RECOVERY ORIENTED
SYSTEMS OF CARE
WYANDOTTE COUNTY
KANSAS CITY, KANSAS
HEARTLAND REGIONAL
ALCOHOL & DRUG
ASSESSMENT CENTER
Jim Clarkson
CEO/Via Positiva
An Overview of Recovery Oriented
Systems of Care
Paradigm Shift From An Acute Care Medical
Model to A Chronic Disease Management Person
Centered Model
Integrated Care: From Silos….
3
To Synergies….
4
ROSC Model
The law of floatation was not discovered by
contemplated the sinking of things, but rather than
by contemplating the characteristics of those
things which floated naturally and intelligently
asking why they did so.
(Judge Thomas Troward)
Box (1987): “All models are wrong, but some are
useful”
Recovery?
“The process by which people are able to live, work,
learn, and participate fully in their communities. For
some individuals, recovery is the ability to live a
fulfilling and productive life, despite a disability. For
others, it implies the reduction or the complete
remission of symptoms”…
--The President’s New Freedom Commission Report
Iatrogenic Suffering
Suffering caused by the physician, practitioner or other
helper, usually unintentional but increasing the amount of
distress a person seeking help already has.
It is often caused by the practitioner’s bedside manner or
barriers placed within a system. The patient bears the
brunt of the practitioner’s unfinished or unconscious
psychological issues regarding death, vulnerability, mental
or other serious illness or the effects from trauma, growing
up in a home with alcoholism, drug addiction, domestic
violence or the like.
Person First

Sanctuary

Value & Therapeutic Alliance
Whatever you can do or dream you can, begin it.
Boldness has genius, power and magic in it!‘--Goethe
Sanctuary
Place of safety, oasis, shelter, sacred place
(S. Covington)
Recovery?
“Recovery is a deeply personal process of (re)gaining
physical, spiritual, mental and emotional balance. It
is a process of healing and restoring wellness during
stressful episodes of life”.
--Mental Health First Aid
Recovery Oriented System of Care

“A recovery oriented system of care identifies and
builds upon each individual’s 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”. –Thomas
Kirk, CDMHAS
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
8
Local
Communities
Toward Communities of Caring
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Estimates of People in Recovery (23 million)
Characteristics of People in Recovery.
Creating Environments for Recovery: Recovery
Oriented Systems of Care
22 million meet the definition of Substance Use
Disorder today in the US.
A possible “tipping point”… 7,500 (5%) in
Wyandotte County to 15,000…
Describing Recovery-Oriented Systems
14
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.
14
Planning Recovery-Oriented
System Change
15
I. Conceptual
Framework
II. Assessment/Gaps
III. Capacity
Building
VI. Evaluation
V. Development
and
Implementation
IV. Planning
15
ROSC Providers…


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Partners in the recovery process of every person
enrolled in the program.
A focal point of powerful social influences…the
recovery community, faith-based organizations,
community organizations and clinical treatment
providers.
A Recovery Hub…a touchstone for non-judgment,
caring and wellness for individuals, families and
communities.
TRI Studies
Studies show that clients in SA treatment, who also have problems
in other areas of their lives (e.g. medical, employment &
psychiatric), have better outcomes when those other problems
areas are also addressed

McLellan compared 2 groups of SA clients



Standard group received treatment as usual
Enhanced group received treatment as usual, plus referrals for help with
other problems (e.g. medical screening & parenting classes)
Enhanced group had better outcomes at 6 months



Stayed in tx longer & had higher tx satisfaction
Had fewer psychological & physical problems
Had less substance use
TRI Studies
Specifically, McLellan found:

After 30 days



After 60 days



39% of Standard group clients still in treatment
68% of Enhanced group clients still in treatment
12% of Standard group clients still in treatment
49% of Enhanced group clients still in treatment
After 6 months (unexpected finding)


60% of Standard group counselors left job
20% of Enhanced group counselors left job
TRI Studies Concluded:
Give Your Clients
Names & Phone Numbers of
Free & Low Cost Service Community Referrals!

Costs you close to nothing

Improves treatment outcomes
What does ROSC really look like?

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Statewide & Local Models
Cross system training
Cross system referrals
Usually voucher based (funding follows client)
Partial Performance Incentive
Outcome and data driven
Engagement, Retention & Continuation (NIATx)
From Acute Care to Chronic Disease
Management

