RECOVERY OPPORTUNITY FOR SYSTEM CHANGE: WHY, HOW AND FOR WHOM

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RECOVERYOPPORTUNITY FOR SYSTEM CHANGEWHY,
HOW AND FOR WHOM?

• Thomas A. Kirk, Jr., Ph.D.
• Maryland Alcohol and Drug Abuse Administration
• Management Conference
• Ellicott City, Maryland
• October 3, 2008

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DMHAS
WE ARE A HEALTHCARE SERVICE AGENCY
Promote health
through prevention and early intervention
services.
Recover and sustain health
through treatment and recovery support services.
Healthy People, Healthy Communities. Lets Make
it Happen!
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WHY MOVE SYSTEM TO RECOVERY-ORIENTED MODEL ?

• System perpetuated stigma
• Acute care service is often wrong model
• Disproportional funding allocations
• Customers vote with their feet
• Weak message to funders and policy makers
• Perception that System is irrelevant and/or
  doesnt work in larger context

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HEARD ALONG THE WAY

• WHY DO THEY THINK WHEN THEY FIRST MEET ME THAT
  THEY CAN JUST GO AHEAD AND CALL ME BY MY FIRST
  NAMEIT IS LIKE THEY SEE ME AS A CHILD

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HEARD ALONG THE WAY

• IM NOT A JUNKIE ANYMORE!

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Doesnt anybody ever get better? Doesnt Work
Drain
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CYCLICAL AND RECURRENT
Traditional Approach to Care
Symptoms
Acute symptoms Discontinuous treatment Crisis
management
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GOAL HELP PEOPLE MOVE INTO RECOVERY ZONE
Symptoms
Improved client outcomes
Time
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HEARD ALONG THE WAY

• WHEN I BEGIN TO GET REALLY FUNCTIONAL, I LOSE
  THE SERVICES THAT I WAS GETTING THAT HELPED ME TO
  GET THERE

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CONTINUING CARE, RECOVERY-ORIENTED HEALTHCARE
SERVICE SYSTEM

• Content
• Structure
• Financing
• Outcomes
• ALL DIFFERENT FROM TYPICAL SYSTEM

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Getting Started
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ESSENTIAL LEADERSHIP STRATEGIES FOR SUCCESSFUL
TRANSFORMATION(John Kotter, Harvard Business
Review, January 2007)

• 1. ESTABLISH A SENSE OF URGENCY
• 2. Form a Powerful Guiding Coalition
• 3. Develop a Vision
• 4. Communicating the Vision
• 5. Empowering Others to Act on the Vision
• 6. Planning for/Creating Short Term Wins
• 7. Consolidating Improvements and Producing
• Still More Change
• 8. Institutionalize New Approaches

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WHAT IS RECOVERY?

• REFERS TO THE WAYS IN WHICH A PERSON WITH A
• SUBSTANCE USE DISORDER AND/OR MENTAL ILLNESS
• EXPERIENCES AND MANAGES HIS OR HER
• CONDITION(S)
• IN THE PROCESS OF RECLAIMING OR
• REBUILDING HIS OR HER LIFE IN THE COMMUNITY.
• AT ITS CORE,
• IT IS THE RESTORATION OF SELF-ESTEEM,
• POSITIVE IDENTITY, A MEANINGFUL ROLE IN SOCIETY
• AND,
• TO THE MAXIMUM EXTENT POSSIBLE, INDEPENDENT
  LIVING

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• You need a little love in your life and some
  food in your stomach before you can hold still
  for some damn fools lecture about how to behave
• Billie Holiday

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A RECOVERY-ORIENTED SYSTEM

• A recovery oriented system of care identifies
  and builds upon each individuals 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.

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RECOVERY ORIENTED SYSTEM OF CARE? TOOLS?

• ANY AND ALL THAT
• A person can choose to use to stay in the
  recovery zone and sustain their recovery
• The funder financially supports and evaluates,
• The service provider offers in service menu,
• The person identifies that work for him/her to
  build up their recovery capital, and
• Within the recovery community that tap into the
  inherent nature to give back

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WHAT DO PEOPLE WANT FROM A HEALTHCARE SYSTEM?

• A welcoming healthcare setting, prompt access
• An expectation of getting better, not
  necessarily cured.
• Hopeful, respectful atmosphere
• Treatment and tools to manage/own their own
  recovery
• (You can do it we can help)
• Show me somebody it worked for
• Have a life againto be renewed

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WHAT DOES A FUNDER WANT?

