http://www.behavioral.net/ME2/Console/XmlSyndication/Display/RSS.asp?xsid=87102F18170C49E7AC5E1288029FEE22 Behavioral Healthcare Current Articles http://www.behavioral.net/ME2/dirmod.asp?type=Publishing&mod=Publications%3A%3AArticle&mid=64D490AC6A7D4FE1AEB453627F1A4A32&tier=4&id=6F36A5B1171B4E38AAFD918C4D2657A5 One of the greatest impediments to success in any treatment program is the shame faced by many individuals with substance use problems.  In an NCAD presentation called “Sex Positive Treatment: Where Angels fear to tread,” psychiatrist Doug Braun-Harvey, PhD cited research saying that individuals with “strong sex-drug linked” addictions carry twice the burden of shame into treatment. They also face a higher likelihood of dropping out of treatment, due to the inability of treatment programs and counselors to acknowledge and work with sexual behaviors linked to substance use.  Sex-drug links can occur in a variety of ways, explained Braun-Harvey.  He cited a number of examples:  a young heroin user, whose first dose caused an intensely emotional experience that triggered her first orgasm—a sensation she associated with the drug; another young woman who traded sex for money to fund her substance use; or users who employ substances to increase libido, prolong sex, or enhance the sexual experience. “Sex negative attitudes are an impediment to some high sex-drug linked addictions,” says Braun-Harvey. “Sometimes, people are ready to recover from substance use, but get held back” by programs that ignore or avoid discussion of sexual behavior, says Braun-Harvey, who advocates a “sex positive” approach.  “There’s a dilemma about sexual health information. Our culture dictates that, within a room, the person who is most uncomfortable about the issue can limit the conversation.”  As a result, “we avoid it [sex] until we can’t avoid it any longer,” said Harvey-Braun, noting that the omission affects treatment programs and counselors alike. But sexual health issues can’t be avoided, he maintains, since individuals with sex-drug linked addictions face a greater likelihood of failure.  In fact, by speaking up within the treatment setting about their behaviors, they may face judgment from their peers or counselors, or perhaps even a diagnosis or referral as a sex addict.  In a number of cases, such “sex-negative” environments may lead to expulsion of the individual from treatment. The solution, pioneered at the Stepping Stone treatment center in San Diego, makes sexual health a central issue in the treatment program, enabling program participants to deal directly with the sexual issues linked to the substance use.  For those with a high sex-drug linked behavior, this process seemed to provide a logical and necessary first step toward successful substance use treatment.  Braun-Harvey theorized that the sex-positive approach helped consumers to mitigate the remembered intensity of the sexual behavior associated with drug use—one set of relapse triggers, just as the treatment process itself helps to mitigate the consumer’s response to the substance—the other set of triggers. Using a sex-positive approach the new approach, Stepping Stone cut the dropout rate in its long-term (six to nine month program) from 70 percent to just 10 percent.  (See Why we talk about sex .)  That program incorporates a sexual health inventory and regular, frank group discussions that enable consumers to have open, positive discussions that build knowledge and understanding about sexuality and the motivations that typically drive human sexual behavior.  Braun-Harvey, who trains sex-positive counseling techniques, is the author of a new book, Sexual Health in Drug and Alcohol Treatment .  Fri, 10 Sep 2010 00:00:00 EST 6F36A5B1171B4E38AAFD918C4D2657A5 http://www.behavioral.net/ME2/dirmod.asp?type=Publishing&mod=Publications%3A%3AArticle&mid=64D490AC6A7D4FE1AEB453627F1A4A32&tier=4&id=1790992B280546C786BEB89564958D66 For a population that only six to seven percent of treatment centers are targeting, according to a recent SAMHSA report, lesbian, gay, bisexual, and transgender populations (LGBT) have some of the highest rates of substance use disorders (SUD). However, as Petros Levounis, MD, MA, director of the Addiction Institute of New York, pointed out in his breakout session at NCAD this afternoon, information on this population hasn't been readily available until recently. This session was one of several dedicated to LGBT treatment at NCAD. “We haven't had much information on addiction in LGBT until the NESARC study in 2004-2005,” he told attendees. The NESARC study revealed conflicts in patients' reports on sexual identity, attraction, and behavior: While only two percent identified themselves as LGBT, same-sex or both-sex attractions and behaviors were reported at higher rates. “People who resolve their attractions have lower SUD rates than those whose sexual identity is