Current Challenges

2. Current Challenges • Simultaneous Changes at Multiple Levels • Changing Business Practices • Changing Roles • New Service Delivery Models • New Infrastructure Enhancements • New Partners • Changing Payors and Payment Mechanisms 11.09.11 Achara Consulting, Inc

3. Reactions of the Field Achara Consulting, Inc

4. How do We Remain Relevant in the New Healthcare Ecosystem? Strategically Address the Triple Aim of the ACA • Improve Quality and Experience of Care • Produce Better Health Outcomes • Control Costs 11.09.11 Achara Consulting, Inc

5. Historical Forces Leading to Recovery Transformation in the U.S. Focus of attention/intervention: Stages of SUD Recovery • Pre-Recovery Initiation • Recovery Initiation and Stabilization • Recovery Maintenance • Quality of Life Enhancement • Community Health (William White)

6. Historical Forces Leading to SUD Recovery Transformation in the U.S. • Unmet Need: < 10 % who need Tx. seek treatment or if they do, arrive under coercive influences • Low Pre-Treatment Initiation Rates • Low Retention: > 50 % do not successfully complete treatment • Inadequate Service Dose: significant % do not receive optimum dose of Tx. as recommended by NIDA • Lack of Continuing Care: only 1 in 5 receive post-discharge planning • Recovery Outcomes:most resume using within 1 year and most do so within the first 90 days of discharge from Tx. • Revolving Door: > 60% one or more Tx. episodes, 24% 3 or more – 50% readmitted within 1 year

7. Historical Forces Leading to MH Recovery Transformation in the U.S. • Unmet Need 2001: less than one half of adults with SMI receive treatment (SAMHSA) • Low Retention: a quarter of individuals have contact with the public systems for 8 days or less (Bray et al., 2004) • Low Dose of Tx: Insufficient doses of medication and short length of treatment have all been associated with poorer outcomes (DHHS, 1999, Young et al., 2001) • High Recidivism: in higher levels of care, often leading to policies that limit access to care • Extremely High Burden of Disability: When compared with all other diseases (such as cancer and heart disease), mental illness ranks first in terms of causing disability in the United States, Canada, and Western Europe, according to a study by the World Health Organization (WHO, 2001)

8. 2 Key Messages

9. What is a ROSC? A ROSCis not: • A model • Primarily focused on the integration of recovery support services • Dependent on new dollars for development • A new initiative • A group of providers that increase their collaboration to improve coordination • An infusion of evidence-based practices A ROSC is: • A value- driven, APRROACH to structuring behavioral health systems and a network of services and supports • A framework to guide systems change

10. 6 Building Blocks of a ROSC Aligning treatment with a Recovery Management (RM) approach Fully integrating recovery support services into the system of care Developing a culture of peer leadership and support throughout the service system Promoting community health and wellness Facilitating cross system partnerships to provide more holistic and effective services Aligning administrative structures

11. Building Block I: Aligning Treatment with a Recovery Management (RM) Approach Impact: Quality, Outcomes, Cost

12. Attraction Achara Consulting

13. RM: Attraction, Assertive Outreach & Engagement • My clients don’t hit bottom; they live on the bottom. If we wait for them to hit bottom, they will die. The obstacle to their engagement in treatment is not an absence of pain; it is an absence of hope. • Outreach Worker (Quoted in White, Woll, and Webber 2003)

14. RM: Attraction, Assertive Outreach & Engagement • Practice Implications • Pre-treatment peer support groups • Offer peer mentors as soon as contact is initiated • In rural settings, utilize social media • Build strong linkages between levels and types of care through peer-based recovery support services • Connect with people before initial appointments and missed appointments via phone • Universal screening and early intervention in primary care • Establish relationships with natural supports to promote early identification • Organizational Implications • Integrate policies that promote same day access • Concurrent documentation • Reduce non-billable time of clinical staff • Reduce extensive documentation requirements • Use the most charismatic and engaging staff in reception areas

15. RM: Global Assessments + Service Planning • Practice Implications • Symptom reduction is viewed as a means to an end • Comprehensive, integrated assessments • Assessment is not viewed as an intake activity • Recovery plans versus treatment plans • Flexible menu of services • Behavioral Health services integrated with primary care • Expand your service menu and target population • Organizational Implications • Team approach to assessment, treatment and recovery supports • Rid your organization of “loosely held federations of tribes” David Lloyd • Develop a client-directed culture • Develop strategic partnerships

16. RM Approach: Culturally Responsive Services Achara Consulting

17. RM: Collaborative Service Relationships Achara Consulting

18. RM: Chronic Care Approach with Continuing Support Slide Acknowledgment: William White. Data Source: O’Brien CP, McLellan AT. Myths about the Treatment of Addiction (1996). The Lancet, Volume 347(8996), 237-240.

