Ask the Expert
Providing a Continuum of Care: Improving Collaboration Among Services
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Ask the Expert:
Thomas. A Kirk, Jr., Ph.D, Commissioner of the Connecticut Department of Mental Health and Addiction Services
- At times, health insurers will limit the amount of coverage in terms of effecting a life-time option to certain procedures or interventions. Will the parity of care for MH/SA services among some health insurers also be limited? If so, will those limitations serve as a status quo aspect in the context of reducing or limiting access to care, especially among high-need underserved populations?
Answer: Last fall, Congress passed the Mental Health Parity Act of 2008 that is scheduled to go into effect January 1, 2010. The law will end inequity in health insurance benefits between mental health/substance use disorders and medical/surgical conditions in health plans covering more than 50 employees. Under the legislation, 113 million Americans will have the right to health care parity, including 82 million people enrolled in self-insured ERISA plans. While the new federal law does not mandate that MH and SA coverage be included within a health plan, if the plan contains such coverage, the coverage limits must not differ from those set for medical/surgical conditions. Thus, plans that contain coverage for mental health and substance use treatment are required to have the same deductibles, copayments, coinsurance, out-of-pocket expenses, treatment limitations (including the number of visits, days of coverage, life-time limits - if any, etc.) as exist for general health care coverage within that plan. This applies to inpatient and outpatient coverage.
- When do or should people access recovery management?
Answer: At any and all stages of their journey in recovery depending on their need, including before they are ever in treatment or if they choose not to be in formal treatment. Recovery coaches or peers can serve as highly effective stabilizing influences to help the person make a decision re treatment. Persons who are well into their recovery journey, maybe long out of any formal treatment and/or association with AA or NA can benefit from recovery management services in a manner consistent with their personal status. The role of various forms of recovery management during treatment and immediately after are clearly important tools to sustaining one’s recovery. See the notation and citation below in question V re the Telephone Recovery Support service provided by people in recovery in Connecticut.
- Since recovery is fluid and dependent on an individual’s life circumstances, how do we measure recovery?
Answer: Outstanding question! There is no one path to recovery as implied by this question. Further, one can choose to assess or measure recovery from the view of the person, from the perspective of the service provider or from the view of the state agency who funds and operates the whole system. Each is likely to be different. That said I expect the questioner is interested in it from the view of the person receiving the service.
What have we explored to date? One early approach was to ask people what they wanted or what recovery meant to them? One slide included in the presentation cited in question VI below offered some responses: getting well/better, having same rights as others, doing everyday things, staying clean and sober, looking forward to life, be looked at as whole people, starting over again, making changes/having goals, making choices, having hope.
A later consideration weighed assessing recovery in accord with SAMHSA Administrator Charles Curie’s and SAMHSA’s matrix: Recovery involves having or attaining a decent place to live, something worthwhile to do, and a life in the community. The latter includes a social life in the community or as some say ‘a date on a Saturday night.’ Those are quite straight forward goals and indices.
An approach that we include in our annual (six years so far) mandatory Consumer Survey is five questions under a Recovery Domain. They are: In general, I am involved in my community. In general, I am able to pursue my interests. In general, I can have the life I want, despite my disease/disorder. In general, I feel like I am in control of my treatment. In general, I give back to my family and/or community.
The other domains included in the 28 item survey are: general satisfaction, access, participation in treatment, quality and appropriateness, respect, outcome, and recovery.
Our most recent annual survey included an extra instrument, the World Health Organization Quality of Life survey. Some clients/patients/consumers were comfortable and liked it and others found it (or at least some of its questions) too intrusive. Despite that we received solid data and we included it our latest survey as an option. For more information re this contact James.Siemianowski@po.state.ct.us. Complete information and results re our annual surveys are available at the DMHAS website at www.dmhas.state.ct.us. Once on the front page of site, click on “Consumer Survey” located on the right side of the page.
A major focus or strategy in the last few years is emphasizing person-centered planning which, in the course of such, the person identifies those goals or areas of preferred or most importance to their treatment and recovery journey. That will give the most direct and succinct view of the person’s sense of how their recovery is progressing at a point of time. For more about out person centered work, go to www.dmhas.state.ct.us and click on DMHAS Presentations on the top of the front page. Drop down to one or two presentations labeled: “Person-Centered Care and Planning: Policy to Practice to Evaluation.” It is a presentation by me and Janis Tondora on June 8, 2007 at the Annual Meeting of the Mental Health Association. Another is “Consumer-Centered Practice: An Implementation Case Study” a presentation by me and Janis Tondora on October 27, 2008. Ms. Tondora can be reached at Janis.tondora@yale.edu.