more complex,” Levounis said, drawing on conclusions from a separate 2009 study. “We don't know yet what this will tell us down the line.” But one thing is clear: SUD is up to 20 percent more prevalent in LGBT populations, and addiction treatment must tailor their services to meet their needs. LGBT drug behaviors Levounis focused much of his breakout session on the significant role played by crystal meth in LGBT SUD. While ecstasy, ketamine, GHB, and cannabis had been linked to LGBT drug use in the past, Levounis pointed out that there are “now more [crystal meth users] than heroin and cocaine combined.” While this populations' vulnerability to SUD is linked to their sexual identity or behavior, the reasons behind LGBT populations' heavy use of crystal meth are associated with their sexuality as well.  Though crystal meth is used heavily in rural areas because of easy opportunities for creation, LGBT populations use the drug to enhance sexual experiences. In fact, Levounis showed that dopamine levels during sex increase up to 500 percent when using crystal meth. “It's hard to convey to patients that sex and sobriety will be as exciting,” he said. “We must modify the way we talk to patients.” LGBT-affirmative treatment When it comes to treating LGBT patients for crystal meth addiction, Levounis said that addiction professionals have historically relied on the Matrix Model, or as he calls it, “the kitchen sink.” Instead of relying on every treatment in the book, he suggested cognitive behavioral therapy, motivational interviewing, and especially contingency management (CM). Through the use of CM, the therapist assumes that the patients will continue to use, but rewards them with vouchers, such as gift cards to restaurants or movie theaters, whenever their drug tests are negative, even if they aren't consistently negative. “It's a 21st century treatment,” he said. “Rich and poor patients respond to it.” Attendees were both surprised at and receptive to Levounis' recommendation of CM. While one attendee suggested that the best reward was the counselor's “acceptance of continued using and the huge relief” associated with that acceptance, another said that achieving these rewards or milestones brings pride to patients working toward recovery. The power of a supportive environment Whatever the reason behind its effectiveness, Levounis maintained that CM is a “powerful intervention for treatment of crystal meth.” But, he said, even the most effective treatments must be delivered in supportive environments to ensure their success. He told attendees to consider what happens both inside and outside of treatment, pointing out that non-clinical staff can have negative effects on LGBT patients if they are not accepting. He recalled the first LGBT clinic he worked at didn't fare well, and later, staff realized the homophobic receptionist may have driven patients away. “It doesn't take much for people to recognize unfriendly clinics,” he said. Other LGBT-specific sessions at NCAD include “What Everyone Needs to Know When Working With Sexual Minorities,” facilitated by Joe Amico, MDiv, CAS, LISAC, president of NALGAP, and “Trauma Sensitive Treatment and Legal Issues/Concerns for the GLBT Population With a History of Relationship, Trauma, and Community Violence,” facilitated by Philip T. McCabe, CSW, CAS, CDVC, DRCC, vice president of NALGAP, London J. Bell, JD, Affirmations Healthcare coordinator, and Cheryl D. Reese, president of EDUCARE Systems, Inc. Thu, 09 Sep 2010 00:00:00 EST 1790992B280546C786BEB89564958D66 http://www.behavioral.net/ME2/dirmod.asp?type=Publishing&mod=Publications%3A%3AArticle&mid=64D490AC6A7D4FE1AEB453627F1A4A32&tier=4&id=2905358FE7F6415A98D2CAD5E7FD3B74 A session presenter at this week’s National Conference on Addiction Disorders (NCAD) urged clinicians working with adolescent clients to explore as much as possible the family dynamics that have shaped youths’ experiences. In his own work with adolescents, “I want to know more about the family than I want to know about them,” said Jeb Bird, regional administrator at the White Deer Run treatment organization in Pennsylvania, a CRC Health Group facility. Bird said he generally finds the youths with whom he works very bright and creative, and often highly injured by their family systems. “I’ve seen so many parents drop off their kids for treatment and then take a three-week vacation,” he said. Many of the children perceive that their parents don’t care about their welfare. Bird acknowledged that insurance restrictions on treatment lengths of stay pose one of the most difficult barriers to clinical success with youths. Discussing the four-week stay typical of White Deer Run’s inpatient program for youths, he said, “What can you do with someone in four weeks?” He added, “It would be great for most of these kids to have six months away from their environment.” He mentioned that