1. RECOVERY ORIENTED SYSTEMS OF CARE WYANDOTTE COUNTY KANSAS CITY, KANSAS HEARTLAND REGIONAL ALCOHOL & DRUG ASSESSMENT CENTER Jim Clarkson CEO/Via Positiva

2. Paradigm Shift From An Acute Care Medical Model to A Chronic Disease Management Person Centered Model An Overview of Recovery Oriented Systems of Care

3. 3 Integrated Care: From Silos….

4. To Synergies…. 4

5. ROSC Model The law of floatation was not discovered by contemplated the sinking of things, but rather than by contemplating the characteristics of those things which floated naturally and intelligently asking why they did so. (Judge Thomas Troward) Box (1987): “All models are wrong, but some are useful”

6. Recovery? “The process by which people are able to live, work, learn, and participate fully in their communities. For some individuals, recovery is the ability to live a fulfilling and productive life, despite a disability. For others, it implies the reduction or the complete remission of symptoms”… -- The President’s New Freedom Commission Report

7. Iatrogenic Suffering Suffering caused by the physician, practitioner or other helper, usually unintentional but increasing the amount of distress a person seeking help already has. It is often caused by the practitioner’s bedside manner or barriers placed within a system. The patient bears the brunt of the practitioner’s unfinished or unconscious psychological issues regarding death, vulnerability, mental or other serious illness or the effects from trauma, growing up in a home with alcoholism, drug addiction, domestic violence or the like.

8. Person First  Sanctuary  Value & Therapeutic Alliance Whatever you can do or dream you can, begin it. Boldness has genius, power and magic in it!‘--Goethe

9. Sanctuary Place of safety, oasis, shelter, sacred place (S. Covington)

10. Recovery? “Recovery is a deeply personal process of (re)gaining physical, spiritual, mental and emotional balance. It is a process of healing and restoring wellness during stressful episodes of life”. -- Mental Health First Aid

11. Recovery Oriented System of Care  “A recovery oriented system of care identifies and builds upon each individual’s assets, strengths, and areas of health and competence to support achieving a sense of mastery over his or her condition while regaining a meaningful, constructive, sense of membership in the broader community”. –Thomas Kirk, CDMHAS

12. 8 Any problems faced by the individual substance user cannot be seen in isolation from their family, local community and society. - Scottish Advisory Committee on Drug Misuse, 2008. Society Local Communities Providers Systems

13. Toward Communities of Caring  Estimates of People in Recovery (23 million)  Characteristics of People in Recovery.  Creating Environments for Recovery: Recovery Oriented Systems of Care  22 million meet the definition of Substance Use Disorder today in the US.  A possible “tipping point”… 7,500 (5%) in Wyandotte County to 15,000…

14. 14 Recovery-oriented systems include:  A comprehensive menu of services and supports that can be combined and readily adjusted to meet the individual’s needs and chosen pathway to recovery.  An ongoing process of systems-improvement that incorporates the experiences of those in recovery and their family members.  The coordination of multiple systems, providing responsive, outcomes-driven approaches to care. 14 Describing Recovery-Oriented Systems

15. Planning Recovery-Oriented System Change 15 I. Conceptual Framework II. Assessment/Gaps III. Capacity Building IV. Planning V. Development and Implementation VI. Evaluation

16. ROSC Providers…  Partners in the recovery process of every person enrolled in the program.  A focal point of powerful social influences…the recovery community, faith-based organizations, community organizations and clinical treatment providers.  A Recovery Hub…a touchstone for non-judgment, caring and wellness for individuals, families and communities.

17. TRI Studies Studies show that clients in SA treatment, who also have problems in other areas of their lives (e.g. medical, employment & psychiatric), have better outcomes when those other problems areas are also addressed  McLellan compared 2 groups of SA clients  Standard group received treatment as usual  Enhanced group received treatment as usual, plus referrals for help with other problems (e.g. medical screening & parenting classes)  Enhanced group had better outcomes at 6 months  Stayed in tx longer & had higher tx satisfaction  Had fewer psychological & physical problems  Had less substance use

18. TRI Studies Specifically, McLellan found:  After 30 days  39% of Standard group clients still in treatment  68% of Enhanced group clients still in treatment  After 60 days  12% of Standard group clients still in treatment  49% of Enhanced group clients still in treatment  After 6 months (unexpected finding)  60% of Standard group counselors left job  20% of Enhanced group counselors left job

19. TRI Studies Concluded: Give Your Clients Names & Phone Numbers of Free & Low Cost Service Community Referrals! Costs you close to nothing Improves treatment outcomes

20. What does ROSC really look like?  Statewide & Local Models  Cross system training  Cross system referrals  Usually voucher based (funding follows client)  Partial Performance Incentive  Outcome and data driven  Engagement, Retention & Continuation (NIATx)

21. From Acute Care to Chronic Disease Management  Addiction (severe alcohol and drug dependency) shares many of the defining characteristics of chronic primary illnesses, e.g., 2 diabetes mellitus, hypertension, and asthma.  Characterizing addiction as a chronic illness does not mean that all AOD problems have a prolonged course requiring professional treatment, that full recovery is not possible, or that self management responsibilities are in any way diminished.  Although long characterized as a chronic disorder, addiction has been treated in an essentially acute-care (AC) model of treatment.  The AC model of addiction treatment is characterized by its crisis-linked point of intervention, brief duration, singular focus on symptom suppression (achievement of abstinence), professionally dominated decision-making process, short service relationship, and expectation of full and permanent problem resolution following “graduation.”  The development of the AC model of addiction treatment grew out of the medicalization, professionalization, and commercialization of addiction treatment and the subsequent growth of managed behavioral health care in the United States. (White 2008)

26. Recovery Oriented System of Care "The phrase recovery-oriented systems of care refers to the complete network of indigenous and professional services and relationships that can support the long- term recovery of individuals and families and the creation of values and policies in the larger cultural and policy environment that are supportive of these recovery processes. The “system” in this phrase is not a federal, state, or local agency, but a macro-level organization of the larger cultural and community environment in which long-term recovery is nested." (William White 2008)

27. Sometimes…  Treatment providers think it is an adjunct to improve what they do…  The Recovery and Advocacy community think, finally, we can formally share what we know works…  Faith-based Organizations think, “they are finally seeing the light!”  RSS providers think, finally they can learn from us…we knew we could help substance users all along!  State: How can we pay for this?  MCO’s: What? Measure? UR? Quality?  Consumers: Wow! Seriously???