Another major avenue we are pursuing is a document titled “Practice Guidelines for Recovery-Oriented Care for Mental Health and Substance Use Conditions.” It is a 169 page document. We recently released the second edition and it is available for download off of our website also. It assesses recovery-oriented care on six domains, each tied to the Institute of Medicine quality approach and another dimension we believe is critical. It includes indicators that can be used for measurement purposes. A good contact for this document prepared for DMHAS by a group under contract to DMHAS is Larry.Davidson@yale.edu.
Recovery-Oriented Care is:
- Consumer and Family Driven
- Timely and Responsive
- Person-Centered
- Effective, Equitable and Efficient
- Safe and Trustworthy
- Maximizes Use of Natural Supports and Settings
- You stated that we need to normalize recovery within the larger health care field; how do we do this? In a larger ROSC system, is there need to normalize recovery in other systems? If so, what are these and how does this occur?
Answer: The data are quite clear that a large part of the general population has some type of life long, continuing care or chronic health condition, e.g. diabetes, problematic blood pressure and so on. In the course of discussing treatment of these conditions, it is quite common or “normal” to describe sustained effective control of them being achieved by adherence to a combination of medication, diet, exercise or other appropriate interventions. Some describe this scenario as disease or chronic care management. This perspective clearly implies that it is the responsibility of the person to manage these life-long health conditions. “Recovery” is not the term or descriptor normally used or applied. It should be.
I believe our field would be better served and the stigma too often associated with substance use and/or mental health conditions would be eased if we described and thought about these conditions the same way (“sustained effective control”) as with diabetes, cardiovascular problems and so on, i.e., if we “normalized” it. On the other hand “recovery” is a term common to our field and we believe that recovery is a life-long journey. However, for too long in my opinion, we have emphasized substance use conditions as “chronic relapsing disorders.” The implication, at least for the general public, is that few will ever get better. It feeds the sense of failure, lack of hope and expectation for improvement on the part of the person. That being the case, why would anyone come to a care setting or health system that did not clearly offer the hope of the person getting better?
A recovery-oriented system of care (ROSC) is one which offers a person the tools or interventions to achieve sustained effective control of their condition or disorder. The larger health field can learn from us and “normalize” their policies, practices and communications by incorporating the language of “recovery” and “recovery oriented system of care” into their framework. Similarly, we can “normalize” into our recovery and ROSC orientation the concept, policies and practices of disease or chronic care management leading to sustained effective control of substance use conditions.
- How does Connecticut fund and/or reimburse for recovery-oriented services?
Answer: We believe that formal treatment and the traditional levels of care are one of the sets of tools that are included in a ROSC and that a person can choose to use for sustained recovery. Thus, they are funded in either in our traditional grant or in a fee for service format. Treatment is thus a part of versus separate from and after traditional treatment.
Quite a few years ago, we were able to set aside a very modest fund for what we called “basic needs.” It came about when Connecticut instituted its welfare reform initiative. Rather than continuing the approach of giving a cash payment each month to enrollees, it was ended as part of the reform. Instead a pilot treatment program was instituted in a few areas of the state for persons with substance abuse care needs and, as part of that, limited funds could be used to support items such as short term temporary housing. The person had to be in treatment to be eligible and it was handled by fee for service. That pilot led to the establishment of what is now known as the General Assistance Behavioral Health program (GABHP).
Subsequently, the first Access to Recovery (ATR) grant application process was released by SAMHSA. Our experience with the above noted pilot program prepared us for generating ideas for an expanded array of recovery-oriented services as well as how to fund and monitor them. Being awarded the first of our two ATR grants ($22 million) around August 2004, we allocated a major share to recovery support services which we believed were critical to helping a person to sustain their recovery. Among those included were funds for: transportation vouchers, housing, employment-related needs (e.g. tools, trade licenses), job training, child care, some services provided by faith-based agencies, education (e.g. tuition for course, books), clothing and personal care items, and so on. All of these and others had to be for time limited periods and at no greater than a designated frequency.
Our experience with ATR I and the expanded menu of recovery support services was extraordinarily successful in drawing new people into care, in re-engaging others and in generally demonstrating the role of recovery support services as an essential component of a care system that had the concept of recovery as its core. Approximately 17,000 different persons were served through ATRI, thousands beyond the goal we had set.
Now involved with our ATR II grant ($15 million) as of September 2007, our experiences are the same and more refined. An even greater proportion of our focus is on recovery support services though we have limited the range due to the reduced funding. Among the especially noteworthy options are Telephone Recovery Support calls provided by persons in recovery associated with the Connecticut Community for Addiction Recovery.
