Recovery in the Community: An Emerging Framework- A Recovery-Oriented Systems Approach SAAS National Conference &

1. Orlando, Florida June 22-25, 2008 Recovery in the Community: An Emerging Framework- A Recovery-Oriented Systems ApproachSAAS National Conference & NIATx Summit Partners for Recovery Jack Stein Director, Division of Services Improvement CSAT Shannon Taitt PFR Coordinator CSAT Melanie Whitter Senior Associate Abt Associates Inc. 1

2. Presentation Goals • To provide an overview of a recovery-oriented systems approach; • To discuss the benefits this emerging approach; • To engage you in the system change process; • To inform you about CSAT programs that support recovery-oriented activities; and • To answer your questions. 2

3. 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 Systems Providers Local Communities 3

4. A Recovery-Oriented Systems Approach 4

5. Draft Description 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 sustain health, wellness, and recovery from alcohol and drug problems. 5

6. Adoption of a Public Health Approach • A public health approach is used to address substance use problems and related health conditions. The science and art of preventing disease, prolonging life and promoting health through the organized efforts and informed choices of society, organizations - public and private - communities and individuals. • C.E.A. Winslow, • Professor of Public Health, • Yale School of Medicine, 1920

7. Key Elements of a Public Health Approach • Population-based • Holistic • Risk factor-oriented • With attention to vulnerable populations • Focused on: • Health promotion • Disease prevention • Evidence-based 7

8. Describing Recovery-Oriented Systems 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. 8

9. Outcomes Evidence-Based Practice Employment/ Education Systems of Care Addictions Child Welfare Menu of Services & Supports Reduced Criminal Involvement Cost Effectiveness Mental Health Peer Support Alcohol/Drug Housing/ Transportation Housing Mental Health Primary Care Community Individual Family Child Care Health Care Wellness Recovery Financial Mutual Aid Employment Educational Education Stability in Housing Vocational Perception Of Care Indian Health Service DoD & Veterans Affairs Spiritual Civic Organizations Legal Case Mgt Private Health Care Criminal Justice Abstinence Retention Organized Recovery Community Human Services Access/Capacity Social Connectedness Health Ongoing Systems Improvement

10. Role of Prevention, Treatment & Recovery Providers • Acts as one of the coordinating bodies for systems improvement • Provides person-centered/self-directed services and supports • Accesses services from other systems for clients • Supports improvement in addressing substance use issues within other systems 10

11. Why do we need this approach? The field faces many challenges: Different values, approaches, & perspectives Insufficient and inefficient use of resources Cumbersome, fragmented, and inflexible systems Access, engagement, retention and appropriate services 11

12. …but we have a lot to build upon • Factors contributing to the change movement: • Federal and State initiatives • Institute of Medicine (IOM) Report • Advances in science and technology • Growth of recovery communities • Emergence of recovery advocacy • Focus on collaboration and accountability 12

13. Recovery-Oriented Systems Elements & Goals 13

14. Systems Elements • Person-Centered: • Individualized & Comprehensive Services Across the Lifespan • Responsive to Culture & Personal Belief Systems • Partnership-consultant Relationships • Strength-based • Community-based • Commitment to Peer Services • Involvement of Recovering Individuals, Families and other Allies 14

15. Systems Elements (cont’d) • Efficiency and Cost-Effectiveness: • Outcomes-oriented • Integrated Services • Systems-wide Education and Training • Continuity of Care • Monitoring and Outreach • Research-based • Adequately & Flexibly Financed 15

16. Goals of Recovery-Oriented Systems • To support preventive strategies related to substance use problems & disorders; • To intervene early with individuals with substance use problems; • To support sustained recovery for those with substance use disorders; and • To improve individual, family and community outcomes. 16

17. Enhancing Current Systems 17

18. Enhancing Current Systems Many of the elements are not new. Systems enhancements include: • Incorporation of ongoing prevention, early engagement and early intervention across systems; • Emphasis on recovery support services throughout the continuum of care;… 18

19. Enhancing Current Systems(cont’d) Systems enhancementsinclude: • Adoption of individualized and flexible menu of services; • Inclusion of chronic care approaches (i.e., recovery management); • Emphasis on evidence-based practices; and • Incorporation of community networks & resources. 19

20. Enhancing the Continuum of Care to Provide a Recovery-Oriented Approach • • A full continuum should be made available through coordination with multiple systems. • Individuals should have access to a full continuum of care regardless of the system they enter or the community in which they live.

21. What are the benefits of a recovery-oriented approach? • Increased responsiveness to individuals, families and communities • Application of recovery-oriented research 21

22. Increased Responsiveness to Clients 22

23. Responsive to Individuals/Families • Systems and policies provide clients with options and the ability to make informed decisions regarding their care. • Systems and services are more welcoming and flexible. • In recovery-oriented systems, treatment is viewed as one of many critical resources needed for a client’s successful integration into the community. • Measures of satisfaction are collected routinely from people in recovery and their families. 23

24. Applying Recovery-Oriented Research 24

25. Recovery-Oriented Research • Preventive Strategies–Recovery management check-ups can significantly decrease relapse and re-admission (Dennis, Scott, & Funk, 2003). • Early Intervention – Early and brief interventions were found to be effective, up to four years later, in reducing alcohol use, days of hospitalization, and emergency department visits (Fleming et al., 2002). • Improving Treatment Outcomes and Sustaining Recovery – Long-term recovery outcome is enhanced by individual choice and commitment (Laudet & White, 2008). • Cost-effectiveness–Individuals with co-occurring substance abuse/medical problems randomized to integrated care had significantly lower total medical costs than those in independent care (Parthasarathy, Mertens, Moore, Weisner, 2003). 25