• Satisfied customers, get better
• Person centered vs. agency centered care
• Good brand recognition
• An effective care system with face validity
• Outcomes understandable to their funders
• Flexible, innovative and dynamic system
• High Value Quality/Cost

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WHAT DO YOU THINK?

• Questions?
• Make sense?
• OK to go on to the How question?

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Shift Gears
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Single Overarching Goal A Value-Driven,
Recovery-Oriented Healthcare System
How do you get there???
Implementing a Recovery-Oriented System of Care
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Many Paths to Recovery
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DMHAS SYSTEMIC APPROACH TO RECOVERY

• Develop core values and principles
• Establish conceptual and policy framework
• Build competencies and skills
• Change programs and service structures
• Align fiscal resources and administrative
  policies in support of recovery
• Monitor, evaluate and adjust

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DMHAS SYSTEMIC APPROACH TO RECOVERY

• Step One

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SAYS WHO?People in Recovery

• Equal opportunity for wellness
• Recovery encompasses all phases of care
• Entire systems to support recovery
• Input at every level
• Recovery-based outcome measures
• New nomenclature
• System wide training culturally diverse, relevant
  and competent services
• Consumers review funding

Direction

• Commitment to Peer Support and to
  Consumer-Operated services
• Participation on Boards, Committees, and other
  decision-making bodies
• Financial support for consumer involvement

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RECOVERY CORE VALUES CONTINUED
Participation
Funding-Operations

• Participation
• No wrong door
• Entry at any time
• Choice is respected
• Right to participate
• Person defines goals
• Individually tailored care
• Culturally competent care
• Staff know resources

• No outcomes, no income
• Person selects provider
• Protection from undue influence
• Providers don't oversee themselves
• Providers compete for business

Programming
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CHALLENGE AND OPPORTUNITY

• SUCCESSFUL INITIATIVES HAVE A 1000 FATHERS AND
  MOTHERS
• FAILED INITIATIVES ARE ORPHANS
• OUR JOURNEY TO A RECOVERY-ORIENTED AND
  TRANSFORMED SERVICE SYSTEM HAS TO HAVE MANY
  PARENTS

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DMHAS SYSTEMIC APPROACH TO RECOVERY

• Step Two

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THE PURSUIT OF MEANINGFUL COMMUNITY LIFE MUST BE
AT THE HEART OF THE CARE AND PLANNING PROCESS
THROUGHOUT!

• A person-centered system of care supports the
  persons efforts in managing his or her
  condition while s/he is regaining or
  establishing a whole life and a meaningful sense
  of membership in the broader community.
• WHILE not AFTER!

faith
work or school
treatment rehabilitation
Self-help
housing
social support
family
belonging
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COMMISSIONERS POLICY 83 PROMOTING A
RECOVERY-ORIENTED SERVICE SYSTEM

• Recovery Guiding principle and operational
  framework
• Recovery a process not an event
• Address needs over time and across levels of
  disability
• Identify and build on ones strengths and areas
  of health
• Encourage hope and emphasize respect

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POLICY CONTINUED

• Embed the language, spirit and culture of
  recovery throughout the system of services, in
  our interactions with one another and with those
  persons and families who entrust us with their
  care

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DMHAS SYSTEMIC APPROACH TO RECOVERY

• Step Three

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CT Implementation Process
Samples of R and D , Tools for Change
ATR, SPF COSIG
NIH,CMS PCP
T-SIG, RS CIT
CORE VALUES AS ARTICULATED BY RECOVERY COMMUNITY
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RECOVERY INSTITUTEFUNDAMENTALS OF
RECOVERY-ORIENTED CARE CURRICULUM

• Recovery Happens
• Providing Recovery Support
• (Example Case Management)
• Person Centered Planning Practical Applications
• Communicating Recovery
• Hitchhikers Guide to Recovery

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TOOLS SHAPE PRACTICE
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TOOLS AND RESOURCES
Manuscript available for download
at www.dmhas.state.ct.us/documents/practiceguidel
ines.pdf
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DMHAS SYSTEMIC APPROACH TO RECOVERY

• Step Four

Change programs and service structures
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Best Practices
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RECOVERY SUPPORT SERVICES

• Short-term Housing
  Recovery Houses
• Case management
• Transportation
• Vocational/Educational Services
• Basic Needs (food, clothing, personal care)
• Faith-based Services
• Peer-based Services