transitional/sober homes for youths are sorely needed and represent a significant business opportunity for treatment organizations. Bird spoke on engagement strategies for youths with co-occurring substance use and mental health disorders. He said there are no standardized treatment interventions for this young client population, and added that analyzing which disorder had the earlier onset in a particular individual doesn’t tell him much. “Which came first doesn’t matter to me, because I really don’t care,” he said. “It’s pretty hard to tease that out,” in part because adolescents aren’t that accurate in relating their history. Thu, 09 Sep 2010 00:00:00 EST 2905358FE7F6415A98D2CAD5E7FD3B74 http://www.behavioral.net/ME2/dirmod.asp?type=Publishing&mod=Publications%3A%3AArticle&mid=64D490AC6A7D4FE1AEB453627F1A4A32&tier=4&id=DE4966CBD65F4619AB08883FF2C5B0C9 In a move that some see as opening the door to uniform licensing standards for substance use counselors, a new commission will begin establishing procedures for the first-ever accreditation of addiction studies education programs at the undergraduate and graduate level. Attendees of the inaugural National Conference on Addiction Disorders (NCAD) learned of the formation of the National Addiction Studies Accreditation Commission at a Sept. 8 luncheon meeting led by NAADAC, The Association for Addiction Professionals. Representatives of NAADAC and the International Coalition for Addiction Studies Education (INCASE) signed an agreement that formally launches the commission. In an exclusive interview with Behavioral Healthcare , NAADAC President-Elect Donald Osborn emphasized the financial support of the Substance Abuse and Mental Health Services Administration (SAMHSA) in encouraging a process that would lead to curriculum and scope-of-practice standards for addiction counselors at all levels. A collaborative committee spearheaded by NAADAC and INCASE leadership has worked for more than three years on this initiative. Osborn said of SAMHSA, “They know that for this profession to survive, and not be absorbed into social work, psychology, or something else, we need a curriculum. That will establish an addictions profession.” Osborn said his own involvement in this effort was fueled by comments made to him several years ago by a state legislator in his home state of Indiana. The lawmaker scoffed at the idea of licensing counselors, telling Osborn that addiction counseling could be considered no more than a subspecialty because it did not have a standardized curriculum and scope of practice. “That lit a fire in me,” Osborn said. The new commission’s goals are to establish a national standardized curriculum for counselors at the associate’s, bachelor’s, master’s and doctorate levels. Osborn said he believes it will be about a year before education programs will be able to begin the process of seeking accreditation. He told the NCAD audience, “We’re entering into a new era in the addictions profession.” Osborn added that some of the work that organizers have completed drew from curriculum standards developed in Indiana, which recently adopted a counselor licensure law that is gaining national attention. He said he also closely studied the process of developing scope-of-practice standards for marriage and family therapists, who are now licensed professionals in all 50 states. Osborn considers this week’s announcement a major development in the effort to convince more state legislatures to embrace licensure for addiction counselors. Plenary speakers At the conference’s opening plenary session, the deputy director of the National Institute on Drug Abuse’s (NIDA’s) Office of Science Policy and Communications sought to get attendees “jazzed” about scientific developments that could improve clinical practice. Lucinda Miner, PhD, also may have helped coin a new word for the field in describing an intervention that could assist recovering persons with relapse triggers. Miner said that through use of a GPS system to record the whereabouts of an individual, that person could receive an encouraging message via Twitter when he/she enters an area that could intensify the urge to drink. That, in essence, would constitute “Tweetment.” Miner announced that in November NIDA will sponsor a National Drug Facts Week that builds on a one-day “chat” event for schoolchildren that in its first year attracted 36,000 questions to experts on drug topics. The Nov. 8-14 event is designed to meet a growing appetite for science-based information among young people, she said. “We realize that scare tactics don’t work with kids,” Miner said. “They need a reliable source for science-based information.” H. Westley Clark, director of the federal Center for Substance Abuse Treatment (CSAT), used part of his morning plenary talk to discuss the impact of the new health reform law, at a time when the discussion in Washington has turned largely