26. Engaging You in the Change Process 26

27. Using a Recovery-Oriented Framework as a Platform for: Collaboration among informal & formal systems Planning Policy development 27

28. Planning Recovery-Oriented System Change I. Conceptual Framework II. Assessment III. Capacity Building VI. Evaluation V. Development and Implementation IV. Planning 28

29. I. Conceptual Framework • Vision • Principles • Definitions 29

30. II. Assessment • Assessments of readiness • Inventories of current services & supports • Assessments of organizational and staff recovery-oriented capabilities • Assessments of strengths and gaps • Stakeholder Surveys 30

31. III. Capacity Building • Awareness raising strategies and materials for multiple audiences • Legislators, recovery community, etc. • Training and educational materials • Cross-systems, organizational, staff, volunteers 31

32. IV. Planning • Strategic Plan • Goals & Priorities 32

33. V. Development and Implementation • Specify Roles within an Organization and with Participating Organizations • Develop and Implement an Action Plan • Implement New Regulations and Contracts • Develop Protocols for Person-Centered/Strength-based//Self-Directed Approaches • Provide or seek training on recovery-oriented approaches 33

34. V. Development and Implementation (cont’d) • Revise and Develop New Job Descriptions • Incorporate Workforce Competencies & Ethical Standards • Adopt Innovative Services and Supports, including Technology • Define Quality Control Standards and Develop Instruments • Develop Measures and Methodology to Assess performance and Outcomes 34

35. VI. Evaluation • Process evaluations • Outcomes evaluations • Quality improvement processes 35

36. Systems change requires conceptual clarity, overcoming resistance, organizational commitment, strong leadership, definition of roles, transparency, and an infrastructure to support the process, including staff and education and training. A perfect plan is not necessary to begin the process. Change agents in your State will assist you with the implementation process. Constant communication is essential. Lessons Learned from State and Community Activities

37. Pursue efforts where you can achieve early success and promote those accomplishments. Use all tools available to you, such as peer-to-peer services and case management. Conduct evaluation and performance measurement at the beginning of the implementation process. Invest in a good grant writer to leverage resources. Recommendations from States and Communities

38. CSAT’s Regional Recovery Meetings: Noteworthy Steps States are Prepared to Take • Convene a Blue Ribbon Panel to create documents that describe the State’s plan for recovery-oriented services; • Offer mini-grants to build recovery-oriented capacity; • Make funding contingent on client-centered care; • Formulate recovery-oriented guidelines and competency-based credentials;… 38

39. CSAT’s Regional Recovery Meetings: Noteworthy Steps States are Prepared to Take (cont’d) • Design new RFPs to solicit recovery orientation – with an ultimate goal of developing recovery- oriented Centers of Excellence; • Define recovery-oriented job functions and services and develop a training curriculum to support those activities; and • Ensure that the State’s management information systems (MIS) can track recovery-oriented support activities. 39

40. CSAT Programs & Initiatives that Support Recovery-Oriented Services & Activities 40

41. AK WA NH VT MT ME ND MN OR ID SD WI NY WY MI MA IA PA NV NE OH RI IL IN CT UT WV NJ CO VA CA KS MO DE KY MD NC DC TN AZ NM AR SC OK AL GA MS TX LA Puerto Rico FL HI Virgin Islands 2007 CSAT TCE/HIV Grantees States with 2007 Grantees

42. Screening, Brief Intervention, and Referral to Treatment (SBIRT)

43. Alcohol & Drug Related Emergency Department (ED) Visits In 2005 there were an estimated 394,224 ED visits that involved alcohol in combination with another drug. Alcohol was most frequently combined with one or more of the following: cocaine, marijuana, and heroin. SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2005 (04/2006 update).

44. Traditional Substance Abuse Intervention 5% Alcoholics 20% At-Risk Drinkers 35% Low Risk Drinkers 40% Abstainers Adapted from Babor,T,F., Higgins-Biddle,J.C., (2001), Brief Intervention for Hazardous and Harmful Drinking: A manual for use in primary care . p 33. WHO/MSD/MSB/01.6b World Health

45. Screening, Brief Intervention & Referral to Treatment (SBIRT) Embeds screening, brief intervention & treatment of substance abuse problems within primary care settings such as emergency centers, community health care clinics, and trauma centers; Identifies patients who don’t perceive a need for treatment; Provides them with a solid strategy to reduce or eliminate substance abuse; and Moves them into appropriate services.

46. SBIRT Current State & College Grants Massachusetts Connecticut Delaware College/University Grants State Grants

47. SBIRT: Core Components Screening:Very brief screening that identifies substance related problems Brief Intervention:Raises awareness of risks and motivation of client toward acknowledgement of problem Brief Treatment:Cognitive behavioral work with clients who acknowledge risks and are seeking help Referral:Referral of those with more serious addictions

48. Reimbursement for screening & brief intervention is available through commercial insurance CPT codes, Medicare G codes and Medicaid HCPCS codes: Coding for SBI ReimbursementFebruary 2008 • HCPCS Codes (Medicaid) • H0049: Alcohol &/or Drug Screening ($24) • H0050: Brief Intervention:15 mins. ($48) • CMS G-Codes (Medicare) • G0396: 15-30 mins ($29.42) • G0397: > 30 mins ($57.69) • CPT Codes (Commercial Health Plans) • 99408: 15-30 mins ($33.41) • 99409: > 30 mins ($65.51)

49. Alcohol to Intoxication & Illegal Drug Use – SBIRT Outcomes The data below represent follow-up from the SBIRT programs as of 3/24/08. Sample selection was random and collected at intake and 6 months post intake. Important to note: Results are from SBIRT early implementation and reflect a more severely involved substance abuse population.

50. Access to Recovery:A Recovery-Oriented Approach