28. Systems Integration Systems integration is the process of understanding how things influence one another within a whole. In organizations, systems consist of people, structures, and processes that work together to make an organization healthy or unhealthy. Systems Thinking has been defined as an approach to problem solving, by viewing "problems" as parts of an overall system, rather than reacting to specific part, outcomes or events and potentially contributing to further development of unintended consequences. Systems thinking is not one thing but a set of habits or practices within a framework that is based on the belief that the component parts of a system can best be understood in the context of relationships with each other and with other systems, rather than in isolation.

30. Wyandotte County Population 157,505 299 Churches 54 Childcare Agencies 87 AA Meetings 17 Transportation 6 Housing Agencies

31. Client Relationship Network  Recovery Support Services Coordinator  Sponsor  Recovery Groups  Spiritual Guide  Clinician  Recovery Coach  SA informed cab driver, childcare provider, job coach, financial coach, legal advisor, housing provider

32. A Good and Modern System A modern mental health and addiction service system provides a continuum of effective treatment and support services that span healthcare, employment, housing and educational sectors. Integration of primary care and behavioral health are essential. As a core component of public health service provision, a modern addictions and mental health service system is accountable, organized, controls costs and improves quality, is accessible, equitable, and effective. It is a public health asset that improves the lives of Americans and lengthens their lifespan.

33. Recovery Necessity, not Medical Necessity The system should include activities and services that go beyond traditional interventions such as the current acute care residential or outpatient services. Coordination, communication, and linkage with primary care can no longer be optional given the prevalence of co-morbid health, mental health and substance use disorders.

34. Remembering Who We Serve Disability Weights Internalized Oppression 34

35. U.S. Adults with a Mental Disorder in Any One Year 9 Type of Mental Disorder% Adults Anxiety disorder18.1. Major depressive disorder6.7. Substance use disorder7.0. Bipolar disorder2.6. Eating disorders2.1. Schizophrenia.44. Any mental disorder26.2.

36. Median Age of Onset One-half of all lifetime cases of mental illness begin by age 14, three-quarters by age 24  Anxiety Disorders – Age 11  Eating Disorders – Age 15  Substance Use Disorders – Age 20  Schizophrenia – Age 23  Bipolar – Age 25  Depression – Age 32 4

37. The Impact of Substance Abuse and Mental Illness  SA/MH can be more disabling than many chronic physical illnesses. For example:  The disability from moderate depression is similar to the impact from relapsing multiple sclerosis, severe asthma, or chronic hepatitis B.  The disability from severe post-traumatic stress disorder is comparable to the disability from paraplegia.  “Disability” refers to the amount of disruption a health problem causes to a person’s ability to:  Work  Carry out daily activities  Engage in satisfying relationships 10

38. Disability Weights  Stouthard et. al (1997) published weightings for 53 illnesses of public health importance.  The World Health Organization has compared the relative impact of different illnesses across the world. According to this data, mental disorders rank as the biggest health problem in North American ahead of both cardiovascular disease and cancer. 38

39. 11

40. Integration The integration of primary care, mental health and addiction services must be an integral part of the vision. Mental health and addiction services need to be integrated into health centers and primary care practice settings where most individuals seek health care. In addition, primary care should be available within organizations that provide mental health and addiction services, especially for those individuals with significant behavioral health issues who tend to view these organizations as their health homes. Providing integrated primary care and behavioral health services will allow for cost effective management of co-morbid conditions.

41. Funding and Payment Strategies In the public sector, individuals/families/youth with complex mental and substance use disorders receive services funded by federal, state, county and local funds. These multiple funding sources often result in a maze of eligibility, program and reporting specifications that create funding silos featuring complicated administrative requirements. If services are to be integrated, then dollars must be also intertwined. In the same way that Medicaid will be required to streamline eligibility and enrollment, the good and modern system must either blend or braid funds in support of comprehensive service provision for consumers, youth and families.

42. Exposure to Trauma  51 – 98% of public mental health clients with severe mental illness, including schizophrenia and bipolar disorder, have been exposed to childhood physical and/or sexual abuse. Most have multiple experiences of trauma (Goodman et al., 1999, Mueser et al., 1998; Cusack et al., 2003).

43. Exposure to Trauma  One in four children and adolescents in the United States experiences at least one potentially traumatic event before the age of 16, and more than 13 % of 17-year-olds—one in eight—have experienced posttraumatic stress disorder (PTSD) at some point in their lives. (National Survey of Adolescents and other studies).

