TIPS & TOPICS from David Mee-Lee, M.D.
Volume 9, No. 1
In this issue
— SAVVY –The 3 Ps to Understanding the Big Picture of Healthcare
— SKILLS –Clinical Implications of the 3 Ps
— SOUL –Celebrating anniversaries
— SHARING- Some readers’ comments
— Until Next Time
Welcome to the start of the 9th year of publishing TIPS and TOPICS (TNT). It was April 2003 when I started this experiment which has blossomed into a widely-read and appreciated resource (at least that’s what many readers tell me – the others don’t say anything- they just don’t read TNT!)
If you are new to TNT, welcome. You can mine the archives of 8 years of these newsletters at www.changecompanies.net. Click on Tips & Topics on the right.
The American Society of Addiction Medicine (ASAM) just held their Annual Medical-Scientific Meeting in Washington, DC. At the opening session, Pamela Hyde, J.D., Administrator of the Substance Abuse and Mental Health Services Administration (SAMHSA) made some introductory remarks that gave me a handle on the big picture of healthcare and where things are going. I will share her 3 Ps which gives a structure to understand where addiction and mental health treatment is headed. I’ll highlight some issues in each section.
Focus on People, Partnerships and Performance Measures
P – People
In the big picture of the changing behavioral healthcare system in the USA, there are a few sets of statistics to ponder. They show there is a huge unmet need for addiction treatment our current treatment system can never accommodate as it is currently designed, funded and delivered.
2006-2009 National Surveys on Drug Use and Health
Each year, SAMHSA conducts a household survey to check on the drug use and health of the USA population. Based on data from SAMHSA’s 2006-2009 National Surveys on Drug Use and Health, the following statistics were found:
· 98.8 percent of the more than 7.4 million American adults aged 21 to 64 with untreated alcohol use disorders don’t believe they need treatment. Or said another way, only 1.2% realizes they do need help.
· Only 506,000 of the nearly 6 million American adults with untreated alcohol dependence recognize they need treatment.
· These findings show “the need to increase public awareness about adult problem drinking, how to identify people with an alcohol problem, how to raise the issue with a problem drinker and how to get help” according to the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA).
2009 household survey
Like previous surveys, the 2009 survey shows the same huge number of people who don’t think they have a problem. This diagram shows the results for people aged 12 years and older and covers the nearly 21 million people:
People don’t see they have a problem because of:
· “Denial” and readiness to change issues
· Societal stigma and discrimination
· Funding and insurance coverage often limits addiction treatment;
· Access to care issues (How many public programs do you know that have treatment on demand, with no waiting lists?)
What will happen if, and when, we actually receive more universal healthcare coverage, and mental health and addiction parity with other illnesses?
· For addiction treatment alone, there is an estimated 4 to 6 million new clients who would be seeking treatment if we reached out as assertively as we do now with hypertension and diabetes.
If you feel your caseload is already way too big, imagine what it would be like if we really treated all who need help? Be aware of the world of healthcare planners. They have their eye on an even bigger picture. What they are discussing is “population health” – a viewpoint/approach to health which aims to improve the health of an entire population, not just a “target” group- i.e those people who come into your program and show up for treatment.
Oh, and did I mention the urgent attention to Federal and State budget deficits. These demand that the current curve of healthcare costs has to bend ‘south’ and flatten out, not keep relentlessly curving northeast and skyward!
P – Partnerships
We struggle already to meet the needs of all who want help, let alone those whose consciousness is yet to be raised and then attracted into health. And I didn’t even talk about statistics for youth substance use, or touch on similar statistics for mental and general health populations.
There is no way that addiction and mental health programs and agencies can meet all these needs in cost effective ways without forming partnerships. Here are some of the partnerships that you might have heard about:
· Partnering with primary care physicians to do Screening, Brief Intervention, Referral and Treatment (SBIRT) to tap into those millions of people with problem drinking, those who would never directly call your addiction treatment center.
· Working with psychiatrists, primary care physicians and addiction medicine specialists who are providing buprenorphine medication assisted treatment for people with opiate dependence.
· Linking mental health and addiction services to provide better integrated services for people with co-occurring conditions.