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Addiction (severe alcohol and drug dependency) shares many of the defining
characteristics of chronic primary illnesses, e.g., 2 diabetes mellitus, hypertension,
and asthma.
Characterizing addiction as a chronic illness does not mean that all AOD problems
have a prolonged course requiring professional treatment, that full recovery is not
possible, or that self management responsibilities are in any way diminished.
Although long characterized as a chronic disorder, addiction has been treated in an
essentially acute-care (AC) model of treatment.
The AC model of addiction treatment is characterized by its crisis-linked point of
intervention, brief duration, singular focus on symptom suppression (achievement of
abstinence), professionally dominated decision-making process, short service
relationship, and expectation of full and permanent problem resolution following
“graduation.”
The development of the AC model of addiction treatment grew out of the
medicalization, professionalization, and commercialization of addiction treatment
and the subsequent growth of managed behavioral health care in the United States.
(White 2008)
Recovery Oriented System of Care
"The phrase recovery-oriented systems of care refers to
the complete network of indigenous and professional
services and relationships that can support the longterm recovery of individuals and families and the
creation of values and policies in the larger cultural
and policy environment that are supportive of these
recovery processes. The “system” in this phrase is not a
federal, state, or local agency, but a macro-level
organization of the larger cultural and community
environment in which long-term recovery is nested."
(William White 2008)
Sometimes…
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Treatment providers think it is an adjunct to improve
what they do…
The Recovery and Advocacy community think, finally, we
can formally share what we know works…
Faith-based Organizations think, “they are finally
seeing the light!”
RSS providers think, finally they can learn from us…we
knew we could help substance users all along!
State: How can we pay for this?
MCO’s: What? Measure? UR? Quality?
Consumers: Wow! Seriously???
Systems Integration
Systems integration is the process of understanding how things influence
one another within a whole. In organizations, systems consist of people,
structures, and processes that work together to make an organization
healthy or unhealthy.
Systems Thinking has been defined as an approach to problem solving,
by viewing "problems" as parts of an overall system, rather than
reacting to specific part, outcomes or events and potentially
contributing to further development of unintended consequences.
Systems thinking is not one thing but a set of habits or practices within a
framework that is based on the belief that the component parts of a
system can best be understood in the context of relationships with each
other and with other systems, rather than in isolation.
Wyandotte County
Population 157,505
299 Churches
54 Childcare
Agencies
17
Transportation
87 AA
Meetings
6 Housing
Agencies
Client Relationship Network
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Recovery Support Services Coordinator
Sponsor
Recovery Groups
Spiritual Guide
Clinician
Recovery Coach
SA informed cab driver, childcare provider, job
coach, financial coach, legal advisor, housing
provider
A Good and Modern System
A modern mental health and addiction service system
provides a continuum of effective treatment and support
services that span healthcare, employment, housing and
educational sectors. Integration of primary care and
behavioral health are essential. As a core component of
public health service provision, a modern addictions and
mental health service system is accountable, organized,
controls costs and improves quality, is accessible,
equitable, and effective. It is a public health asset that
improves the lives of Americans and lengthens their
lifespan.
Recovery Necessity, not Medical
Necessity
The system should include activities and services that
go beyond traditional interventions such as the
current acute care residential or outpatient services.
Coordination, communication, and linkage with
primary care can no longer be optional given the
prevalence of co-morbid health, mental health and
substance use disorders.
Remembering Who We Serve
34
•
Disability Weights
•
Internalized Oppression
U.S. Adults with a Mental Disorder
in Any One Year
Type of Mental Disorder
Anxiety disorder
% Adults
18.1
.
Major depressive disorder
6.7
.
Substance use disorder
7.0
.
Bipolar disorder
2.6
.
Eating disorders
2.1
.
Schizophrenia
.44
.
26.2
.
Any mental disorder
9
Median Age of Onset
One-half of all lifetime cases of mental illness
begin by age 14, three-quarters by age 24
 Anxiety
Disorders – Age 11
 Eating Disorders – Age 15
 Substance Use Disorders – Age 20
 Schizophrenia – Age 23
 Bipolar – Age 25
 Depression – Age 32
4
The Impact of Substance Abuse and Mental Illness

SA/MH can be more disabling than many chronic physical
illnesses. For example:



The disability from moderate depression is similar to the impact from
relapsing multiple sclerosis, severe asthma, or chronic hepatitis B.
The disability from severe post-traumatic stress disorder is comparable
to the disability from paraplegia.
“Disability” refers to the amount of disruption a health problem
causes to a person’s ability to:



Work
Carry out daily activities
Engage in satisfying relationships
10
Disability Weights
38


Stouthard et. al (1997) published weightings
for 53 illnesses of public health importance.
The World Health Organization has compared
the relative impact of different illnesses across
the world. According to this data, mental
disorders rank as the biggest health problem in
North American ahead of both cardiovascular
disease and cancer.
11
Integration
The integration of primary care, mental health and
addiction services must be an integral part of the vision.
Mental health and addiction services need to be
integrated into health centers and primary care practice
settings where most individuals seek health care. In
addition, primary care should be available within
organizations that provide mental health and addiction
services, especially for those individuals with significant
behavioral health issues who tend to view these
organizations as their health homes. Providing integrated
primary care and behavioral health services will allow for
cost effective management of co-morbid conditions.
Funding and Payment Strategies
In the public sector, individuals/families/youth with
complex mental and substance use disorders receive
services funded by federal, state, county and local
funds. These multiple funding sources often result in a
maze of eligibility, program and reporting
specifications that create funding silos featuring
complicated administrative requirements. If services are
to be integrated, then dollars must be also intertwined.
In the same way that Medicaid will be required to
streamline eligibility and enrollment, the good and
modern system must either blend or braid funds in
support of comprehensive service provision for
consumers, youth and families.
Exposure to Trauma

51 – 98% of public mental health clients
with severe mental illness, including
schizophrenia and bipolar disorder, have
been exposed to childhood physical
and/or sexual abuse. Most have multiple
experiences of trauma (Goodman et al.,
1999, Mueser et al., 1998; Cusack et al.,
2003).
Exposure to Trauma

One in four children and adolescents in the United
States experiences at least one potentially traumatic
event before the age of 16, and more than 13 % of
17-year-olds—one in eight—have experienced
posttraumatic stress disorder (PTSD) at some point in
their lives.
(National Survey of Adolescents and other studies).
44
Trauma—Adverse Childhood
Experience Study
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17,000 Kaiser Permanente Members & Partnership
with CDC
63% at least one category of trauma
20% at least 3 categories of trauma
11% emotional abuse
28% physical abuse
21% sexual abuse
19% grew up with someone in the household with MI
10% physical neglect
13% saw mother being treated violently
27% grew up w/someone using Alcohol and/or drugs
45
Trauma—Adverse Childhood
Experience Study
Internalized Oppression
46
Core Beliefs of the Addict (Paraphrased P. Carnes)
1)
2)
3)
4)
I am a bad, unworthy person
If people knew me they would not like me.
If I have to get my needs met I will have to do it
myself.
I will find something to make me feel better.
>>Internalized “self talk”
Helping Clients Navigate to Success