44. Trauma—Adverse Childhood Experience Study  17,000 Kaiser Permanente Members & Partnership with CDC  63% at least one category of trauma  20% at least 3 categories of trauma  11% emotional abuse  28% physical abuse  21% sexual abuse  19% grew up with someone in the household with MI  10% physical neglect  13% saw mother being treated violently  27% grew up w/someone using Alcohol and/or drugs 44

45. Trauma—Adverse Childhood Experience Study 45

46. Internalized Oppression Core Beliefs of the Addict (Paraphrased P. Carnes) 1) I am a bad, unworthy person 2) If people knew me they would not like me. 3) If I have to get my needs met I will have to do it myself. 4) I will find something to make me feel better. >>Internalized “self talk” 46

47. Helping Clients Navigate to Success  The companies that truly stand at the intersection of Information Technology and the Humanities will create the opportunities, indeed, the economies of the 21 st Century. (Steve Jobs)  The first principle of the Apple Marketing Philosophy is Empathy, an intimate connection with the feelings of the customer: We will truly understand their needs better than any other company. (Mike Markkula)  Network for Improvement of Addiction Treatment’s First Principle: Understand and involve the customer.

48. Navigation The integration of primary care, mental health and addiction services must be an integral part of the vision. Mental health and addiction services need to be integrated into health centers and primary care practice settings where most individuals seek health care. In addition, primary care should be available within organizations that provide mental health and addiction services, especially for those individuals with significant behavioral health issues who tend to view these organizations as their health homes.

49. ROSC Opportunities Within the Unfolding Behavioral Health Landscape Funding Considerations

50. HOW MANY SA PROVIDERS ARE THERE? SAMHSA11,246 NIDA 13,000 ONDCP 20,000+ 50

51. AND 13,918 McDonalds! 51

52. COMPARED TO 11,168 Starbucks! 52

53. Where we are now: a few relevant facts  Population characteristics  Funding trends  State agency spending  MH/SA providers 53

54. Percentages of Adults with Mental Disorders and/or Medical Conditions National Comorbidity Survey Replication, 2001-2003 54

55. Average Monthly $ for Medicaid Beneficiaries w/ & w/o Co- Occurring Physical Conditions (2003) 55 Source: Medicaid Analytic eXtract (MAX), 2003 Substance Abuse and Mental Health Services Administration. (2010). Mental health and substance abuse services in Medicaid, 2003: Charts and state tables. HHS Publication No. (SMA) 10-XXXX. Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration.

56. SA Funding Trends – 1986 - 2005 56 Source: SAMHSA Spending Estimates, preliminary data

57. 2014 Coverage Expansion Below 133% FPL ($29,500 family) Medicaid Expansion To Childless Adults  Coverage for essential MH/SA at parity for benchmark plan  Feds pay 100% for 3 years, then down 90%  Simplified enrollment, express apps: web too  Integrated data with State exchanges: one application  Foster kids up to age 26 133 – 400% FPL ($88,000 family) State Exchanges  Coverage for essential MH/SA at parity & prevention @ no co-pays  Helps individuals and small employers with purchasing health insurance  Assist by voucher to pay premiums or cost sharing  Develops consumer friendly tools & plain language on insurance  One application to both exchanges or Medicaid; can do on the web 57

58. 58 Possible SAPT Block Grant Changes  Static or Decreased funding  Changes in Mission  ROSC  Encouragement of integrated planning  Redirection of funds towards services and persons that Medicaid cannot pay for

59. Major Features of the SA Treatment System  Financing  More than three-quarters of funding comes from public sources  Primary source is state and local funding other than Medicaid  Federal block grant is third largest source of public funding after Medicaid 59

60. Major Features of the SA Treatment System  Providers  Majority are standalone non- profit/government facilities  A quarter provide residential treatment w/an avg size of 32 beds 60

61. Major Features of the SA Treatment System  Services  Most often consist of abstinence-oriented counseling/education delivered by treatment staff with limited professional training  A third of providers have no physician on staff or contract  Limited use of medication 61

62. Major Features of the SA Treatment System  Billing/administration  40% of providers do not accept private insurance or Medicaid or both  Half have no mgd care contracts  20% have no IT system of any kind; few have an integrated clinical system 62

63. Effects - Funding  Overall increase in funding  Shift toward more federal financing  Transition from grant/contract funding to health plan model 63

64. Effects - Providers  Partnerships  Medicalization  Integration/diversification (FQHCs, CMHCs)  Deinstitutionalization (IMD exclusion) 64

65. Effects – State Administration  Medicaid Authorities  Increase in SA service users and spending  Greater authority over provider enrollment & rate setting  Need to improve Medicaid SA coverage to meet 2014 benchmark requirements 65

66. Effects - State Administration  SA Authorities  Shift of half or more of service population to Medicaid  Need to mainstream SA providers into general health care  Need for closer integration with Medicaid and person- centered focus 66

67. Effective Engagement and Accurate Assessment “Unless people believe it is safe enough to be vulnerable around us, we can never really teach them anything, for they will never let us see themselves as they actually are.” (paraphrased from Rudolph Dreykurs)

68. Conclusions  Parity, health care reform, and declines in state general revenue will significantly change the behavioral health service system, particularly the public part of that system and that which deals with substance abuse.  Overall support for these services should expand, while increasing the variety of providers offering such services.  Financing, administration, and delivery of these services will become more similar to general health care, with greater emphasis on outpatient-based programs that integrate services. 68

69. Health Care Reform and New Medicaid Eligibility  Will include non-elderly adults without dependent children  Incomes less than 133% of the federal poverty level  2014 32 Million Newly Insured (6-10 SA, about ½ Medicaid)  15 million will remain uninsured  States will have to manage coordination of benefits and recovery support services.