19. Approaches to Continuing Support • Implications for Practices • Multi-media (face to face, technology based, mail) • Eliminate administrative discharges for relapse • Planning for continuing support starts at the beginning of the treatment process not the end • Individualize based on need, recovery capital and preferences • Peer support groups • Recovery check-ups • Peer leadership councils • Recovery centers • Clinic based individual and group sessions • Family engagement • Recovery Housing • Internet-based RSS • Assertive linkages to natural supports • Recovery community organizations • Embedded within primary care settings

20. Building Block II: Integrating Recovery Support Services (RSS) Impact: Quality, Experience, Outcomes, Costs

21. 4 Overlapping Stages of RSS Continuum of SUD Recovery Enhancement of Quality of Life in Long-term Recovery Pre-Recovery Engagement Recovery Initiation & Stabilization Recovery Maintenance (William White)

22. Potential Functions of P-BRSS (Recovery Coaches) • Assertive outreach • Pre-treatment support and motivation enhancement • Recovery capital and needs assessment of individual/family/community • Recovery planning • Community resource identification • Assistance with basic needs • Volunteer recruitment • Assertive linkages to natural supports • Recovery focused skill training aimed at full community integration • Companionship, cultivating hope and modeling • Recovery check-ups (sustained monitoring and support) • Recovery advocacy for individual/family needs • Continued engagement • Real world skill building in the natural environment (stress management, etc) • Supporting multiple pathways to recovery • Problem solving obstacles

23. Achara Consulting

24. Building Block III: Developing a Culture or Peer Leadership and Support:

25. Building Block IV: Promoting Community Health and Recovery Capital Impact: Outcomes and Cost

26. Promoting Community Health And Prevention Achara Consulting

27. Philadelphia Department of Behavioral Health and Intellectual disAbilities Achara Consulting

28. Philadelphia Department of Behavioral Health and Intellectual disAbilities

29. Building Block VI: Aligning Administrative Structures Achara Consulting

30. 3 Approaches to Developing a ROSC ADDITIVE SELECTIVE TRANSFORMATIONAL Cultural, values based change drives practice, community, policy and fiscal changes in all parts of the system. Everything is viewed through the lens of and aligned with recovery Adding peer and community based recovery supports to the existing treatment system. Practice and Administrative alignment in selected parts of the system – e.g. pilot projects.

31. That’s Nice but… • We have no money • We have no time • What about all of the competing demands on our time? • The regulations are not aligned • How do we know this is the direction of the future?

32. ROSC and Service Integration Achara Consulting, Inc

33. ROSC and Service Integration Achara Consulting, Inc

34. Lessons Learned from the Field • “To be successful, you have to go through a cultural change” • “We can no longer be provider centric, its time for us to meet them where they are…” • “Be the answer for the behavioral health headaches that primary care has” • “We have been clear about setting the direction, communicating it, and explicitly inviting staff to assess whether or not this is a good fit for them.” • “This requires attention to leadership and change management”

35. Capitalizing on the Opportunities Four Areas of Focus • Identify the recovery-oriented practice changes that will improve access, quality and outcomes Examples: • Expand the focus of services to re-building a holistic life (global assessment and service planning processes leading to individualized recovery plans • Use pre-treatment recovery supports • Shift to a collaborative-partnership approach to assessment and treatment planning • Identify mechanisms for continuing support e.g. recovery check-ups • Assertively link people to new levels of care or services • Integrate peer-support services • Develop an expanded menu of services that facilitates choice

36. Capitalizing on the Opportunities 2. Identify key organizational/administrative changes that need to occur in the short and long-term Examples: • Change processes and policies to incorporate same day access • Incorporate concurrent documentation • Incorporate centralized scheduling for clinicians • Develop procedures for collecting and tracking data related to access, retention, outcomes • Streamline paperwork and duplicative processes (e.g. structured process notes vs. long narrative notes) • Incorporate data-driven decision making • Integrate electronic health records • Shift the norm to working as a part of interdisciplinary teams • Identify mechanisms to consistently track client perceptions • Explore how you can take your services into other settings

37. Capitalizing on the Opportunities 3. Identify your Change Management Structure and Process • Identify your point person/s • Engage stakeholders at all levels of the organization • Identify 2 short-term wins • Remember the parallel processes! • Clearly articulate the emerging vision of your organization and extend an invitation to staff • Identify mechanisms to monitor your progress • Over-communicate X10 • Remember the implications of transformational change • Use rapid cycle change processes

38. Capitalizing on the Opportunities 4. Develop Strategic Partnerships and Enhance your Community Relations “If you think poor, you’re going to be poor, we have to think differently, who are the quality partners…?” “Relationships and having people trust may be even more important than data” “Figure out the landscape of your community…and make yourself a part of the puzzle” • Identify strategic primary care partners, be the first to introduce yourself and communicate your value prop • Explore referrals, information flow, risk • Identify the most urgent needs (e.g. high recidivism in ER) • Define your expertise and expand it into all levels and sectors of the healthcare delivery system • Create different messages for different “clients” • Anonymity can perpetuate stigma, show the hope of recovery

39. Let’s Go For It!!!

40. Contact Information Ijeoma Achara, PsyD Achara Consulting Inc. ijeoma.achara@yahoo.com 11.09.11 Achara Consulting, Inc