· Integrating behavioral health services, case management and other services into primary care to create “medical homes” or “health homes” responsible for ALL the care of a certain population of people.
· Developing Accountable Care Organizations (ACOs). In this model, physicians, hospitals and other health care providers partner together in a system that holds the organization accountable for outcomes and effectiveness. It doesn’t just pay them a fee for their healthcare service.
Why are these partnership issues even important to think about- when you are just busy doing your daily work?
We are all expanding our awareness of the magnitude of the national debt and deficit spending which will only worsen without fundamental structural change. These big picture issues may seem too large to wrap our heads around. Nevertheless we must start looking at how to fundamentally change the structure of the design and delivery of services to date. Partnerships are one of the structural solutions we must pay attention to.
P – Performance Measures
These days we are interested in ‘performance’ in many areas of our lives. Think of yourself as an individual consumer. More than in the past, you probably zero in on how many calories are in the food and drinks you buy. When considering purchasing a new vehicle, you find yourself interested in the “numbers”- what is the EPA gas mileage for the car you are considering? You now consider the “value” of the name-brand medication, soap, cereal or soda product versus the generic or look-alike one. Likewise in our work, that same consciousness has arrived. Increasingly we will be held accountable as to whether what we do is making a measureable difference.
· As yet, our clients and patients might not be as discriminating and demanding of value and performance measures in healthcare (as with their cars or smartphones). However funders and payers are certainly stepping up that pressure. There are no more ‘blank checks’. We must be able to justify that our service is making a positive difference.
· What is the value of what we deliver in treatment? Value is the combination of quality and cost. If your service is high quality but costs an arm and a leg, the value proposition is not there. Naturally, if money is no object, you don’t worry about “value”, you just want what you want. But no one can take that attitude about healthcare except the very rich.
· If your service is low cost, but poor quality, again the value proposition is not there. Unfortunately, the poor and disenfranchised have no choice. But we owe them better than that.
· The focus for all of us needs to be on maximizing value – How do we provide the highest quality in the most cost-effective manner?
Resources are limited. As the demand for “bending the cost curve” becomes more imperative, all of us must start focusing on performance measures now. You have heard the saying: You can’t manage what you don’t measure. Hard to stick to the speed limit if you don’t have a functioning speedometer. You’ll surely bounce that check if you don’t balance your checkbook. And we’ll serve fewer people if we don’t improve the value of what we do in treatment.
What happens at the individual clinician and counselor level? All this “big picture” view can feel irrelevant, overwhelming and far from the daily pressures of case loads, running groups, seeing clients and doing documentation. While it is true that much of this is out of our direct control, there are clinical implications that make sense for today. So here are the 3 Ps again, from a clinical perspective.
Identify Where to Start on PEOPLE
Even though you are not focused on population health, on the micro clinical level there is much you can do in prevention, early intervention and treatment:
- Encourage Screening, Brief Intervention, Referral and Treatment (SBIRT) for alcohol and other drug problems in your practice, in primary care health providers and emergency health personnel and settings. For some excellent online training resources from the National Institute on Alcohol Abuse and Alcoholism, see the video cases on “Helping Patients Who Drink Too Much.”
- In that learning opportunity, there are 4 interactive, 10-minute video cases using evidence-based clinical strategies for patients with different levels of severity and readiness to change. There are even continuing education credits for physicians. http://www.niaaa.nih.gov/Publications/EducationTrainingMaterials/Pages/CME_CE.aspx
- If you are in an addiction treatment setting, ensure screening for all mental health conditions.
- If you are in mental health, ensure screening for all substance-related conditions. Co-occurring conditions should be ruled out or in for all clients.
- When you are working with the identified addiction or mental health client, remember there are significant early intervention and prevention opportunities by working with clients’ families sooner rather than later. (There are an estimated 28 million children of people with alcohol use disorders. Usually at least 1 or 2 significant others are affected by their loved one’s addiction and/or mental disorder.)
- All clients’ addiction and mental health can be greatly enhanced, or negatively impacted by poor physical health and lifestyle choices, like smoking, exercise, nutrition, sleep patterns and work-life balance. In behavioral health, we often neglect assessment and services for these areas of the “whole person”.