70. Opportunities Exercise 70

71. Screening, Brief Intervention and Referral to Treatment (SBIRT) SBIRT is a comprehensive, integrated, public health approach to the delivery of early intervention and treatment services for persons with substance use disorders, as well as those who are at risk of developing these disorders. Primary care centers, hospital emergency rooms, trauma centers, and other community settings provide opportunities for early intervention with at-risk substance users before more severe consequences occur. 71

72. SBIRT continued Payer Code Description Fee Schedule: Commercial Insurance CPT 99408 Alcohol and/or substance abuse structured screening and brief intervention services; 15 to 30 minutes $33.41 CPT 99409 Alcohol and/or substance abuse structured screening and brief intervention services; greater than 30 minutes $65.51 Medicare G0396 Alcohol and/or substance abuse structured screening and brief intervention services; 15 to 30 minutes $29.42 G0397 Alcohol and/or substance abuse structured screening and brief intervention services; greater than 30 minutes $57.69 Medicaid H0049 Alcohol and/or drug screening $24.00 H0050 Alcohol and/or drug service, brief intervention, per 15 minutes $48.00 72

73. Introduction  Paul Wellstone and Pete Domenici Mental Health  Parity and Addiction Equity Act of 2008 (MHPAEA)  – Applies to both mental health and substance use  disorder (MH/SUD) benefits  Interim Final Regulations issued February 2, 2010 (75  Fed. Reg. 5410)  – Agencies requested comments — may issue revisions  – Most health plans will need to be reviewed and possibly  amended in light of these rules  Affordable Care Act of 2010  – Beginning in 2014, applies MHPAEA to most plans

74. What is Parity  Dictionary – equal or equivalent, at symmetry, not favoring one over another, fairly matched  Parity As A Legal Construct: A group of State Laws Beginning In the mid 1990s – Over Half of States Have Some Form of Parity Law 1996 Federal Mental Health Parity Act: Prohibit different annual and lifetime dollar limits did not extend to substance use 2008 Medicare Improvements for Patients and Providers Act  By 1/1/2014 Phases out higher coinsurance for outpatient mental health care 2008 Federal Mental Health Parity and Addictions Equity Act: Effective October 3, 2009 Regulations Effective As Policies Renew On/After July 1, 2010 2010 Health Reform Law Expands To Broader Population In 2014 (SAMHSA)

75. Goal of Parity  Goal Of Parity Law Is To: Increase Access To Treatment Remove Discriminatory Financial Costs More Equal Treatment For These Medical Conditions

76. Details  The Law Stipulates: Covered group health insurance plans that offer both medical/surgical and mental health/ substance use benefits must offer them at parity  Parity Is Defined To Include: Financial requirements including deductibles, coinsurance, co-payments, and other cost sharing requirements, as well as annual and lifetime limits on the total amount of coverage. Treatment limitations include restrictions on the number of visits or days of coverage, or Other limits on the duration and scope of treatment.  Does Not Preempt Stricter State Laws – Impact on State Regulated Insurance

77. Essential Health Benefits The Affordable Care Act ensures Americans have access to quality, affordable health insurance. To achieve this goal, the law ensures health plans offered in the individual and small group markets, both inside and outside of the Affordable Insurance Exchanges (Exchanges), offer a comprehensive package of items and services, known as “essential health benefits.” Essential health benefits must include items and services within at least the following 10 categories:

78. Essential Health Benefits  Ambulatory patient services  Emergency services  Hospitalization  Maternity and newborn care  Mental health and substance use disorder services, including behavioral health treatment  Prescription drugs  Rehabilitative and habilitative services and devices  Laboratory services  Preventive and wellness services and chronic disease management, and  Pediatric services, including oral and vision care

79. Regulation  MH/SUD benefits may not be subject to any separate cost sharing requirements or treatment limitations that only apply to such benefits  If a group plan provides for out of network medical/surgical benefits, it must provide for out of network mental health and substance use benefits  Standards for medical necessity determinations and reasons for any denial of benefits relating to MH/SUD must be disclosed upon request

80. Four Major Dimensions and 10 Principles of ROSC Principles of Recovery Oriented Systems of Care

81. Attitude & Aptitude

83. Essential Qualities for Positive Therapeutic Outcomes 1) Factors related to what the client brings to the situation (about 40%) 2) The therapeutic relationship (about 30%) 3) Expectancy and Hope (about 15%) 4) An explanatory system that guides the healing practices (about 15%)

84. Sooooo….. “This means that 60% of what accounts for whether or not a person responds to treatment hinges on the people delivering the treatment. If they develop a positive, warm, supportive and empathic relationship, support the development of hope that progress can be made, have a clear rationale for what they are doing that outlines a therapeutic map of recovery, and empower the client to help themselves, there is likely to be improvement.” (Bloom 2009)

85. Recovery “A process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential.” (SAMHSA, 2011)

86. Four Major Dimensions of Recovery  Health  Home  Purpose  Community

87. Health  Overcoming or managing one’s disease(s) or symptoms—for example, abstaining from use of alcohol, illicit drugs, and non-prescribed medications if one has an addiction problem—and for everyone in recovery, making informed, healthy choices that support physical and emotional wellbeing.

88. Home  a stable and safe place to live.

89. Purpose  Meaningful daily activities, such as a job, school, volunteerism, family caretaking, or creative endeavors, and the independence, income and resources to participate in society.

90. Community  Relationships and social networks that provide support, friendship, love, and hope.

91. Hope  Recovery emerges from hope: The belief that recovery is real provides the essential and motivating message of a better future – that people can and do overcome the internal and external challenges, barriers, and obstacles that confront them. Hope is internalized and can be fostered by peers, families, providers, allies, and others. Hope is the catalyst of the recovery process.

92. Person Centered  Self-determination and self-direction are the foundations for recovery as individuals define their own life goals and design their unique path(s) towards those goals.