The companies that truly stand at the intersection of
Information Technology and the Humanities will create
the opportunities, indeed, the economies of the 21st
Century. (Steve Jobs)
The first principle of the Apple Marketing Philosophy is
Empathy, an intimate connection with the feelings of the
customer: We will truly understand their needs better
than any other company. (Mike Markkula)
Network for Improvement of Addiction Treatment’s First
Principle: Understand and involve the customer.
Navigation
The integration of primary care, mental health and
addiction services must be an integral part of the
vision. Mental health and addiction services need to
be integrated into health centers and primary care
practice settings where most individuals seek health
care. In addition, primary care should be available
within organizations that provide mental health and
addiction services, especially for those individuals with
significant behavioral health issues who tend to view
these organizations as their health homes.
Funding Considerations
ROSC Opportunities Within the Unfolding
Behavioral Health Landscape
HOW MANY SA PROVIDERS ARE
THERE?
SAMHSA
NIDA
ONDCP
50
11,246
13,000
20,000+
AND
13,918
McDonalds!
51
COMPARED TO
11,168
Starbucks!
52
Where we are now: a few relevant facts

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53
Population characteristics
Funding trends
State agency spending
MH/SA providers
Percentages of Adults with Mental
Disorders and/or Medical Conditions
54
National Comorbidity Survey Replication, 2001-2003
Average Monthly $ for Medicaid Beneficiaries w/ & w/o CoOccurring Physical Conditions (2003)
$5,000
$4,717
$4,500
$4,032
$4,000
$3,500
$3,233
$3,000
$2,739 $2,627
$2,500
$2,000
$1,601 $1,382
$1,500
$1,000
$500
$-
$2,052
$1,999
$751 $680
$212
No Costly Physical
Conditions
Mental Health Service Users
One Costly Physical Two Costly Physical Three or More Costly
Condition
Conditions
Physical Conditions
Substance Abuse Service Users All Other Medicaid Beneficiaries
Source: Medicaid Analytic eXtract (MAX), 2003
Substance Abuse and Mental Health Services Administration. (2010). Mental health and substance abuse services in Medicaid , 2003: Charts and
state tables. HHS Publication No. (SMA) 10-XXXX. Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health
Services Administration.
55
SA Funding Trends – 1986 - 2005
100%
10%
Percent Distribution
80%
9%
15%
27%
7%
60%
8%
16%
12%
40%
20%
10%
31%
21%
29%
7%
7%
12%
11%
6%
10%
7%
6%
7%
19%
20%
20%
15%
15%
14%
Private
Insurance
Other Private
Medicare
Medicaid
36%
38%
40%
Other Federal
Other State and
Local
0%
1986
$9 Billion
1992
$13 Billion
Source: SAMHSA Spending Estimates, preliminary data
56
Out-of-Pocket
1998
$14 Billion
2002
$19 Billion
2005
$22 Billion
2014 Coverage Expansion
133 – 400% FPL ($88,000
Below 133% FPL ($29,500 family)
Medicaid Expansion To
Childless Adults

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57
family)
State Exchanges

Coverage for essential MH/SA at parity for
benchmark plan

Feds pay 100% for 3 years, then down
90%

Simplified enrollment, express apps: web
too

Integrated data with State exchanges: one
application

Foster kids up to age 26
Coverage for essential MH/SA at parity &
prevention @ no co-pays
Helps individuals and small employers
with purchasing health insurance
Assist by voucher to pay premiums or cost
sharing
Develops consumer friendly tools & plain
language on insurance
One application to both exchanges or
Medicaid; can do on the web
Possible SAPT Block Grant
Changes



Static or Decreased funding
Changes in Mission
ROSC
 Encouragement
of integrated planning
 Redirection of funds towards services and persons
that Medicaid cannot pay for
58
Major Features of the SA Treatment
System

59
Financing
 More than three-quarters of funding comes from
public sources
 Primary source is state and local funding other
than Medicaid
 Federal block grant is third largest source of
public funding after Medicaid
Major Features of the SA
Treatment System

Providers
 Majority
are standalone nonprofit/government facilities
 A quarter provide residential treatment w/an
avg size of 32 beds
60
Major Features of the SA
Treatment System

61
Services
 Most often consist of abstinence-oriented
counseling/education delivered by treatment staff
with limited professional training
 A third of providers have no physician on staff or
contract
 Limited use of medication
Major Features of the SA
Treatment System

Billing/administration
 40%
of providers do not accept private
insurance or Medicaid or both
 Half have no mgd care contracts
 20% have no IT system of any kind; few have
an integrated clinical system
62
Effects - Funding



63
Overall increase in funding
Shift toward more federal financing
Transition from grant/contract funding to health plan
model
Effects - Providers

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64
Partnerships
Medicalization
Integration/diversification (FQHCs, CMHCs)
Deinstitutionalization (IMD exclusion)
Effects – State Administration

Medicaid Authorities
 Increase
in SA service users and spending
 Greater authority over provider enrollment & rate
setting
 Need to improve Medicaid SA coverage to meet 2014
benchmark requirements
65
Effects - State Administration

SA Authorities
 Shift
of half or more of service population to Medicaid
 Need to mainstream SA providers into general health
care
 Need for closer integration with Medicaid and personcentered focus
66
Effective Engagement and Accurate
Assessment
“Unless people believe it is safe enough to be
vulnerable around us, we can never really teach them
anything, for they will never let us see themselves as
they actually are.”
(paraphrased from Rudolph Dreykurs)
Conclusions