to whether the law could be repealed after the November mid-term elections. Clark argued that “when the Baby Boomers see the cost of ‘no insurance,’” they may change their mind [about opposing the Affordable Care Act].” Clark discussed the many ways in which the act will lead to integration with primary medicine. He also lamented that the field has much work to do in preparedness, after a disappointing show of hands from questions he posed about how many attendees possess advanced electronic health record capabilities or have established working relationships with community health centers. “We under healthcare reform will no longer have to suffer healthcare apartheid, with mental health and substance abuse somewhere ‘over there,’” separated from the rest of the delivery system, Clark said. The Sept. 8-11 NCAD meeting in Washington, D.C. is being presented by Vendome Group, publisher of Addiction Professional and Behavioral Healthcare magazines, in collaboration with NAADAC, INCASE, the National Association of Addiction Treatment Providers (NAATP) and NALGAP, The Association of Lesbian, Gay, Bisexual and Transgender Addiction Professionals and Their Allies. Wed, 08 Sep 2010 00:00:00 EST DE4966CBD65F4619AB08883FF2C5B0C9 http://www.behavioral.net/ME2/dirmod.asp?type=Publishing&mod=Publications%3A%3AArticle&mid=64D490AC6A7D4FE1AEB453627F1A4A32&tier=4&id=DCA4E71B32C445B7BDC394A18C3589D7 Gathering steam from director of the federal Center for Substance Abuse Treatment (CSAT) Dr. H. Westley Clark's morning plenary on integration, Michael Miller, MD, FASAM, FAPA, gathered with addiction professionals in an afternoon breakout session to discuss the emerging roles of physicians in addiction treatment. Miller, who is the medical director at Rogers Memorial Hospital's Herrington Recovery Center in Wisconsin, agreed with Clark, telling attendees that the specialty care delivery system works for some, but misses much of the population affected by addiction. "As Clark said, [specialty care] is not where doctors practice, and it's part of stigma," Miller said.  But healthcare reform aims to change that by investing the majority of funding into federally qualified health centers (FQHCs), which will integrate primary care and addiction services through the co-location of services or consults.  "Addiction must be treated in primary care," he said. Physicians face paradigm shift The specialty care delivery system that the majority of addiction professionals work in will be affected by healthcare reform's emphasis on integration, but it's unlikely that they'll be skeptical of its benefits. On the other hand, Miller pointed out, physicians may need more convincing. "The biggest failure of American medicine is to appreciate addiction as a brain disease," he said. "Education has failed doctors in regard to understanding what these issues are all about." However, Miller sees hope in the effectiveness of pharmacotherapies for withdrawal, detox, and addiction, including naltrexone, buprenorphine, methodone, and nicotine replacement therapies. These therapies medicalize the process of addiction treatment and finally “allow doctors to be doctors." "I was in the business of subtraction, and now I'm adding medications," Miller said. "This changes doctors' thinking." New roles, new partnerships With this new attitude toward addiction, physicians will be responsible not only for providing direct treatment to patients, but for implementing Screening, Brief Intervention, and Referral to Treatment (SBIRT) in their practices as well.  Though SAMHSA has funded SBIRT initiatives since 2007, Miller estimated that four out of five doctors still don't recognize or acknowledge addiction. “Some have never heard of case finding by SBIRT,” he added. In addition to screening, physicians working in integrated care will also be responsible for providing what Miller calls the five A's: “ask, advise, assess motivational level, and arrange follow-up.” One attendee pointed out the possibility of physicians hiring addiction professionals to screen patients for addiction, to which Miller responded by citing a study that showed non-physicians achieved better outcomes in similar efforts. Another attendee added that their organization staffs a counselor at a primary care facility part-time just to screen patients, saying that “it works great.” Miller sees these types of multidisciplinary teams as another staple of effective integration in the wake of healthcare reform.   Miller will also facilitate a breakout session tomorrow, Sept. 9, at NCAD. This session will focus on new opportunities available for providers through integration, healthcare reform, parity, and information technology. Wed, 08 Sep 2010 00:00:00 EST DCA4E71B32C445B7BDC394A18C3589D7 http://www.behavioral.net/ME2/dirmod.asp?type=Publishing&mod=Publications%3A%3AArticle&mid=64D490AC6A7D4FE1AEB453627F1A4A32&tier=4&id=FA8DD8042CA74A82AD34088CB0040E2C A new report, developed by a group of 65 prominent figures representing all aspects of the behavioral healthcare field, calls on government agencies to implement five recommendations to drive ongoing health system reforms essential for serving adults with serious mental illness (SMI).  