93. Many Pathways to Recovery  Recovery occurs via many pathways: Individuals are unique with distinct needs, strengths, preferences, goals, culture, and backgrounds including trauma experiences that affect and determine their pathway(s) to recovery.

94. Holistic  Recovery is holistic: Recovery encompasses an individual’s whole life, including mind, body, spirit, and community.

95. Supported by Peers and Allies Recovery is supported by peers and allies: Mutual support and mutual aid groups, including the sharing of experiential knowledge and skills, as well as social learning, play an invaluable role in recovery.

96. Relationship and Social Network  Recovery is supported through relationship and social networks: An important factor in the recovery process is the presence and involvement of people who believe in the person’s ability to recover; who offer hope, support, and encouragement; and who also suggest strategies and resources for change.

97. Recovery is culturally-based and influenced  Culture and cultural background in all of its diverse representations including values, traditions, and beliefs are keys in determining a person’s journey and unique pathway to recovery.

98. Addresses Trauma  The experience of trauma (such as physical or sexual abuse, domestic violence, war, disaster, and others) is often a precursor to or associated with alcohol and drug use, mental health problems, and related issues.  Services and supports should be trauma-informed to foster safety (physical and emotional) and trust, as well as promote choice, empowerment, and collaboration.

99. Strengths and Responsibility  Recovery involves individual, family, and community strengths and responsibility: Individuals, families, and communities have strengths and resources that serve as a foundation for recovery.

100. Respect  Recovery is based on respect: Community, systems, and societal acceptance and appreciation for people affected by mental health and substance use problems – including protecting their rights and eliminating discrimination – are crucial in achieving recovery.

101. Ensure genuine, free, and independent client choice… Ingredients Within Successful Recovery Oriented Systems of Care

102. Using ROSC as a Framework. Recovery Oriented Systems of Care is a framework for coordinating multiple systems, services and supports that are person centered and designed to readily adjust to meet the needs of the individual’s needs and chosen path to recovery.

103. Harnesses and Aligns Community Healing and Resiliency Factors  ROSC harnesses and coordinates the healing power of clinical treatment providers, the recovery community, the faith-based community and an array of recovery support service providers.

104. Choice  Ensure genuine, free, and independent client choice for substance abuse clinical treatment and recovery support services appropriate to the level of care needed by the client. Choice is defined as a client being able to choose from among two or more providers qualified to render the services needed by the client, among them at least one provider to which the client has no religious objection.

105. Strong Leadership/Central Model  Strong mission driven leadership.  Ensures each client receives an assessment for the appropriate level of clinical and recovery support services and is then provided a genuine, free, and independent choice among eligible providers.

106. Voucher Based Payment  Allow eligible clients to use their vouchers to pay for assessment and other clinical treatment and recovery support services from a broad network of eligible providers. The network of eligible providers should include provider organizations that have not previously received public funding. Eligible service providers for the voucher program may include the following: public and private, nonprofit, proprietary organizations, including faith- based and community-based organizations.

107. Outreach and Training of FBOs  Ensure that faith-based organizations otherwise eligible to participate in this program are not discriminated against on the basis of their religious character or affiliation.

108. Incentivize for Outcomes  Maintain accountability by creating an incentive system for positive outcomes and taking active steps to prevent waste, fraud and abuse.

109. Community Structure  Advisory Council  Monthly Provider Meetings and Data Sharing.

110. Leverage Existing Funding and Resources  Expand clinical treatment and recovery support services by leveraging use of all Federal, State and Local Funding.  Investigate and coordinate funding for those seeking services.  Healthcare Navigation/Peer Supports.

111. Other Keys to Success  Clear Credentialing Requirements and Process.  Set of trainings for FBOs and Recovery Support Services Providers.  Use of GPRA/NOMS and other measures for outcomes.  Mobile assessments and assertive outreach.  EBPs such as Motivational Interviewing, CRA, CRAFT, 12 Step Facilitation Therapy & Education, Trauma Informed Care, Matrix Model.  EBP to Introduce EBPs--NIATx.

112. Preparation: Process Improvement NIATx (www.niatx.net)  Since 2003 Partnership between Robert Wood Johnson Foundations Paths To Recovery, The Substance Abuse and Mental Health Services Administration (SAMHSA) and the National Institute on Drug Abuse.  There are agencies in all 50 states using NIATx process improvement principles along with 25 State Substance Abuse Authorities. Free Provider Tool Kit.

113. NIATx Aims  Reduce Waiting Time  Reduce No-Shows  Increase Admissions  Increase Continuation Each of these activities has had a marked improvement in agency bottom lines (Business Case Series 3/07).

114. NIATx Principles  Understand and involve the customer  Fix key problems that keep the CEO up at night  Pick a powerful change leader  Get ideas from outside the organization or field  Use rapid-cycle testing to establish effective changes (Plan-Do-Study-Act)

115. NIATx Results  34.8% reduction in waiting times  33.0% reduction in no shows  21.5% Increased Admissions  22.3% Increase in continuation

116. Walk Through  Staff members experience the treatment process just as a customer does. The goal is to see and feel the agency from the customer’s perspective. Taking this perspective of services—from the first call for help, to the intake process, and through final discharge—is the most useful way to understand how the customer feels and to discover how to make improvements that will serve the customer better.