68
Parity, health care reform, and declines in state general
revenue will significantly change the behavioral health service
system, particularly the public part of that system and that
which deals with substance abuse.
Overall support for these services should expand, while
increasing the variety of providers offering such services.
Financing, administration, and delivery of these services will
become more similar to general health care, with greater
emphasis on outpatient-based programs that integrate
services.
Health Care Reform and New
Medicaid Eligibility



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
Will include non-elderly adults without dependent
children
Incomes less than 133% of the federal poverty level
2014 32 Million Newly Insured (6-10 SA, about ½
Medicaid)
15 million will remain uninsured
States will have to manage coordination of benefits
and recovery support services.
Opportunities Exercise
70
Screening, Brief Intervention and
Referral to Treatment (SBIRT)
SBIRT is a comprehensive, integrated, public health approach
to the delivery of early intervention and treatment services
for persons with substance use disorders, as well as those
who are at risk of developing these disorders. Primary care
centers, hospital emergency rooms, trauma centers, and other
community settings provide opportunities for early
intervention with at-risk substance users before more severe
consequences occur.
71
SBIRT continued
Payer Code Description Fee Schedule:
Commercial Insurance CPT 99408 Alcohol and/or substance abuse
structured screening and brief intervention services; 15 to 30 minutes
$33.41 CPT 99409 Alcohol and/or substance abuse structured screening
and brief intervention services; greater than 30 minutes $65.51
Medicare G0396 Alcohol and/or substance abuse structured screening and
brief intervention services; 15 to 30 minutes $29.42 G0397 Alcohol
and/or substance abuse structured screening and brief intervention
services; greater than 30 minutes $57.69
Medicaid H0049 Alcohol and/or drug screening $24.00 H0050 Alcohol
and/or drug service, brief intervention, per 15 minutes $48.00
72
Introduction
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Paul Wellstone and Pete Domenici Mental Health
Parity and Addiction Equity Act of 2008 (MHPAEA)
– Applies to both mental health and substance use
disorder (MH/SUD) benefits
Interim Final Regulations issued February 2, 2010 (75
Fed. Reg. 5410)
– Agencies requested comments — may issue revisions
– Most health plans will need to be reviewed and possibly
amended in light of these rules
Affordable Care Act of 2010
– Beginning in 2014, applies MHPAEA to most plans
What is Parity


Dictionary – equal or equivalent, at symmetry, not favoring one
over another, fairly matched
Parity As A Legal Construct:


A group of State Laws Beginning In the mid 1990s – Over Half of States
Have Some Form of Parity Law
1996 Federal Mental Health Parity Act:
Prohibit different annual and lifetime dollar limits
did not extend to substance use

2008 Medicare Improvements for Patients and Providers Act


By 1/1/2014 Phases out higher coinsurance for outpatient mental health care
2008 Federal Mental Health Parity and Addictions Equity Act:
Effective October 3, 2009
Regulations Effective As Policies Renew On/After July 1, 2010

2010 Health Reform Law Expands To Broader Population In 2014
(SAMHSA)
Goal of Parity

Goal Of Parity Law Is To:
 Increase
Access To Treatment
 Remove Discriminatory Financial Costs
 More Equal Treatment For These Medical Conditions
Details

The Law Stipulates:
Covered group health insurance plans that offer both medical/surgical and mental health/
substance use benefits must offer them at parity

Parity Is Defined To Include:
Financial requirements including deductibles, coinsurance, co-payments, and other cost
sharing requirements, as well as annual and lifetime limits on the total amount of coverage.
Treatment limitations include restrictions on the number of visits or days of coverage, or
Other limits on the duration and scope of treatment.

Does Not Preempt Stricter State Laws – Impact on State Regulated
Insurance
Essential Health Benefits
The Affordable Care Act ensures Americans have
access to quality, affordable health insurance. To
achieve this goal, the law ensures health plans
offered in the individual and small group markets,
both inside and outside of the Affordable Insurance
Exchanges (Exchanges), offer a comprehensive
package of items and services, known as “essential
health benefits.” Essential health benefits must include
items and services within at least the following 10
categories:
Essential Health Benefits










Ambulatory patient services
Emergency services
Hospitalization
Maternity and newborn care
Mental health and substance use disorder services, including
behavioral health treatment
Prescription drugs
Rehabilitative and habilitative services and devices
Laboratory services
Preventive and wellness services and chronic disease management,
and
Pediatric services, including oral and vision care
Regulation



MH/SUD benefits may not be subject to any
separate cost sharing requirements or treatment
limitations that only apply to such benefits
If a group plan provides for out of network
medical/surgical benefits, it must provide for out of
network mental health and substance use benefits
Standards for medical necessity determinations and
reasons for any denial of benefits relating to
MH/SUD must be disclosed upon request
Principles of Recovery Oriented Systems
of Care
Four Major Dimensions and 10 Principles of
ROSC
Attitude & Aptitude
Attitude & Aptitude
Essential Qualities for Positive
Therapeutic Outcomes
1)
2)
3)
4)
Factors related to what the client brings to the
situation (about 40%)
The therapeutic relationship (about 30%)
Expectancy and Hope (about 15%)
An explanatory system that guides the healing
practices (about 15%)
Sooooo…..
“This means that 60% of what accounts for whether or
not a person responds to treatment hinges on the
people delivering the treatment. If they develop a
positive, warm, supportive and empathic relationship,
support the development of hope that progress can
be made, have a clear rationale for what they are
doing that outlines a therapeutic map of recovery,
and empower the client to help themselves, there is
likely to be improvement.” (Bloom 2009)
Recovery
“A process of change through which individuals improve
their health and wellness, live a self-directed life, and
strive to reach their full potential.” (SAMHSA, 2011)
Four Major Dimensions of Recovery