According to the report, adults with SMI, who comprise just six percent of the U.S. population, rank among the highest-cost Medicaid beneficiaries, yet die an average of 25 years sooner than the general population, often from preventable, co-occurring diseases including asthma, diabetes, cancer, and heart disease. The report grew out of a November 2009 forum, the National Action Meeting on Fostering System Reform for Adults with Serious Mental Illness, which was hosted by Ron Manderscheid, Executive Director of the National Association of County Behavioral Health and Developmental Disabilities Directors (NACBHDD). The meeting was funded by Janssen Pharmaceuticals, which, under recently passed federal laws, had no input on the planning, conduct of, or conclusions reached by the forum. The goal of the meeting was simple, Manderscheid explains: to clearly define needed solutions for adults with SMI, together with a “practical agenda with a reasonable chance of adoption by Congress and the Obama Administration.” On the eve of health reform, meeting participants sought to unite around strategies that could reshape the nation’s approach to mental health service delivery, improve system and service efficiency, and greatly improve individual outcomes.  From among 18 proposed recommendations, participants selected five recommendations that are now the focus of a concerted advocacy effort. These, recommendations, detailed in the report, are: 1. Design and implement, through HHS, a robust set of performance measures, including consumer measures, with risk adjusted financial incentives. 2. Close the 25-year gap in life expectancy by designating adults with SMI as a “health disparities group” through action by Congress and relevant agencies within HHS. 3. The federal government should require and provide incentives for an electronic health record that supports behavioral health content. 4.  Federally sponsored primary care medical homes should be required to include behavioral, substance use, and mental healthcare. 5. The federal government should define medical necessity to align with research on the range of services required by persons with serious mental illness. “This report represents the consensus of the field,” says Manderscheid, who explains that the recommendations are the basis for “work on regulations—mostly with federal agencies. Our focus will be on impacting regulation, agency practice, and implementation in the field.” He adds that, beyond the recommendations, there’s also consensus around a new approach by behavioral healthcare to integrate with the rest of the U.S. healthcare system, a key component of system-wide reform.  “The world has changed. Adults with serious mental illness used to be treated as a separate group,” he explains. “The feeling was, ‘SAMHSA takes care of this group.’” But that’s all changed now. One big example is the recommendation to designate adults with SMI as a “health disparities population,” a change that, according to Manderscheid, “no one has ever talked about before.” Though such a designation would require action by Congress and HRSA (the Health Resources Services Administration), it would result in tracking and monitoring of disparities encountered by adults with SMI by HRSA and create new opportunities to focus HRSA and other federal resources to address these disparities.  Among other likely outcomes that would result from implementation of the report’s recommendations are: • Standardized definitions of service, outcome measures, and performance measures across states and within licensing and practice standards. • Consistent access to behavioral health information needed by healthcare providers for continuity of care or emergency care • Reduced fragmentation and duplication of services, as well as improved outcomes, through more individualized care within Person Centered Medical Homes or Person Centered Healthcare Homes. • A national definition of “medical necessity” that sets a national standard for all payers to follow by paying for a scope of services that meets the needs of individuals with SMI, service providers, and payers. For additional details, consult the complete report, Recommendations to Foster System Reform for Adults with Serious Mental Illness . Thu, 02 Sep 2010 00:00:00 EST FA8DD8042CA74A82AD34088CB0040E2C http://www.behavioral.net/ME2/dirmod.asp?type=Publishing&mod=Publications%3A%3AArticle&mid=64D490AC6A7D4FE1AEB453627F1A4A32&tier=4&id=33D482FDC7324A84A9EBDD9DDCE73251 Government funding cuts and uncertain times for private philanthropy have combined to force the planned closing