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TELEPHONE RECOVERY SUPPORT

• In the spirit of KISS, a new recoveree would
  receive a phone call from a trained volunteer
  (usually another person in recovery) once a week
  for 12 weeks
• Volunteer follows script
• Low cost, win/win scenario
• CCAR gives new recoveree a better shot at
  maintaining their recovery AND helps the
  Volunteer making the call
• Provider helps their clientele
• Prior to discharge, provider offers recoveree the
  telephone support program. 
• Results, outcomes, evaluations all outstanding

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Telephone Recovery Support IT WORKS! STAYING IN
THE RECOVERY ZONE

• When asked if I find the TRS (Telephone Recovery
  Support) calls helpful I cant say yes enough. 
  Theres something so supportive about knowing
  that no matter what happens in my life theres
  someone who genuinely cares about how my recovery
  is going.  My volunteer has shared in every
  victory I have had in my recovery since the calls
  began.  I hope to continue receiving these calls
  for a long time to come. Constance, recoveree
  enrolled in CCARs TRS program for the last 55
  weeks

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TELEPHONE RECOVERY SUPPORT A WIN-WIN SITUATION

• Out of all of the commitments Ive had TRS is
  my favorite way of giving back.  Honestly its
  a toss up as to who gets more out of itme or
  them. Caroline, TRS Volunteer
• When I was using my phone never rang and I
  wanted it to.  I remember just sitting there,
  staring at the phone wishing someone would call
  me, talk to mepossibly help me.  Now Im in
  recovery, for me this is the perfect way of
  giving back being that phone call that I never
  got. Curtiss, TRS Volunteer

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SUPPORT CREATES RECOVERY CAPITAL

Improved Outcomes


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SYSTEMS CHANGE WHAT WORKS LESSONS LEARNED
1
1

• Emphasize community life and natural supports
• Recognize that people in recovery have valuable
  and useful contributions to make
• Use multiple forms of evidence to guide policy
• Use a combination of approaches to address
  cultural needs and elimination of health
  disparities
• Establish clear service expectations for
  providers and monitoring outcomes
• UsePractice Management Tools "adapted from the
  private sector to improve outcomes for people
  using public sector services

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3
4
5
6
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Lesson 1 Focus on community life and natural
supports Example 1 Supported Housing and
Employment
DMHAS established new supportive housing units
for over 550 people with psychiatric or substance
use disorders. Over 60 of these people are now
working or in training, and their inpatient costs
have decreased 70. Based on a Corporation for
Supportive Housing study, these supportive
housing units are projected to generate over 140
million in direct and indirect economic benefits
for the state.

More people working, less inpatient costs
Working or in training
Inpatient costs
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LESSON 5 NECESSITY OF CLEAR EXPECTATIONS AND
GUIDELINES

• Provider Recovery Self-Assessment
• Consumer survey and language required by
  contracts
• Recovery-oriented performance measures
• Recovery-Oriented Practice Guidelines

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IMPROVED CARE, BETTER VALUEOATP 4/01 NOW
(2000 CASES)
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OPIATE AGONIST TREATMENT PROTOCOL (OATP) BEFORE
AND AFTER
Average Admissions Per Person
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OATP IMPACT ON RESIDENTIAL DETOXIFICATION BED
UTILIZATION
Service Days
Fiscal Year
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DMHAS SYSTEMIC APPROACH TO RECOVERY

• Steps Five and Six

• Align fiscal resources and administrative
  policies in support of recovery
• Monitor, evaluate and adjust

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HOW? CTS STRATEGY FOR FINANCING
RECOVERY-ORIENTED SYSTEM OF CARE FOR ADDICTION

• Goals
• Maximize existing service capacity
• Achieve savings by interrupting cycle of repeated
  crisis and acute care admissions
• Reinvest savings into recovery supports and
  clinical services to promote sustained recovery

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REINVESTMENT,SYSTEM ENHANCEMENT CYCLE
Innovation
Reinvestment
Improved Outcomes
Savings
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BETTER CARE, BETTER RESOURCE MANAGEMENT
Acute Care Claims Paid for People Receiving OATP
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GENERAL ASSISTANCE INTENSIVE CASE MANAGEMENT
(GA-ICM)

• ASO identifies people with 3 or more acute
  hospital admissions within 90 days
• Recovery specialist initiates contact while
  person is still in acute care
• Recovery plan developed to fill support gaps
• Recovery specialist helps with transition to
  community care

