Access to Recovery Kansas Summit Jim Clarkson, MA, LADAC July 19, 2010

1. Access to RecoveryKansas Summit Jim Clarkson, MA, LADACJuly 19, 2010

2. Access to Recovery • ATR is a presidential initiative which provides vouchers to clients for purchase of substance abuse clinical treatment and recovery support services. The goals of the program are to expand capacity, support client choice, and increase the array of faith-based and community based providers for clinical treatment and recovery support services using voucher based reimbursement.

3. ATR I 2004 • President Bush announced in the 2003 State of the Union Address a new substance abuse treatment initiative, Access to Recovery.  This new initiative will provide people seeking drug and alcohol treatment with vouchers to pay for a range of appropriate community-based services. 

4. ATR I Continued • 44 states and 22 tribes and territories applied. • Up to 7.5 million awarded for three years. • 14 states and one tribal organization were awarded: California, Connecticut, Florida, Idaho, Illinois, Louisiana, Missouri, New Jersey, New Mexico, Tennessee, Texas, Washington, Wisconsin, Wyoming, and the California Rural Indian Health Board. 

5. ATR II 2007 • Methamphetamine Initiative. • 40 states/tribes applied. • 24 awards up to 4.5 million for three years.

6. ATR II Awards • 24 three-year Access to Recovery grants were awarded in September 2007 to:  Louisiana, Hawaii, Missouri, New Mexico, Oklahoma Cherokee Nation, California,Alaska South central Foundation, Inter-Tribal Council of Michigan, Indiana, Illinois, Connecticut, Tennessee, Oklahoma, Montana Wyoming Tribal Leaders Council, District of Columbia, California Rural Indian Health Board, Arizona, Rhode Island, Washington, Ohio, Iowa, Texas, Colorado, and Wisconsin.

7. Jurisdictions funded in ATR I but not ATR II • Of the original 14 ATR grantee recipients 5 did not receive ATR II funding.

8. ATR II Client Level Results--Demographics • Served over the targeted 160,000 individuals. • 69% males. • 31% females. • 50% white. • 30% African American. • 9.7% Native American/Alaskan Native. • 1.5% Asian/Pacific Islanders. • Ethnicity: About 10% reporting being Hispanic.

9. ATR II Client Level Results--Services • 89% received recovery support services. • 49% of dollars expended on recovery support services. • 28% of dollars paid to faith-based organizations. • Faith-based organizations accounted for 33% of Recovery Support and 31% of Clinical Treatment services.

10. Outcomes (measured at 6 months post intake) • 80.4% abstinent from substance use. • 46.5% reported being stably housed. • 49.8% reported being employed. • 90.8 % reported being socially connected. • 90.6% reported no involvement in the criminal justice system.

11. ATR III • 30 awards for between 2-4 million per year for up to 4 years will be announced. • Requires returning veterans substance abuse recovery component.

12. ATR III Requirements ATR grantees will be expected to use their ATR grant funds to facilitate individual choice and promote multiple pathways to recovery through the development and implementation of substance abuse treatment and recovery support service voucher systems

13. ATR III Requirements Continued • 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.

14. ATR III Requirements Continued Provide all substance abuse assessment, clinical treatment, and recovery support services funded through the ATR grant through vouchers given to a client by an SSA/Tribe/Tribal Organization. No funding shall be given directly to a provider through a grant or contract to provide any services under this program, including assessments. By vouchering services, the ATR program employs an indirect funding mechanism.

15. ATR III Requirements Continued Ensure each client receives an assessment for the appropriate level of services and is then provided a genuine, free, and independent choice among eligible providers, among them at least one provider to which the client has no religious objection.

16. ATR III Requirements Continued 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, as approved through established procedures by the SSA.

17. ATR III Requirements Continued 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.

18. ATR III Requirements Continued Maintain accountability by creating an incentive system for positive outcomes and taking active steps to prevent waste, fraud and abuse.

19. ATR III Requirements Continued Expand clinical treatment and recovery support services by leveraging use of all Federal funds, preventing cost shifting, and ensuring that these funds are used to supplement and not supplant current funding for substance abuse clinical treatment and recovery support services in the State.

20. Important ATR III Milestones • Grantees are expected to fully implement their voucher programs no later than 4 months after the award date. • Grantees must complete and maintain an 80% GPRA follow up rate. • Service mix should reflect an approximate 50-50 recovery support and clinical services utilization rate. • Faith and community based providers should be part of the Access to Recovery network. • Grantees must hit their annual and aggregate target for clients served within annual allowable budget.