The beauty of the ATR efforts, among other factors, is that our Governor and Legislature are increasingly comfortable in allocating more non-grant state funding to the “recovery support services” of our fee for service GABHP. Thus, some types of services that were covered under ATR I have been picked up through state funding.
The success has also led the Governor and Legislature to positively respond to the idea of a funded “Discharge Fund ” which can be flexibly used to wrap certain types of support services around an individual being discharged from the hospital.
A further source of funds for our recovery-oriented service system come about from a quality enhancement/innovation/reinvestment model we use. It is based on targeting quality initiatives that focus on persons who are high users of costly acute care services, e.g. inpatient or residential detox, inpatient hospital care. The savings in funds currently committed to paying for such services come about because of providing alternatives to such persons that yield sustained and improved care for the persons such as intensive case management, recovery coaches and other interventions being provided to those persons. Those acute care savings are reinvested in expanded recovery support or other innovative parts of a recovery-oriented system. So, it is not new money but better use of existing money.
In sum, varied sources of new and conversion of existing funds have been used to add new elements and better use of existing services to promote our Recovery-Oriented System of Care. Further, the federal grants such as ATR have served as research and demonstration tools to teach us how to better use our existing funds. That said, once the grant ends, we can retool current funding rather than dropping everything because the grant is over. Moreso than ever, it is not about spending more or less money. Rather it is about spending our funding differently.
For highly informative one page INFO Briefs published by DMHAS re all of the above, go to www.dmhas.state.ct.us, click on Information Briefings near the top of the front page and go to the ones listing for 2009 as follows:
- “Telephone Recovery Supports: We Call Because We Care.” June 9, 2009
- “ATR II: Path to a Better Future.” May 20, 2009
- “Quality Healthcare: A Good Investment.” February 25, 2009
- “A Healthcare Investment: Better Value for the Dollar.” February 18, 2009.
I also suggest that those interested in the above should again also go to the DMHAS website and, on the top of the first page, click on DMHAS Presentations. Go to the one titled “Facilitating Addiction Recovery Using Healthcare Financing” presented by Paul DiLeo of DMHAS and dated July 8, 2008.
- How did Connecticut transform its system? What is your number one lesson learned regarding the implementation of a recovery-oriented system? What would you have done differently in the implementation of a recovery-oriented system? How would you tell a city, county, regional or state system to start the process of transforming its own system?
Answer: One of the more comprehensive presentations I have done re the transformation to date of our system was done June 2, 2008 at the National Institute on Drug Abuse Blending Conference in Cincinnati, Ohio.
The PowerPoint presentation used can be retrieved off of the DMHAS website at www.dmhas.state.ct.us. Once at the opening page of the site, click on to DMHAS Presentations at the top of the page. Then proceed down to the above mentioned document. It addresses several of the questions raised and more.
In particular, the document covers our approach to a “Continuing Care, Long Term Recovery Management System.” It addresses why we made the system shift, what routes were taken, financing and reinvestment strategies used, current and potential outcome measures, lessons learned – good and bad, types of recovery support services, and the question of should we focus solely on evidence based practices or attend more to a evidence informed recovery management service SYSTEM.
As to why we made the shift to a recovery-oriented model, it was because the traditional system perpetuates stigma, used an acute care model that is costly and often wrong, involved disproportionate funding allocations, less than meaningful outcome measures, sent a weak message to funders and policy makes and is too often viewed as an irrelevant and ineffective system of care.
Probably the number one suggestion I would give to any group starting the journey and the key lesson we learned was: start by listening to people in recovery as to what they expect and want from our addiction service system. Back in 1999, we gathered together two groups of people in recovery - one from the mental health community and another from the addiction recovery community. They worked together (amazingly given the history of tension between the two fields) to develop a succinct document “Recovery Core Values.” It listed the 24 values in four categories: Participation, Funding-Operations, Programming, and Direction. In review of the two slides in the NIDA presentation, it is clearly evident that those 24 Values are as appropriate for 2009 as they were 10 years ago.
Another slide in the presentation is “Ct Implementation Process.” It graphically details the journey from the Core Values in 1999 and the Recovery Policy in 2002 to the various tiers of activities including the major grant fund awards we used as “research and development” tools. Additional system change tools are listed: Policies, values, Infrastructure, Practice Requirements/Guides, outcomes and finance strategy.
Do differently? Work during the first few years (2000-2002) was done within DMHAS but with as a special task and DMHAS staff separate from the day to day operations of the agency. We should have considered meshing operations and the recovery development work a little sooner. Understand that one key challenge is that much of this whole transformation is akin to redesigning a plane in mid flight
The last few slides in the presentation summarize the challenges along the way, the policy/operational and planning challenges, other key challenges and opportunities, and four take home messages.