of New Leaf, a San Francisco behavioral health agency specializing in services for the gay and lesbian community. But New Leaf’s imprint will remain noticeable long after its mid-October departure, particularly at the many nonprofit agencies where staff members once received training as New Leaf interns. “We trained thousands of clinicians to work with the LGBT community,” says Thom Lynch, who became interim director of New Leaf 10 months ago. Two years of budget cuts from the city and county of San Francisco, in combination with challenges to maintain needed levels of private fundraising, led to the decision to close New Leaf after 35 years of operation. The organization, which offers both addiction and mental health services, is in the process of ensuring continuity of care for its clients by parceling out its various programs to other service agencies. Lynch believes ongoing funding uncertainties make this a good time for human-services organizations to consider mergers and other consolidation arrangements, although factors such as New Leaf’s debt and union contract obligations made such a move impossible for his agency. “People need to look into becoming leaner machines,” Lynch says. “We probably need a few less executive directors, boards and development directors.” He adds that with so many nonprofit agencies in the San Francisco area, private donors feel challenged in terms of what causes they can reasonably support. “Donors are overwhelmed by the number of requests they receive,” he says. New Leaf is working closely with local government leaders to ensure that the public dollars that supported its programs remain in the community, Lynch says. The agency has seen numerous changes in the human-services arena, having been founded at a time when the American Psychiatric Association (APA) still formally considered homosexuality to be an illness. Lynch says that with many LGBT organizations now funneling their dollars to political causes such as marriage equality, it is a precarious time for agencies that specialize in human services and supports for this population. Wed, 01 Sep 2010 00:00:00 EST 33D482FDC7324A84A9EBDD9DDCE73251 http://www.behavioral.net/ME2/dirmod.asp?type=Publishing&mod=Publications%3A%3AArticle&mid=64D490AC6A7D4FE1AEB453627F1A4A32&tier=4&id=BC6397FA13794E138C83EED3C5B41D07 Today marks the debut of the inaugural National Conference on Addiction Disorders (NCAD), a comprehensive event with programs and tracks that deal not only with behavioral health and addiction treatment, but also administration, finance, technology, and medical professional issues. The conference is founded and produced by Vendome Group, the publisher of Addiction Professional and Behavioral Healthcare , along with: • NAADAC, the Association for Addiction Professionals; • The National Association of Addiction Treatment Providers (NAATP); • The International Coalition for Addiction Studies Education (INCASE); and • The National Association of Lesbian, Gay, Bisexual, Transgender Addiction Professionals and Their Allies (NALGAP). The editorial team at Behavioral Healthcare and its sister publication Addiction Professional are onsite at the Hyatt Regency in Crystal City to bring you up-to-the-minute coverage of NCAD from Sept. 8 to 11, 2010. Whether you’re missing out on this year’s conference or joining us in Crystal City, check out ongoing coverage of the NCAD conference here: Historic accreditation announcement delivered at NCAD conference Reform shapes physicians' role in addiction treatment NCAD speaker: To help the adolescent, understand the family Paving the way for progress Sex positive treatment Tue, 31 Aug 2010 00:00:00 EST BC6397FA13794E138C83EED3C5B41D07 http://www.behavioral.net/ME2/dirmod.asp?type=Publishing&mod=Publications%3A%3AArticle&mid=64D490AC6A7D4FE1AEB453627F1A4A32&tier=4&id=5BE20354D2C24481B2D98C4A8469FEC7 Long before word processors gave us the luxury of tracking our text edits for the next reader, Bill Wilson, founder of Alcoholics Anonymous (AA), passed around 400 physical copies of his recovery doctrine for revisions and suggestions. Afterward, he and a few of his colleagues copied the most significant of those contributions onto one manuscript, which would eventually become the AA Big Book —a text used faithfully by addiction professionals and those in recovery since its first publication in April 1939. The Big Book went on to sell over 20 million copies worldwide, but the original manuscript and its many contributions remained hidden from public view. It was stored in Bill and Lois Wilson’s home until 1978, when Lois passed the manuscript on to friend Barry Leach, who maintained its privacy for 30 more years. The manuscript eventually went up for auction in 2007 and was secured by Ken Roberts for $850,000. Roberts then presented the manuscript to Hazelden, who will release the book in two editions, one cloth and one