21. Keys to Success • Meet annual client targets. • Meet and maintain the 80% GPRA follow up rate. • Manage the project within budget and within allowable cost bands for services. Possible supplemental funding may be available if these requirements are met.

22. ATR Kansas Proposed ATR Clinical Service Array • Clinical Assessment • Outpatient Counseling • Intensive Outpatient Treatment • Adult Residential • Medication Assisted Treatment • Tobacco Medication Assisted Treatment

23. ATR Kansas Proposed Recovery Support Services Array • Recovery Support Services Assessment • Transportation • Housing Gap Fund • Smoking Cessation Support • Peer Mentoring • Child Care • Family Support Services • Job Development • Pastoral Guidance/Spiritual Support • Stress Reduction Management

24. ATR Kansas Targets • Goal of 10,000 individuals served over 4 years. • Year One 1,500 • Year Two 2,000 • Year Three 3,000 • Year Four 3,500

25. ATR Kansas Eligibility • Eligibility criteria for clients to receive vouchers. Client eligibility will include verification of Kansas residency, adult age 18 or over, income level, and meeting of clinical criteria for substance use disorders – based on the Kansas Client Placement Criteria Instrument (KCPC).

26. ATR Kansas Eligibility Continued • Kansas ATR has proposed the following priority populations: • Priority persons under current block grant and Medicaid funding at 200% and below poverty level will be eligible for recovery supports not available under current funding streams. This includes those currently on waiting lists with a focused priority on pregnant and parenting women and women with a need for gender specific, trauma informed care. • Uninsured/underinsured persons at 400% and below poverty level will be eligible for treatment of choice at public funded and private programs (may supplement sliding fee scales when appropriate) to reduce barriers to engaging in treatment services and to support recovery stability upon discharge. • Offender on post-release and community-based supervision who meet ASAM criteria and in need of recovery supports.

27. ATR Kansas Eligibility Continued • Veterans returning from current wars at 400% or below poverty levels who meet ASAM criteria, with a preference for those identified with Traumatic Brain Injury (TBI) or Post Traumatic Stress Disorder (PTSD) and substance use disorders (exemptions from income requirements will be allowable for returning veterans with justification that ATR type services cannot be adequately accessed in other venues).

28. Preparation: GPRA • Government Performance and Results Act. • Interview covering drug and alcohol use, family and living conditions, education, employment and income, crime and criminal justice status, mental health problems, physical health problems and treatment and recovery. • Must be completed before a voucher can be issued at intake, at discharge from ATR and at 6 months post intake. • Client engagement and retention critical in ATR. • Client incentives, assertive outreach, health study locator forms, cross provider communication, etc. • CSAT Trainings/State Trainings.

29. Preparation: Recovery Oriented System of Care Recovery-oriented systems support person-centered and self-directed approaches to care that build on the strengths and resilience of individuals, families, and communities to take responsibility for their sustained health, wellness, and recovery from alcohol and drug problems.

30. Preparation ROSC: Identifying Partner Providers and Referral Sources • Who are the natural partners to develop a recovery oriented system of care with current providers? • Develop a plan to gather these agencies/individuals together.

31. Preparation: Process ImprovementNIATx (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. • University of Wisconsin Center for Health Enhancement System Studies. • There are agencies in all 50 states using NIATx process improvement principles along with 25 State Substance Abuse Authorities. Free Provider Tool Kit.

32. 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).

33. NIATx 5 Key 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)

34. NIATX Results • 34.8% reduction in waiting times • 33.0% reduction in no shows • 21.5% Increased Admissions • 22.3% Increase in continuation

35. Begin with a 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.

36. Preparation: The Spirit of Motivational Interviewing • “Motivational Interviewing, Preparing People for Change” (Miller & Rollnick, 2002, The Guilford Press) • Faith/Hope Effect: The counselor, doctor, or teacher’s beliefs about a person’s ability to change can become a self-fulfilling prophecy. • Accurate empathy, nonpossessive warmth, and genuineness. • Directive, confrontational counseling styles increase resistance. • Empathetic counseling styles facilitate change by empowering clients to deal with painful issues and ambivalence.

37. 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

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

39. 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

41. Thank You! Jim Clarkson Director, Grants Management Practice ValueOptions (505) 944-5284 Jim.Clarkson@valueoptions.com