Health
Home
Purpose
Community
Health

Overcoming or managing one’s disease(s) or
symptoms—for example, abstaining from use of
alcohol, illicit drugs, and non-prescribed medications
if one has an addiction problem—and for everyone
in recovery, making informed, healthy choices that
support physical and emotional wellbeing.
Home

a stable and safe place to live.
Purpose

Meaningful daily activities, such as a job, school,
volunteerism, family caretaking, or creative
endeavors, and the independence, income and
resources to participate in society.
Community

Relationships and social networks that provide
support, friendship, love, and hope.
Hope

Recovery emerges from hope: The belief that
recovery is real provides the essential and
motivating message of a better future – that people
can and do overcome the internal and external
challenges, barriers, and obstacles that confront
them. Hope is internalized and can be fostered by
peers, families, providers, allies, and others. Hope
is the catalyst of the recovery process.
Person Centered

Self-determination and self-direction are the
foundations for recovery as individuals define their
own life goals and design their unique path(s)
towards those goals.
Many Pathways to Recovery

Recovery occurs via many pathways: Individuals are
unique with distinct needs, strengths, preferences,
goals, culture, and backgrounds including trauma
experiences that affect and determine their
pathway(s) to recovery.
Holistic

Recovery is holistic: Recovery encompasses an
individual’s whole life, including mind, body, spirit,
and community.
Supported by Peers and Allies
Recovery is supported by peers and allies: Mutual
support and mutual aid groups, including the
sharing of experiential knowledge and skills, as well
as social learning, play an invaluable role in
recovery.
Relationship and Social Network

Recovery is supported through relationship and social
networks: An important factor in the recovery
process is the presence and involvement of people
who believe in the person’s ability to recover; who
offer hope, support, and encouragement; and who
also suggest strategies and resources for change.
Recovery is culturally-based and influenced

Culture and cultural background in all of its diverse
representations including values, traditions, and
beliefs are keys in determining a person’s journey
and unique pathway to recovery.
Addresses Trauma


The experience of trauma (such as physical or
sexual abuse, domestic violence, war, disaster, and
others) is often a precursor to or associated with
alcohol and drug use, mental health problems, and
related issues.
Services and supports should be trauma-informed to
foster safety (physical and emotional) and trust, as
well as promote choice, empowerment, and
collaboration.
Strengths and Responsibility

Recovery involves individual, family, and community
strengths and responsibility: Individuals, families, and
communities have strengths and resources that serve
as a foundation for recovery.
Respect

Recovery is based on respect: Community, systems,
and societal acceptance and appreciation for
people affected by mental health and substance
use problems – including protecting their rights and
eliminating discrimination – are crucial in achieving
recovery.
Ingredients Within Successful Recovery
Oriented Systems of Care
Ensure genuine, free, and independent client
choice…
Using ROSC as a Framework.
Recovery Oriented Systems of Care is a framework
for coordinating multiple systems, services and
supports that are person centered and designed to
readily adjust to meet the needs of the individual’s
needs and chosen path to recovery.
Harnesses and Aligns Community Healing
and Resiliency Factors

ROSC harnesses and coordinates the healing power
of clinical treatment providers, the recovery
community, the faith-based community and an array
of recovery support service providers.
Choice

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.
Strong Leadership/Central Model


Strong mission driven leadership.
Ensures each client receives an assessment for
the appropriate level of clinical and recovery
support services and is then provided a
genuine, free, and independent choice among
eligible providers.
Voucher Based Payment

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 faithbased and community-based organizations.
Outreach and Training of FBOs

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.
Incentivize for Outcomes

Maintain accountability by creating an
incentive system for positive outcomes and
taking active steps to prevent waste, fraud and
abuse.
Community Structure


Advisory Council
Monthly Provider Meetings and Data Sharing.
Leverage Existing Funding and Resources
Expand clinical treatment and recovery
support services by leveraging use of all
Federal, State and Local Funding.
 Investigate and coordinate funding for those
seeking services.
 Healthcare Navigation/Peer Supports.

Other Keys to Success




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Clear Credentialing Requirements and Process.
Set of trainings for FBOs and Recovery Support
Services Providers.
Use of GPRA/NOMS and other measures for outcomes.
Mobile assessments and assertive outreach.
EBPs such as Motivational Interviewing, CRA, CRAFT, 12
Step Facilitation Therapy & Education, Trauma Informed
Care, Matrix Model.
EBP to Introduce EBPs--NIATx.
Preparation: Process Improvement
NIATx (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.
There are agencies in all 50 states using NIATx
process improvement principles along with 25
State Substance Abuse Authorities. Free
Provider Tool Kit.
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).
NIATx 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)

NIATx Results

34.8% reduction in waiting times

33.0% reduction in no shows

21.5% Increased Admissions

22.3% Increase in continuation
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.
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
Motivational Interviewing
Client-centered approach
 Meets the client where they are at
 Self-determination
 Self-autonomy
 Non-judgmental