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Impact of GA-Intensive Case Mgmt (using Recovery
Specialist)
Care Episodes 12 Mos. Before 12 Mos. After
Initiating GA-ICM
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COST SAVINGS, BETTER USE OF RESOURCES
Change in Program Expenditures 12 Mos. After
Initiating GA-ICM
Millions
Net Savings 2.6 million
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CUTTING TREATMENT DROPOUT RATE
General Assistance Intensive Case Management GAICM
HU High Utilizer
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MORE PEOPLE STAY CONNECTED TO CARE AND
READMISSION RATES DECLINE
GAICM Target Population
Percentage
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SAMPLE RECOVERY SUPPORT (RS) OUTCOMES

• Urban Initiative (housing) 600 Decrease in ER
  visits, 375 decrease in detox days
• Recovery House 69 Connect to care vs. 36
  without Recovery House stay
• Supportive housing 61 decrease in inpatient
  costs

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GABHP - Alternatives to Hospitalization (ATH)

• Relieve gridlock in general hospital emergency
  depts.
• Decrease inappropriate use of mental health
  inpatient
• Improve access to
• appropriate substance abuse treatment
• Treatment of co-occurring psychiatric and
  substance use disorders
• Savings used to expand access to community care

49 of ATH Clients Successfully Diverted
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Outcomes
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SAMPLE CONTINUING CARE, RECOVERY MANAGEMENT
SYSTEM OUTCOME MEASURES

• Rate of readmissions into crisis or acute care
  services
• Satisfaction survey access, appropriateness,
  general satisfaction, outcomes, recovery,
  respect, participation in treatment
• Access, retention and drop out indices
• of first time admissions into existing service
  capacity
• Overall rate of growth of costs
• Percent of total costs for each level of care
• Percent of total client admissions into each loc
• Pre/Post recovery support service
  costs/completions

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VOICES OF RECOVERY
Getting well/getting better
Having same rights as others
Having hope
Doing everyday things
Making choices
Making changes, having goals
Staying clean and sober
Looking forward to life
Starting over again
Be looked at as whole people
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WHAT HELPS PEOPLE MOVE INTO AND STAY IN RECOVERY
ZONE?

• Expectation of improved health and stabilization
  
• Whatever is needed, whenever it is needed
• Continuity of relationships and care
• Housing, employment or something worthwhile to do
• Recognition that they own their recovery
• Inclusion in larger community
• Access to varying recovery oriented services

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Shift Gears
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CHALLENGES ALONG THE WAY

• Redesigning in mid air
• Client empowerment Staff reaction
• Hit the Wallthe plateaus
• Ive been wrong all these years
• Advocacychasing windmills
• Too complicated
• Project Du Jour. And Ill Be Out of Business
• Buy inStaff you never asked me
• Who made you recovery champion?

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LETS MAKE IT HAPPEN!
GO AHEAD, THE WATERS FINE.
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The Fiscal Realities Of

• 2008
• 2009?
• 2010?

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• Ok, good idea. Lets just stick our heads in the
  sand.

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KEY POLICY ISSUES/QUESTIONS

• Do you want bricks and mortar or people living
  communities with natural supports?
• Should we focus on healthcare costs or on the
  cost of disability and disease?
• How do we widen and reinforce the Recovery Zone
  for people with disabilities?
• Should addiction and mental health be The
  Agenda or part of Every Agenda?
• Are we talking about spending more or less, or
  spending differently?

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PART OF EVERY AGENDA, NOT NECESSARILY THE
AGENDA
POINTS OF IMPACT CHILD WELFARE, CORRECTION,
PUBLIC HEALTH, PUBLIC SAFETY, EDUCATION, LABOR,
HOSPITALS, SOCIAL SERVICES   COMMUNICATION COUCH
ED IN HEALTHCARE, PUBLIC SAFETY OR ECONOMIC
LANGUAGE PACKAGE
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TAKE HOME MESSAGES

• Creating recovery-oriented care requires service
  system changes at all levels
• A reinvestment financing strategy can leverage
  major system changes
• Non-traditional services help people get better,
  many paths to recovery
• Use federal grant money or dedicated state
  dollars as R D funds to spawn innovation
• Its a Marathon, not a sprint

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• For such individuals, like Billie Holiday, it
  may not be a matter of more (e.g., detox,
  treatment, medication) but of something different
  that may be required to initiate, pursue, and
  maintain recovery

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• STARSHIP DMHAS

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DMHAS, THE EVIL EMPIRE
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THANK YOU FOR THE CASSEROLE
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Thank You
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CONTACT INFORMATION
Thomas A Kirk, Jr., Ph.D. Commissioner Department
of Mental Health and Addiction Services
Office Phone [phone] Office
Fax [phone] e-mail thomas.kirk_at_po.state.ct.
us