I’m sure some of you may be saying- What about adding to the list areas you are passionate about? Trauma informed work, cultural competence; gender-specific or sexual orientation sensitivities; recovery oriented systems of care; drug and mental health courts? The list goes on.
Identify Where to Start on PARTNERSHIPS
Within the behavioral health field, we have been slowly breaking down the walls between mental health, addiction and criminal justice. Many clients present already involved in multiple systems ( Criminal Justice, Child Protective Services, workplace…) Their needs cut across disciplines and varying missions of many organizations/systems. To treat the whole person requires partnership.
Here are some ways to initiate or strengthen partnerships at the clinical level:
· Ask around and see if your local health clinic, family physician or group practice has an office that could be freed up a couple of hours every other day. You or another clinician could make yourselves available to see referral clients identified during SBIRT screening in the clinic.
· Buddy up mental health and addiction agencies in your county to offer a variety of services:
- cross training on mental health, addiction and co-occurring conditions
- interagency consultation and case conferencing on clients who may be at both agencies
- establish a co-occurring disorders group; choose one clinician from addictions and one from mental health; agree to co-lead the group ; billing would work by which agency/ system the client first showed up at.
· Meet with the drug and/or mental health court team. Cover the following areas:
- clarify lines of communication
- clarify respective roles and boundaries – e.g the court mandates treatment and monitors treatment adherence, while clinicians assesses, treats and reports on clinical progress.
· Work with Child Protective Services also. Cover the same topics referenced above re: the Drug and Mental Health teams.
· Develop community partnerships for universal, selected and indicated prevention and early intervention.
Just this month, the Board of Directors of the American Society of Addiction Medicine (ASAM) approved a working partnership with The Change Companies (TCC) to improve awareness, training, consultation and implementation support for the ASAM Patient Placement Criteria (PPC).
You’ll be hearing lots more about this in the coming weeks. But it is fitting that in this month, the 20th anniversary of the publication of the First Edition of the ASAM Patient Placement Criteria for the Treatment of Substance-Related Disorders, ASAM and TCC are entering into a partnership that will bring a more focused and supportive array of services and products to help understand the spirit and content of the ASAM Criteria.
We will want to know more from you about:
- What you know or don’t know about the ASAM Criteria
- What you need to help you understand and implement the ASAM Criteria
- What your misconceptions, misgivings and misunderstandings might be about the ASAM Criteria
- Why your agency, county or state does or does not use the ASAM Criteria.
- And more….
If you already have some burning thoughts and suggestions about this, I welcome your comments – the good, bad and the ugly.
Identify Where to Start on PERFORMANCE Measures
In your work, you probably collect (and faithfully submit) a lot of data and documentation now. It’s likely that it disappears into the black hole of data gathering, never to be analyzed or fed back to you in any meaningful shape or form. This is not how data should be handled, and this is not how it will be handled in the future.
· Take a look at your quality improvement process (QI). See if the performance measures are meaningful, studied and improved through process improvement like the NIATx system (www.niatx.net)
· What are your waiting list times, client dropout or premature discharge rates?
· What is the value of the services you provide? I don’t mean what do you charge. Do you have a way to make the value proposition compelling for what you do? What is the cost/quality benefit ratio?
· Do you collect statistics on length of stay by level of care? Do the statistics reveal person-centered individualized care? Or do you find lengths of stay all clustered around a predetermined length of stay in a particular level of care? If they do, they indicate program-driven care rather than clinically-driven care.
· Check back with your referral sources, especially those mandating people to treatment. Ask them what outcomes are important to them. What makes for good value to them?
- Is it decreased legal recidivism?
- Is it increased public safety and safety for children and families that they want?
- Are they looking for less workers compensation?
- Are they an employer or Employee Assistance Program hoping for increased productivity, decreased absenteeism or presenteeism?
- Is the referrer a funder? Are they looking for efficient use of levels of care with flexible lengths of stay and easy access to care with seamless linkage to continuing care?
· In your day to day, session by session clinical work, do you know about formal client feedback measures in real time such as Feedback Informed Treatment (FIT)? In the past it has been called Client-Directed, Outcome Informed work? (Take a look at the International Center for Clinical Excellence.). www.centerforclinicalexcellence.com
· You might not yet use formal measures of outcome and the therapeutic alliance. However if you are curious about these, please check them out. I wrote a whole SKILLS section on how to do that in the February 2009 edition of Tips and Topics. You can see that in the archives of Tips and Topics at http://www.changecompanies.net/tipsntopics/?m=200902
Who is going to be demanding these outcomes and performance measures?