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

The Peer Recovery Support Specialist
PEER RECOVERY SUPPORT SERVICES
(PRSS)
Services to help individuals and families initiate,
stabilize, and sustain recovery
•Non-professional and non-clinical
•Distinct from mutual aid support, such as 12 Step
•Provide links to professional treatment and
indigenous communities of support
•Provided by peers with “lived experience” of
addiction and recovery
WHY DO PRSS WORK?
Focus on establishing trust and building relationship
•Start with a person’s strengths and Recovery Capital
•Promote recovery choices and goals through a selfdirected Recovery Plan
•Utilize recovery community resources and strengths
•Provide entry to healthcare system and services
•Elevate recovery as an expectation
BENEFITS OF PRSS
Effective outreach and engagement
•Manages recovery from a chronic condition perspective
•Stage-appropriate
•Cost-effective
•Reduce relapse
•Promote recovery reengagement
•Facilitate reentry and reduce recidivism
•Reduce emergency room visits
•Create stronger and accountable communities
WHEN ARE PRSS DELIVERED?
Across the full continuum of the recovery process:
• Prior to treatment
• During treatment
• Post treatment
• In lieu of treatment
•Peer services are designed and delivered to be
responsive and appropriate to all stages of recovery
WHERE ARE PRSS DELIVERED?
Recovery community centers
•Faith and community-based organizations
•Emergency departments and primary care settings
•Addiction and mental health agencies
•Criminal justice systems
•HIV/AIDs and other health and social service centers
•Children, youth, and family service agencies
•Recovery residences and Oxford Houses
WHERE ELSE AND IN THE FUTURE?
Emergency departments
•Primary care practices
•Patient-centered health homes
•Federally Qualified Health Centers
•Accountable Care Organizations
•Community-based alternatives to jails and prisons
•Schools & colleges
•Veterans’ centers
WHO IS PAYING FOR PRSS?
State, County, and Municipal service contracts
•SAPT Block Grants
•Federal and State grants and discretionary funds
•Other Federal funding: TANF, US Department of
Justice, VA
•Medicaid
•Managed Care
•Foundation support
•Community support
PEER RECOVERY COACH
Personal guide and mentor for individuals seeking to
achieve or sustain long-term recovery from addiction,
regardless of pathway to recovery
•Connector to instrumental recovery-supportive
resources, including housing, employment, and other
services
•Liaison to formal and informal community supports,
resources, and recovery-supporting activities
MUCH MORE THAN RECOVERY
COACHES
Peer telephone continuing support
•Peer-facilitated educational and support groups
•Peer-connected and –navigated health and
community supports
•Peer-operated recovery residences
•Peer-operated recovery community centers
RECOVERY COMMUNITY CENTERS

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
Positioning as a community institution (like a Senior Center)
•Provides public and visible space for recovery to flourish in
community: Recovery on Main Street
•Serves as a “community organizing engine” for civic engagement,
leadership development, and advocacy
•Operates as a “hub” for PRSS and recovery-related activities
•Includes participation of family members and allies in recovery
community culture, services, and programs
•Provides volunteer and service opportunities for community
members
•Positions the recovery community to interface as a key stakeholder
with the greater community
ACA





ACA Enrollment
•Outreach to the recovery community
•Uninsured people living in recovery residences,
participating in recovery community centers
(estimated over 50% are uninsured)
•Community members reentering from incarceration
•Strategic communication and tailored messaging
ACA Enrollment




Navigator contracts to recovery community
organizations or advocacy organizations to conduct
education, outreach and enrollment of hard to
reach individuals with mental illness. June 7, 2013
deadline.
•Creating venues and events to conduct enrollment
activities
•Connecting enrollees to health care services
•Keeping people in the health system once enrolled
Recovery Oriented Systems of Care Within the
Current Behavioral Health Landscape.
Policy and Practice
Introduction




Core values
Mission and vision
Recovery oriented approach
The True North
General Articles





Credentialing of Providers
Termination
Conflict of Interest
Confidentiality
Rates
Recovery Support Services;
Descriptions and Definitions



Recovery Support Service Coordination (Case
Management)
Recovery Support Service Coordinator Position
(RSSC)
Recovery Support Service Mobile Coordinator
Position (RSSMC)
Service Definitions for Recovery Support Services with
Eligibility Standards and Documentation Requirements
Childcare
Transportation
Family Support
Group/Peer Support
Housing Services
Housing Case Management
Reimbursement
Gap Fund
Gap Case Management
Reimbursement
Job Development
Mentoring
Life Skills
Physical Fitness & Wellbeing
Spiritual Support
Pastoral Guidance
Traditional Healing
Intensive Recovery Support
Aftercare
Procedures for Recovery Support Services Vouchers


RSS Coordinator
RSS Provider
Clinical Treatment Agency Model Program
Content



Service Philosophy
Basic Services Required
Required Service Mix
Roles & Responsibilities of Clinical
Supervision





Required minimally once per month
Face to Face/Individual or group
Motivational and reflective
Distinct from administrative supervision
Includes self-care plan and professional growth
plan
Provider Operating Requirements &
Procedures (1)









Voucher Eligibility, Referral and Management
Voucher Oversight
Voucher Life and Cap
Web Training Requirement
Evidence of Appropriate Business Licenses
Licensure, Certification, Credentials, or Other Staff
Qualification
Program Compliance with Health & Safety Regulations
Organizational Governance
Religious Activity & Charitable Choice
Provider Operating Requirements & Procedures
(2)









New Services
Staff Changes
Program Operating Standards
Program Rules
Code of Ethics
Protection of Individuals
Support Service Program Responsibility
Support Service Governance
Support Services
Provider Operating Requirements &
Procedures (3)



Quality Assurance
Conflict of Interest
GPRA
Personnel or Volunteer Policies

Confidentiality and Individual Records
Program Structure
Policies and Procedures
FACTORS FOR RECOVERY
Recovery-Oriented Systems of Care
Recovery Advocacy Movement
Mental Health Parity and Addiction Equity Act
Affordable Care Act
Managed Care Expansion
Criminal Justice and Drug Policy Reform Movement
Association for Recovery Community
Organizations
82 member organizations (33 states) with local, state,
and national focus
Assistance to recovery community organizations
National Alliance for Medication-Assisted Recovery
(NAMA-Recovery)
Building capacity to operate; develop leadership;
advocate and deliver peer recovery support
WHY IS IT IMPORTANT? WHAT DOES IT
MEAN?