117. Motivational Interviewing Model describes how people change Helps people change their behavior and improve their motivation to change Identifies fears and difficulties and helps to resolve these issues

118. Motivational Interviewing Client-centered approach Meets the client where they are at Self-determination Self-autonomy  Non-judgmental

119. Motivational Interviewing Counselor  Respect individual differences  Tolerance for disagreement and ambivalence  Patience with gradual changes  Caring and interest in client  Not the expert, but a partner  Willing to negotiate with the client  Open to ideas from client  Supports what the client wants to do

120. The Peer Recovery Support Specialist

121. PEER RECOVERY SUPPORT SERVICES (PRSS) Services to help individuals and families initiate, stabilize, and sustain recovery Non-professional and non-clinical Distinct from mutual aid support, such as 12 Step Provide links to professional treatment and indigenous communities of support Provided by peers with “lived experience” of addiction and recovery

122. WHY DO PRSS WORK? Focus on establishing trust and building relationship Start with a person’s strengths and Recovery Capital Promote recovery choices and goals through a self- directed Recovery Plan Utilize recovery community resources and strengths Provide entry to healthcare system and services Elevate recovery as an expectation

123. BENEFITS OF PRSS Effective outreach and engagement Manages recovery from a chronic condition perspective Stage-appropriate Cost-effective Reduce relapse Promote recovery reengagement Facilitate reentry and reduce recidivism Reduce emergency room visits Create stronger and accountable communities

124. WHEN ARE PRSS DELIVERED? Across the full continuum of the recovery process: Prior to treatment During treatment Post treatment In lieu of treatment Peer services are designed and delivered to be responsive and appropriate to all stages of recovery

125. WHERE ARE PRSS DELIVERED? Recovery community centers Faith and community-based organizations Emergency departments and primary care settings Addiction and mental health agencies Criminal justice systems HIV/AIDs and other health and social service centers Children, youth, and family service agencies Recovery residences and Oxford Houses

126. WHERE ELSE AND IN THE FUTURE? Emergency departments Primary care practices Patient-centered health homes Federally Qualified Health Centers Accountable Care Organizations Community-based alternatives to jails and prisons Schools & colleges Veterans’ centers

127. WHO IS PAYING FOR PRSS? State, County, and Municipal service contracts SAPT Block Grants Federal and State grants and discretionary funds Other Federal funding: TANF, US Department of Justice, VA Medicaid Managed Care Foundation support Community support

128. PEER RECOVERY COACH Personal guide and mentor for individuals seeking to achieve or sustain long-term recovery from addiction, regardless of pathway to recovery Connector to instrumental recovery-supportive resources, including housing, employment, and other services Liaison to formal and informal community supports, resources, and recovery-supporting activities

129. MUCH MORE THAN RECOVERY COACHES Peer telephone continuing support Peer-facilitated educational and support groups Peer-connected and –navigated health and community supports Peer-operated recovery residences Peer-operated recovery community centers

130. RECOVERY COMMUNITY CENTERS  Positioning as a community institution (like a Senior Center)  Provides public and visible space for recovery to flourish in community: Recovery on Main Street  Serves as a “community organizing engine” for civic engagement, leadership development, and advocacy  Operates as a “hub” for PRSS and recovery-related activities  Includes participation of family members and allies in recovery community culture, services, and programs  Provides volunteer and service opportunities for community members  Positions the recovery community to interface as a key stakeholder with the greater community

131. ACA  ACA Enrollment  Outreach to the recovery community  Uninsured people living in recovery residences, participating in recovery community centers (estimated over 50% are uninsured)  Community members reentering from incarceration  Strategic communication and tailored messaging

132. ACA Enrollment  Navigator contracts to recovery community organizations or advocacy organizations to conduct education, outreach and enrollment of hard to reach individuals with mental illness. June 7, 2013 deadline.  Creating venues and events to conduct enrollment activities  Connecting enrollees to health care services  Keeping people in the health system once enrolled

133. Policy and Practice Recovery Oriented Systems of Care Within the Current Behavioral Health Landscape.

134. Introduction  Core values  Mission and vision  Recovery oriented approach  The True North

135. General Articles  Credentialing of Providers  Termination  Conflict of Interest  Confidentiality  Rates

136. Recovery Support Services; Descriptions and Definitions  Recovery Support Service Coordination (Case Management)  Recovery Support Service Coordinator Position (RSSC)  Recovery Support Service Mobile Coordinator Position (RSSMC)

137. Service Definitions for Recovery Support Services with Eligibility Standards and Documentation Requirements Childcare Transportation Family Support Group/Peer Support Housing Services Housing Case Management Reimbursement Gap Fund Gap Case Management Reimbursement Job Development Mentoring Life Skills Physical Fitness & Wellbeing Spiritual Support Pastoral Guidance Traditional Healing Intensive Recovery Support Aftercare

138. Procedures for Recovery Support Services Vouchers  RSS Coordinator  RSS Provider

139. Clinical Treatment Agency Model Program Content  Service Philosophy  Basic Services Required  Required Service Mix

140. Roles & Responsibilities of Clinical Supervision  Required minimally once per month  Face to Face/Individual or group  Motivational and reflective  Distinct from administrative supervision  Includes self-care plan and professional growth plan

141. Provider Operating Requirements & Procedures (1)  Voucher Eligibility, Referral and Management  Voucher Oversight  Voucher Life and Cap  Web Training Requirement  Evidence of Appropriate Business Licenses  Licensure, Certification, Credentials, or Other Staff Qualification  Program Compliance with Health & Safety Regulations  Organizational Governance  Religious Activity & Charitable Choice

142. Provider Operating Requirements & Procedures (2)  New Services  Staff Changes  Program Operating Standards  Program Rules  Code of Ethics  Protection of Individuals  Support Service Program Responsibility  Support Service Governance  Support Services

143. Provider Operating Requirements & Procedures (3)  Quality Assurance  Conflict of Interest  GPRA

144. Personnel or Volunteer Policies  Confidentiality and Individual Records

145. Policies and Procedures Program Structure

146. FACTORS FOR RECOVERY Recovery-Oriented Systems of Care Recovery Advocacy Movement Mental Health Parity and Addiction Equity Act Affordable Care Act Managed Care Expansion Criminal Justice and Drug Policy Reform Movement