leather-bound, this October. “It’s arguably one of the most important books of the 20th century as it relates to addiction and recovery,” says Nick Motu, senior vice president of Hazelden and publisher at Hazelden Publishing. “To those that use the Big Book and the 12 Step process as core to their profession, it would be very interesting for them to understand what went into the conceptual beginnings of the 12 Step model of treatment.” The manuscript shows text revisions and comments inked in a variety of colors, indicating the work of four to eight core contributors that Hazelden will identify in its release this fall. “Readers … will see the rejected suggestions, inserts, crossed-out comments, and then last minute changes,” Motu says. Along with the original manuscript, Hazelden’s editions will include: • Comments from leading archivists in the margins; • Two essays by Big Book and AA historians; • Annotated notes on the text; • A publication timeline; and • A 1954 speech by Bill Wilson on the making of the Big Book . Debate over spirituality uncovered Though it’s no secret to the addiction profession, much debate arose over how AA would present its principles, which relied heavily on religion. “Of special interest in the manuscript will be the debates that occurred … over the role of religion and spirituality in AA,” says Motu. “Bill Wilson really was adamant about making AA spiritual rather than religious, and you will see that not only in the comments of those that were accepted but also of those that were rejected.” For example, on the opening page of Chapter 5, one contributor noted that ideas in the text “should be studied from the mold angle.” Fred Holmquist, historian and director of Hazelden’s The Lodge Program, attributes this commentary to the fellowship’s fear of triggering newcomers’ religious prejudices. “It talks about their understanding that religions sometimes pour people into a mold, and it’s a little bit one-size-fits-all,” he says. “Typically, alcoholics had not found relief from alcoholism in their religions, yet some had, but the idea was that they did not want to arouse religious prejudice that already existed in people.” Page 30. Revisions to the first page of Chapter 5: How it Works, featuring Steps 1 through 9, show the internal debate between AA members over the use of religious language and references. To view a larger version of page 30 the original AA Big Book manuscript featuring the 12 Steps, click here. Similarly, another contributor makes a note of “His Divine Consideration” across the bottom of the page near Step 9, which states, “Made direct amends to people wherever possible, except when to do so would injure them or others.” To Holmquist, this reference is still obscure, but he has some speculations. “If it’s referencing Step 9, then the idea of doing what you need to do unless it will injure them or others would be a matter of Divine Consideration,” he says. “They were avoiding the density of religious-sounding language, and that would be an example of somebody maybe noting what spiritual or religious principle it represented, simultaneously written in pragmatic language.” From “prescribing” to “describing” a program of recovery Widespread changes in the manuscript signal AA’s decision to avoid prescriptive language—such as “you should do this”—in favor of descriptive language—such as “we did this.” Holmquist says this typifies AA’s strategy of addressing the newcomer with gentleness and accessibility while maintaining respect for the medical community. “They were respecting the attitude of the newcomer as perhaps being defensive or quick to run,” he says. “Also, to other professionals, it was clear they took out specific references that could make the authors sound like they were prescribing medical or psychiatric or psychological recommendations.” Holmquist attributes the original use of a prescriptive voice as the result of the founding members’ sincerity and seriousness about their program of recovery. “Their heart was right, but they realized in looking at it that it would probably be overwhelming for a newcomer to look at and think, ‘I have to do all of this stuff,’” he says. “So they just reverted to sharing what they did, which is what I think is at the heart of attraction not promotion.” Page 31. Revisions to the page featuring Steps 10, 11, and 12 show a shift from the use of prescriptive to descriptive language. The passage, “If you are not convinced of these vital issues, you ought to re-read the book to this point or else throw it away,” was circled in red and removed from the final version of the Big Book. To view a larger version of page 31 of the original AA Big Book manuscript featuring the 12 Steps, click here.   