Addiction is costly in terms of finances, physical and
mental health, family functioning, employment, and
legal involvement.
Recovery is associated with dramatic improvements in
all areas of life – better health/ finances/family
life/civic engagement/ employment coupled with
dramatic decreases in public health and safety risks.
Life keeps getting better as recovery progresses.
Policies, services, and funding are needed to help more
people initiate and sustain recovery, and for additional
research to identify effective and cost-effective
recovery-promoting policies and services.
ESSENTIAL INGREDIENTS FOR SUSTAINED
RECOVERY
HEALTH AND WELLNESS
•Safe and affordable place to live
•Steady employment and job readiness
•Education and vocational skills
•Life and recovery skills
•Health and wellness
•Sober social support networks
•Sense of belonging and purpose
•Connection to family and community
ESSENTIAL INGREDIENTS FOR
SUSTAINED RECOVERY
Safe and affordable recovery housing (substance
free)
•Some need sober group living situations
•Recovery housing for single mothers and children
•Housing discrimination against people in recovery
with criminal justice history
•Recovery housing: NIMBY issues
EMPLOYMENT, EDUCATION AND
CIVIC ENGAGEMENT
Recovery Jobs: Recovery-oriented employers and
employment programs
•Job readiness and preparation
•Opportunities to volunteer and build work histories
•Leadership development: volunteer and career
ladders
•Recovery GED programs, high schools and colleges
EMPLOYMENT, EDUCATION AND
CIVIC ENGAGEMENT
Recovery GED programs, high schools and colleges
•Community college programs for people in recovery
•Employment discrimination against people in
recovery with criminal justice history
•Restrictions on voting rights for people with criminal
justice history
OTHER INGREDIENTS
Legal assistance
•Expunging criminal records
•Financial assistance: debt, taxes, basic budgeting,
etc.
•Obtaining driver’s licenses
•Dealing with revoked professional and business
licenses
•Regaining custody of children
•Relationship and parenting skills
RECOVERY AND WELLNESS FOCUS
Shifting from a crisis-oriented, professionally-directed,
acute-care approach with its emphasis on isolated
treatment episodes…. To a person-directed, recovery
management approach that provides long-term
supports and recognizes the many pathways to health
and wellness.
ROSC
Build on the strengths and resilience of individuals,
families and communities as individuals take
responsibility for their long-term recovery, health and
wellness.
•Make services and resources available that people
can use to meet their needs
•Offer a variety of supports that work for and with
each person to restore their lives (an ongoing process)
Mobilization
Mobilizing all of the resources in our communities to:
•Change discriminatory public policies in the areas of
health care, jobs, education and housing to eliminate
barriers and support the ability of people to get into
and sustain their recovery for the long haul.
•Develop networks and systems that work together to
treat addiction as a public health problem
Mobilization
Mobilizing all of the resources in our communities to:
•Accord people in or seeking recovery dignity and
respect
•Engage people to seek help in the health system
•Help more people find and sustain their recovery for
the long-term
•Build the capacity of communities, organizations and
institutions to support recovery
Making Systems Work
Public education and awareness about addiction prevention and the
many pathways to recovery
•Greater focus on what happens BEFORE and AFTER primary treatment
•Transition from professionally-directed treatment plans to individuallydeveloped recovery plans – recovery self-management
•Greater emphasis on the physical, social and cultural environment
where people live their daily lives
•Integration of primary care, prevention, professional treatment and
recovery support
•Recovery community representation at all policy and decision making
levels
Compensation Continuum for Performance-based Payments

A shift toward increased collaboration and outcome-based payment

Requires several steps to achieve full integration

This modular set of performance-based contracting options align with a provider’s risk readiness
Compensation Continuum
(Level of Financial Risk)
Small % of financial risk
Fee-forservice
Performancebased
Contracting
• Physician
• Hospital
Patient-centered
Medical Home
Limited Integration
Moderate % of financial risk
Bundled and
Episodic
Payments
Shared
Savings
Moderate Integration
Large % of financial risk
Shared
Risk
Capitation
Full Integration
Capitation +
Performancebased
Contracting
Reimbursement Methodologies
Definition
Pro’s
Cons
Fee for Service (FFS)
Separate payment to a health-care
provider for each unbundled medical
service rendered to a patient
 Payments match services
 Complete utilization data
 Provides audit trail
 May incentivize over-utilization
 May discourage efficiencies
 Doesn’t address
quality/performance directly
Performance-Based
Contracting
Providers are rewarded for meeting
pre-established targets for delivery of
health-care services
 Incentivizes positive outcomes
 Supports improvement in quality
measures
 May encourage efficiency
 May direct provider attention only
to impacted measures
 May be difficult to evaluate
causality
Case Rate
A flat payment for bundled group of
procedures and/or services
 Controls cost per episode of care
 Decreases UM oversight
 Increased provider risk
 Incentivizes shifting treatment to
other settings/codes
Diagnostic Related
Group (DRG)
A flat payment for bundled group of
procedures and/or services
 Aggregates claims by diagnostic
category instead of lumping all
diagnoses into one case rate
 May result in premature
discharge or under treatment
 May incentivize making cases
more complicated
Capitation
A set payment for each enrolled
person assigned to a provider or
group of providers, whether or not
that person seeks care, per period of
time
 Predictable and stable costs
 Reduces billing
 May promote under-treatment or
selection incentives
Achieving the Triple Aim
Improved Population Health, Quality and Affordability
These are the fundamental avenues of focus for improving care and outcomes,
and enhancing employee health
Triple Aim
Payment
Reform
Performance-based contracting
and other more sophisticated
reimbursement approaches as
providers’ sophistication
matures
Facilitates provider quality and
accountability
Employee Responsibility/
Incentives
Consumer Tools/Transparency
Centers of Excellence
Benefit tiering/high performing
networks
Helps members make informed
choices
Population
Analysis
Sophisticated Analytics
Intra-provider incentives
Electronic Health Records that
allow Provider
Interoperability
Consumer support tools
Facilitates total population
management
Direction from Health and Human Services/Center for
Medicare/Medicaid Services