147. Association for Recovery Community Organizations 82 member organizations (33 states) with local, state, and national focus Assistance to recovery community organizations National Alliance for Medication-Assisted Recovery (NAMA-Recovery) Building capacity to operate; develop leadership; advocate and deliver peer recovery support

149. WHY IS IT IMPORTANT? WHAT DOES IT MEAN?  Addiction is costly in terms of finances, physical and mental health, family functioning, employment, and legal involvement.  Recovery is associated with dramatic improvements in all areas of life – better health/ finances/family life/civic engagement/ employment coupled with dramatic decreases in public health and safety risks.  Life keeps getting better as recovery progresses.  Policies, services, and funding are needed to help more people initiate and sustain recovery, and for additional research to identify effective and cost-effective recovery-promoting policies and services.

150. ESSENTIAL INGREDIENTS FOR SUSTAINED RECOVERY HEALTH AND WELLNESS Safe and affordable place to live Steady employment and job readiness Education and vocational skills Life and recovery skills Health and wellness Sober social support networks Sense of belonging and purpose Connection to family and community

151. ESSENTIAL INGREDIENTS FOR SUSTAINED RECOVERY Safe and affordable recovery housing (substance free) Some need sober group living situations Recovery housing for single mothers and children Housing discrimination against people in recovery with criminal justice history Recovery housing: NIMBY issues

152. EMPLOYMENT, EDUCATION AND CIVIC ENGAGEMENT Recovery Jobs: Recovery-oriented employers and employment programs Job readiness and preparation Opportunities to volunteer and build work histories Leadership development: volunteer and career ladders Recovery GED programs, high schools and colleges

153. EMPLOYMENT, EDUCATION AND CIVIC ENGAGEMENT Recovery GED programs, high schools and colleges Community college programs for people in recovery Employment discrimination against people in recovery with criminal justice history Restrictions on voting rights for people with criminal justice history

154. OTHER INGREDIENTS Legal assistance Expunging criminal records Financial assistance: debt, taxes, basic budgeting, etc. Obtaining driver’s licenses Dealing with revoked professional and business licenses Regaining custody of children Relationship and parenting skills

155. RECOVERY AND WELLNESS FOCUS Shifting from a crisis-oriented, professionally-directed, acute-care approach with its emphasis on isolated treatment episodes…. To a person-directed, recovery management approach that provides long-term supports and recognizes the many pathways to health and wellness.

156. ROSC Build on the strengths and resilience of individuals, families and communities as individuals take responsibility for their long-term recovery, health and wellness. Make services and resources available that people can use to meet their needs Offer a variety of supports that work for and with each person to restore their lives (an ongoing process)

157. Mobilization Mobilizing all of the resources in our communities to: Change discriminatory public policies in the areas of health care, jobs, education and housing to eliminate barriers and support the ability of people to get into and sustain their recovery for the long haul. Develop networks and systems that work together to treat addiction as a public health problem

158. Mobilization Mobilizing all of the resources in our communities to: Accord people in or seeking recovery dignity and respect Engage people to seek help in the health system Help more people find and sustain their recovery for the long-term Build the capacity of communities, organizations and institutions to support recovery

159. Making Systems Work Public education and awareness about addiction prevention and the many pathways to recovery Greater focus on what happens BEFORE and AFTER primary treatment Transition from professionally-directed treatment plans to individually- developed recovery plans – recovery self-management Greater emphasis on the physical, social and cultural environment where people live their daily lives Integration of primary care, prevention, professional treatment and recovery support Recovery community representation at all policy and decision making levels

160. Compensation Continuum for Performance-based Payments  A shift toward increased collaboration and outcome-based payment  Requires several steps to achieve full integration  This modular set of performance-based contracting options align with a provider’s risk readiness Compensation Continuum (Level of Financial Risk) Small % of financial riskLarge % of financial riskModerate % of financial risk Limited Integration Full IntegrationModerate Integration Fee-for- service Performance- based Contracting Physician Hospital Patient-centered Medical Home Bundled and Episodic Payments Shared Savings Shared Risk Capitation Capitation + Performance- based Contracting

161. Reimbursement Methodologies DefinitionPro’sCons Separate payment to a health-care provider for each unbundled medical service rendered to a patient  Payments match services  Complete utilization data  Provides audit trail  May incentivize over-utilization  May discourage efficiencies  Doesn’t address quality/performance directly Providers are rewarded for meeting pre-established targets for delivery of health-care services  Incentivizes positive outcomes  Supports improvement in quality measures  May encourage efficiency  May direct provider attention only to impacted measures  May be difficult to evaluate causality A flat payment for bundled group of procedures and/or services  Controls cost per episode of care  Decreases UM oversight  Increased provider risk  Incentivizes shifting treatment to other settings/codes A flat payment for bundled group of procedures and/or services  Aggregates claims by diagnostic category instead of lumping all diagnoses into one case rate  May result in premature discharge or under treatment  May incentivize making cases more complicated A set payment for each enrolled person assigned to a provider or group of providers, whether or not that person seeks care, per period of time  Predictable and stable costs  Reduces billing  May promote under-treatment or selection incentives Fee for Service (FFS) Performance-Based Contracting Case Rate Diagnostic Related Group (DRG) Capitation

162. These are the fundamental avenues of focus for improving care and outcomes, and enhancing employee health Achieving the Triple Aim Improved Population Health, Quality and Affordability Performance-based contracting and other more sophisticated reimbursement approaches as providers’ sophistication matures Facilitates provider quality and accountability Payment Reform Consumer Tools/Transparency Centers of Excellence Benefit tiering/high performing networks Helps members make informed choices Employee Responsibility/ Incentives Sophisticated Analytics Intra-provider incentives Electronic Health Records that allow Provider Interoperability Consumer support tools Facilitates total population management Population Analysis Triple Aim