*payers and managed care
*quality and accreditation bodies
*licensing and funding agencies.
Because clients care about value…..Because funders definitely will hold you accountable…..Because we will never meet the unmet needs if we don’t change the way we do business.
You know you’re getting old when you start speaking of anniversaries in terms of decades. Not like the young infatuated couple who celebrate the three month “anniversary” of their first date!
So April is the anniversary of a few milestones in my career:
(1) Commencing the 9th year of publishing Tips and Topics (nearly a decade!)
(2) It has been 2 decades since the 1st edition of the ASAM Patient Placement Criteria; and
(3) 3 decades/30 years since I started and directed my first addiction treatment program in 1981.
What is it about April? Perhaps an April Fool!
However these were no foolish endeavors. Even though careful planning and thought went in all three projects, I certainly never planned or anticipated the impact they could have. Not too long ago, I received this message from a patient I treated 27 years ago. In part he said:
“I was a resident in anesthesiology and was suffering from multiple substance addiction, most primarily involving opiates. Since March of 1984, I have remained completely and continuously abstinent from all substances, including alcohol. My recovery then, as now, is very largely based on active participation in the fellowship of Alcoholics Anonymous and the working of the AA “program”. I remain forever indebted to AA, and I would also like to very belatedly express my gratitude to you for having so skillfully guided me to and through exactly the help that I needed back in 1984.
Following discharge from treatment, I returned to my residency in anesthesiology and have been one of the fortunate few with opiate addiction that have been able to successfully return to the practice of anesthesiology. My career to date has been full and rewarding. In my personal life, neither my wife nor three children have ever seen me use a substance, and all have been tremendously supportive of my very busy (4 + meetings per week) continued involvement in recovery. It has been, and I reckon, always promises to be, a wonderful ride.”
My ex-patient certainly remembers the anniversary of his sobriety and well he should. It changed the course of his life and has enabled him to serve many thousands.
The influence of these anniversaries lives on.
TNT readers keep enjoying the monthly issues. There are many great recovery stories out there like my physician patient, and we can feel encouraged by that. And now in April 2011, a new chapter for the use of the ASAM Criteria begins with this partnership to spread the use of the Criteria- its second life 20 years later!
From time to time I share comments from readers usually made about the last edition of Tips and Topics. Here are a couple of comments- the first from the chair of the workgroup on residential levels of care for the ASAM Criteria:
I agree with your comments about residential treatment and its value and I would like to add one more disadvantage. While in residential treatment, for however long, the patient receives structured support and high intensity treatment. All of a sudden one day, the high level of support to which they have become accustomed suddenly ends and the intensity of treatment suddenly drops. For some people, that abrupt change is too much to negotiate after discharge and they relapse.
You and I agree that too many people are treated in residential care, not because they are in imminent danger, but because they have no safe place to live, don’t have transportation to outpatient, etc. An alternative to the inappropriate use of residential treatment is the combination of supportive living and high intensity outpatient treatment, such as a Partial Hospital Program, something I have called “OutpatientPlus” in my trainings.
There are two advantages to this system: (1) it reduces overutilization of resources; and (2) the level of structured support and treatment intensity can be lowered gradually so the individual does not have to manage the abrupt change from residential to outpatient.
Just a thought.
Gerald D. Shulman, M.A.
Shulman & Associates, Training and Consulting in Behavioral Health
Jacksonville, FL 32256
Here is the second comment in response to renaming Graduation or Treatment Completion Ceremonies in residential addiction treatment.
“As a member of our county’s Drug Court Program sanctioned by the National Association of Drug Court Professionals, we prefer to use the term COMMENCEMENT upon the completion of the substance abuse phase and drug court programs, framing this process as another exciting step in continuing to grow, strengthen and mature in their recovery as they expand the other areas of their lives, which makes their involvement in ALUMNI GROUPS even more important.”
Until Next Time
Thanks for reading. See you in late May.