HHS and CMS are facilitating the following strategies as a major focus of
Health care reform:

Public Reporting: engaging consumers and others stakeholders

Health Information Technology: enabling improvement

Value-Based Payment: rewarding achievement

Clinically-Integrated Delivery Systems: achieving patient-centered, coordinated care



The Department of Health and Human Services in setting the stage for health care reform has commissioned
the National Quality Forum to aid in the development of a national measurement strategy.
NQF will be convening a behavioral health workgroup to examine and assimilate measures.
Performance-Based Contracting – At A Glance
Incentivizing provider performance leads to better outcomes for consumers
Sample Facility
Participation
Requirements

•
•
•
Sample Metrics
• Reduction in Average Length of Stay
• Reduction in 30 day Readmission rate to any inpatient LOC
• Improved results on ambulatory follow-up rates (7 days post inpatient discharge)
Sample Performance
Incentives
Demonstrated use of Evidence-Based Practices (EBP)
Qualifies as High-Volume provider
Participates in periodic meetings with clinical operations staff to review data
Submits claims electronically
• Facility will earn escalator based sharing of savings if performance is within targeted range
• Facility will earn performance bonus for achievement of quality metrics
Recovery Oriented Systems of Care Within the
Current Healthcare Landscape
Outcomes, Options and Transformations
Quality Measures
If addiction is a chronic illness requiring sustained
monitoring, support, and early re-intervention,
can the current acute-care model of addiction
treatment provide such continuity of support over
an extended period of time?
Quality Measures






a recovery-focused organizational culture;
adequate capitalization, funding diversification,
availability of funding streams that enable sustained
support, and financial stewardship;
stability of organizational ownership;
administrative and clinical leadership and workforce
stability;
recovery representation at policy and clinical decisionmaking levels;
Quality Measures




Recovery-focused performance measures include three dimensions of
systems evaluation: 1) measures of infrastructure stability and adaptive
capacity, 2) recovery-focused service process measures, and 3) long-term
recovery outcome measures.
Infrastructure stability and adaptive capacity reflect the capacity of an
organization to undergo systems-transformation processes (e.g., from an AC
to an RM model of care) and the capacity of an organization to fulfill its
commitment to continuity of contact and support over time for individuals
and families seeking long-term recovery.
Recovery-oriented service process measures (e.g., early identification,
engagement, retention, etc.) are intermediary outcomes that are linked to
the final goal of long-term individual and family recovery.
Long-term recovery outcome measures represent the major fruits of
recovery, defined here as the resolution of alcohol and other drug
problems, the progressive achievement of global (physical, emotional,
relational) health, and citizenship (life meaning and purpose, selfdevelopment, social stability, social contribution, and elimination of threats
to public safety).
WHAT DOES LONG TERM RECOVERY LOOK LIKE? LIFE IN
RECOVERY SURVEY
Alexandre Laudet, PhD
Understanding the experiences of people in recovery
should inform this opportunity.
•Build recovery-oriented communities where the services
and supports that people identify that they need are
available – when they are needed.
•First nationwide survey of people in recovery from
alcohol and other drug problems.
•3,228 participated.
•44 items representing experiences and indices of
functioning in work, finances, legal, family, social, and
citizenship domains “in active addiction” and “since you
entered recovery.”
Outcomes and Successful ROSC




IAIA
Access to Recovery Data
Philadelphia
Connecticut
Institute of American Indian Arts



90% of students indicated that the Healing Circle
Program improved their college experience.
Students said that the program was conducive to
learning, creative expression and human wellness.
There was a 100% drop in suicide attempts from 3
per semester to 0 during the 2 year term of the
Healing Circle Program.
Incident reports related to alcohol or drug use
dropped 95% during the Healing Circle Program.
Access to Recovery





At six months post intake, 80.4% were abstinent from
substance use.
At six months post intake, 46.5% reported being stably
housed.
At six months post intake, 49.8% reported being
employed.
At six months post intake, 90.8% were socially
connected (attended self help groups or had someone
to whom to turn in times of trouble).
At six months post intake, 96.0% reported no
involvement in the criminal justice system.
Connecticut

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Short-term housing;
•
Transportation;
•
Faith-based services;
•
Basic needs (food, clothing, etc.);
•
Case management;
•
Childcare; and
•
Vocational and educational services.
Connecticut Peer Services

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Telephone recovery support;
•
Family/community education;
•
Family support groups;
•
All-recovery groups;
•
Volunteer training;
•
Recovery training;
•
Peer-operated transportation company;
Connecticut Partners
Department of Corrections
•Judicial Branch
Department of Children and Families•
Department of Social Services•
Primary Healthcare Sites (Hospital ED & FQHC Sites)•
DMHAS-funded Outreach & Engagement Urban
Initiatives
Connecticut
Wisconsin
Wisconsin
Wisconsin
Data Management System
Allow clients to choose and change network providers;
• the capture of all client information, including GPRA
outcome data;
• the generation and monitoring of vouchers; and,
• individual providers billing services rendered to the
ATR client.
New Mexico
Moving Forward!
A Recovery Oriented System of Care in
Wyandotte County
Getting Started…
Planning Recovery-Oriented
System Change
184
I. Conceptual
Framework
II. Assessment
III. Capacity
Building
VI. Evaluation
V. Development
and
Implementation
IV. Planning
184
A Meeting of Key Stakeholders and
Interested Community Members






Next steps…
Grants?
Coalition?
Action Plan?
Learning Collaborative?
Further Training?
Thank you!
Jim Clarkson
(505) 944-5284
Jim.Clarkson@Prodigy.Net
Final Quiz!