherence/performance within the model.refine adherence/performance within the model.

Service Components of the Service Components of the Adopted Model for Access to Adopted Model for Access to CareCare• Recovery Support Specialists to initiate consumer Recovery Support Specialists to initiate consumer

engagement and drive acts’ commitment to seamless, engagement and drive acts’ commitment to seamless, continuous care,continuous care,

• Daily recovery support treatment readiness walk in Daily recovery support treatment readiness walk in capacity co-located and integrated with outpatient capacity co-located and integrated with outpatient detoxification services.detoxification services.

• A 20 bed secure addictions receiving facility for acute care A 20 bed secure addictions receiving facility for acute care detoxification & medical stabilization,detoxification & medical stabilization,

• A co-located, 10 bed recovery support structured, Room & A co-located, 10 bed recovery support structured, Room & Board capability for AARF step down consumers positioned Board capability for AARF step down consumers positioned to continued and engage in care andto continued and engage in care and

• A transportation component (to support consumers access A transportation component (to support consumers access to community based recovery and supportive services and to community based recovery and supportive services and acts’ Outpatient detoxification & Recovery Access acts’ Outpatient detoxification & Recovery Access Services).Services).

Michele Smith

Program AdministratorJuvenile Assessment Receiving Facility (JARF) & Adult

Addictions Receiving Facility (AARF)The Agency

for Community Treatment Services

actsThe Agency for Community Treatment Services

Programmatic Re-Programmatic Re-StructuringStructuring• Acute care bed space reduced Acute care bed space reduced • Transitional program added to AARFTransitional program added to AARF

( 10 bed capacity)( 10 bed capacity)• Reduction in required nursing staffReduction in required nursing staff• Added transportation & case Added transportation & case

management servicesmanagement services• Utilize existing facility layout/dorm Utilize existing facility layout/dorm

configuration for re-structuringconfiguration for re-structuring

Existing Facility Existing Facility ConfigurationConfiguration

• Two large dorms (1 male, 1 female) Two large dorms (1 male, 1 female) on one hall on one hall

• Two smaller dorms on a separate hall Two smaller dorms on a separate hall for flexible gender placementfor flexible gender placement

• All dorms on secure area of unit.All dorms on secure area of unit.

• No physical barriers between No physical barriers between hallwayshallways

Facility ChallengesFacility Challenges

• Equal acute care gender bed capacityEqual acute care gender bed capacity

• Reduced flexibility for gender Reduced flexibility for gender placementplacement

• Single point of egressSingle point of egress

• Increased security and safety risks Increased security and safety risks

• Restricted privileges for non-acute Restricted privileges for non-acute clientsclients

Benefits of RestructuringBenefits of Restructuring

• Streamline acute care service deliveryStreamline acute care service delivery

• Improved diversion of OPD eligible clients Improved diversion of OPD eligible clients

• Transitional placements to focus on client Transitional placements to focus on client individual needs/aftercare planningindividual needs/aftercare planning

• Allow clients time to progress in stages of Allow clients time to progress in stages of change, begin to internalize recovery change, begin to internalize recovery conceptsconcepts

Benefits Benefits (continued)(continued)

• Client access to ancillary servicesClient access to ancillary services

through transportation and case through transportation and case managementmanagement

• Direct linkage to OPD/ Recovery SupportDirect linkage to OPD/ Recovery Support

• Reduces recidivism to acute care Reduces recidivism to acute care servicesservices

by bridging the gap to follow up careby bridging the gap to follow up care

• Reduced cost to clientReduced cost to client

ConsequencesConsequences

• Community perception to reduction in Community perception to reduction in acute care bedsacute care beds

• Restricted availability for voluntary Restricted availability for voluntary admissionsadmissions

• Adjustment to realignment of Nursing StaffAdjustment to realignment of Nursing Staff

• Staff resistance to changeStaff resistance to change

• Difficulty achieving parity between Difficulty achieving parity between male/female censusmale/female census

ChallengesChallenges

• Incorporating different levels of care into Incorporating different levels of care into the AARF paradigm the AARF paradigm

• Educating and cross training of staffEducating and cross training of staff• Implementing and assimilating new Implementing and assimilating new

protocols and recovery conceptsprotocols and recovery concepts• Realigning relationships with our own and Realigning relationships with our own and

other community service providers other community service providers • Establishing expanded role in the Establishing expanded role in the

communitycommunity• Strengthening team infrastructureStrengthening team infrastructure

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actsactsThe Agency for Community Treatment ServicesThe Agency for Community Treatment Services

Camille Francis, LCSW

Program Supervisor

Outpatient Detox, Med Clinic, & Recovery Support

OUTPATIENT DETOX SERVICESOUTPATIENT DETOX SERVICES

1.1. OPD Curriculum OPD Curriculum

2.2. Health EducationHealth Education

3.3. Vital signsVital signs

4.4. Nutrition Class w/ LunchNutrition Class w/ Lunch

5.5. Recovery Support GroupRecovery Support Group

6.6. Family Support GroupFamily Support Group

7.7. Med ClinicMed Clinic

OPD CurriculumOPD Curriculum

1.1. 10 – 14 days10 – 14 days2.2. Introduction to the following topicsIntroduction to the following topics

1.1. Understanding AddictionUnderstanding Addiction2.2. Dealing with Triggers and CravingsDealing with Triggers and Cravings3.3. Motivation to ChangeMotivation to Change4.4. Emotional Well BeingEmotional Well Being5.5. Anger ManagementAnger Management6.6. Social Well BeingSocial Well Being7.7. Self-help EducationSelf-help Education

Recovery Support CurriculumRecovery Support Curriculum

1.1. Six Week CurriculumSix Week Curriculum

2.2. Topics includeTopics include1.1. OrientationOrientation

2.2. Engagement GroupsEngagement Groups

3.3. Coping Skills GroupsCoping Skills Groups

4.4. Relapse Prevention GroupsRelapse Prevention Groups

5.5. Change AssessmentsChange Assessments

6.6. ReviewReview

PROGRAM MIND SHIFTPROGRAM MIND SHIFT

• BillingBilling

• ResponsibilitiesResponsibilities

• Program FormatProgram Format

• Direct Service ProviderDirect Service Provider

• ProtocolProtocol

BOTTOM LINEBOTTOM LINE• Increased numbers servedIncreased numbers served

• Higher potential for engagement in treatmentHigher potential for engagement in treatment

• Less disruptiveLess disruptive

• Ability to “practice” new behaviors at home and work while in Ability to “practice” new behaviors at home and work while in programprogram

• Actual provider experience of successfully providing outpatient Actual provider experience of successfully providing outpatient detoxification servicesdetoxification services

• Ability for clinical members of provider teams to meet regularly to Ability for clinical members of provider teams to meet regularly to facilitate program development, share best practices and problem facilitate program development, share best practices and problem solve challengessolve challenges

• OPD slots are significantly less expensiveOPD slots are significantly less expensive

• Win Win SituationWin Win Situation

ACTS TREATMENT SERVICES FLOW ACTS TREATMENT SERVICES FLOW CHARTCHART

Assessments

OutpatientDetox

Medication Management

Clinic

Non-residentialTreatment

After Care

ResidentialTreatment

Community

RecoverySupport

restructuring services

Documents