163. Direction from Health and Human Services/Center for Medicare/Medicaid Services  HHS and CMS are facilitating the following strategies as a major focus of  Health care reform:  Public Reporting: engaging consumers and others stakeholders  Health Information Technology: enabling improvement  Value-Based Payment: rewarding achievement  Clinically-Integrated Delivery Systems: achieving patient-centered, coordinated care  The Department of Health and Human Services in setting the stage for health care reform has commissioned the National Quality Forum to aid in the development of a national measurement strategy.  NQF will be convening a behavioral health workgroup to examine and assimilate measures.

164. Performance-Based Contracting – At A Glance  Demonstrated use of Evidence-Based Practices (EBP) Qualifies as High-Volume provider Participates in periodic meetings with clinical operations staff to review data Submits claims electronically Sample Facility Participation Requirements Sample Metrics Facility will earn escalator based sharing of savings if performance is within targeted range Facility will earn performance bonus for achievement of quality metrics Sample Performance Incentives Reduction in Average Length of Stay Reduction in 30 day Readmission rate to any inpatient LOC Improved results on ambulatory follow-up rates (7 days post inpatient discharge) Incentivizing provider performance leads to better outcomes for consumers

165. Outcomes, Options and Transformations Recovery Oriented Systems of Care Within the Current Healthcare Landscape

166. Quality Measures If addiction is a chronic illness requiring sustained monitoring, support, and early re-intervention, can the current acute-care model of addiction treatment provide such continuity of support over an extended period of time?

167. Quality Measures  a recovery-focused organizational culture;  adequate capitalization, funding diversification, availability of funding streams that enable sustained  support, and financial stewardship;  stability of organizational ownership;  administrative and clinical leadership and workforce stability;  recovery representation at policy and clinical decision- making levels;

168. Quality Measures  Recovery-focused performance measures include three dimensions of systems evaluation: 1) measures of infrastructure stability and adaptive capacity, 2) recovery-focused service process measures, and 3) long-term recovery outcome measures.  Infrastructure stability and adaptive capacity reflect the capacity of an organization to undergo systems-transformation processes (e.g., from an AC to an RM model of care) and the capacity of an organization to fulfill its commitment to continuity of contact and support over time for individuals and families seeking long-term recovery.  Recovery-oriented service process measures (e.g., early identification, engagement, retention, etc.) are intermediary outcomes that are linked to the final goal of long-term individual and family recovery.  Long-term recovery outcome measures represent the major fruits of recovery, defined here as the resolution of alcohol and other drug problems, the progressive achievement of global (physical, emotional, relational) health, and citizenship (life meaning and purpose, self- development, social stability, social contribution, and elimination of threats to public safety).

169. WHAT DOES LONG TERM RECOVERY LOOK LIKE? LIFE IN RECOVERY SURVEY Alexandre Laudet, PhD Understanding the experiences of people in recovery should inform this opportunity. Build recovery-oriented communities where the services and supports that people identify that they need are available – when they are needed. First nationwide survey of people in recovery from alcohol and other drug problems. 3,228 participated. 44 items representing experiences and indices of functioning in work, finances, legal, family, social, and citizenship domains “in active addiction” and “since you entered recovery.”

170. Outcomes and Successful ROSC  IAIA  Access to Recovery Data  Philadelphia  Connecticut

171. Institute of American Indian Arts  90% of students indicated that the Healing Circle Program improved their college experience. Students said that the program was conducive to learning, creative expression and human wellness.  There was a 100% drop in suicide attempts from 3 per semester to 0 during the 2 year term of the Healing Circle Program.  Incident reports related to alcohol or drug use dropped 95% during the Healing Circle Program.

172. Access to Recovery  At six months post intake, 80.4% were abstinent from substance use.  At six months post intake, 46.5% reported being stably housed.  At six months post intake, 49.8% reported being employed.  At six months post intake, 90.8% were socially connected (attended self help groups or had someone to whom to turn in times of trouble).  At six months post intake, 96.0% reported no involvement in the criminal justice system.

173. Connecticut  Short-term housing;   Transportation;   Faith-based services;   Basic needs (food, clothing, etc.);   Case management;   Childcare; and   Vocational and educational services.

174. Connecticut Peer Services  Telephone recovery support;   Family/community education;   Family support groups;   All-recovery groups;   Volunteer training;   Recovery training;   Peer-operated transportation company;

175. Connecticut Partners Department of Corrections Judicial Branch Department of Children and Families Department of Social Services Primary Healthcare Sites (Hospital ED & FQHC Sites) DMHAS-funded Outreach & Engagement Urban Initiatives

176. Connecticut

177. Wisconsin

180. Data Management System Allow clients to choose and change network providers; the capture of all client information, including GPRA outcome data; the generation and monitoring of vouchers; and, individual providers billing services rendered to the ATR client.

181. New Mexico

182. A Recovery Oriented System of Care in Wyandotte County Moving Forward!

183. Getting Started…

184. Planning Recovery-Oriented System Change 184 I. Conceptual Framework II. Assessment III. Capacity Building IV. Planning V. Development and Implementation VI. Evaluation

185. A Meeting of Key Stakeholders and Interested Community Members  Next steps…  Grants?  Coalition?  Action Plan?  Learning Collaborative?  Further Training?

186. Thank you! Jim Clarkson (505) 944-5284 Jim.Clarkson@Prodigy.Net Final Quiz!