This is evident in the paragraph following the final step on page 31, where the original text read: “You may exclaim, what an order! I can’t go through with it!” The contributors changed this to, “Many of us exclaimed,” which allows the newcomer to share in the original AA fellowship’s own experience of feeling overwhelmed by the program’s requirements. “These people realized it was far more pragmatic to … settle for doing a little bit better each day,” Holmquist says. “That’s why the idea of this being both a program of action and a fellowship is so important, because you get so much from the combination of both versus just one.” Thu, 26 Aug 2010 00:00:00 EST 5BE20354D2C24481B2D98C4A8469FEC7 http://www.behavioral.net/ME2/dirmod.asp?type=Publishing&mod=Publications%3A%3AArticle&mid=64D490AC6A7D4FE1AEB453627F1A4A32&tier=4&id=C49E32DA23FE4BC6990380C10E82D213 Behavioral healthcare providers have two key issues at hand: meeting the requirements of healthcare reform and addressing the funding shortages which have all but put them out of business. In a way, these two issues can be resolved together, and last week, the National Council for Community Behavioral Healthcare told over 400 providers how during its free webinar, “Are You Ready to Become a Federally Qualified Health Center (FQHC)?” Led by Pamela J. Byrnes, PhD, Director of Health Center Growth and Development at the  National Association of Community Health Centers, Inc. (NACHC), the webinar covered requirements for becoming a FQHC, which is a comprehensive health provider that receives both grants and enhanced Medicaid and Medicare reimbursements. With integration of primary and behavioral health services a requirement of healthcare reform, a provider’s pursuit of FQHC status could be the solution it needs to stay afloat financially and keep up with industry changes. Criteria for FQHC status Last week’s announcement of $250 million in available grant funding for New Access Points by the U.S. Department of Health and Human Services (HSS) presents a perfect opportunity for behavioral health providers to start looking toward the future as a FQHC. Whether an organization already satisfies many of the requirements or simply has a solid plan to do so, a provider at any stage that meets or plans to meet basic criteria can apply for FQHC status with the Health Resources and Services Administration (HRSA). “The more compliant and operational you are, the likelier you are to get funded,” Byrnes said. “But paper starts do get funded.” According to Byrnes, the basic criteria for meeting FQHC status are: • Be a nonprofit or public entity and a Medicaid/Medicare provider; • Operate as a Community Health Center serving medically underserved areas or populations as outlined by the federal government, OR operate under The Health Center Program as a Migrant Health Center, Health Care for the Homeless Program, or Public Housing Primary Care Program; • Adhere to Board of Directors governance requirements; • Provide primary, preventive, supplemental, and case management services; and • Adhere to access, staffing, and organizational management requirements. Providers are also able to achieve FQHC “lookalike” status, which means that they aren’t eligible or funding isn’t available for grants under The Health Center Program, but they have met basic criteria to receive the enhanced Medicaid and Medicare reimbursements. Byrnes’ advice As the NACHC’s Director of Health Center Growth and Development, Byrnes helps providers through the application and readiness process, as well as provides training and technical assistance to current FQHCs. It’s only natural, then, that she’s picked up a few tricks along the way, and she shared them with webinar participants. Understanding medically underserved designations. Byrnes cleared up any assumptions for her behavioral health-centric audience from the get-go: persons with mental illness are not considered medically underserved populations. In fact, no disease is considered a population; rather, these designations are reserved for income status or ethnicities, among others. Similarly, Byrnes pointed out that providers may be closer to medically underserved areas than they may think. For instance, she said that though a provider may not reside within an underserved area, they can still be considered as long as they can prove their location is accessible to the underserved area. To find medically underserved areas in your state or county, use the HRSA’s Find Shortage Areas online tool . Putting your board together. FQHCs must follow strict guidelines for the formation of a governing board of directors in order to maintain their status and integrity. For instance, Byrnes said that of the nine to 25 board members required, a majority must be consumers of the FQHC’s services. “This works because the people who receive the care drive the bus,” she said. In addition, she pointed out that no more than half of the non-consumer members may make more than 10 percent of their income in the healthcare industry. Providing primary care. According to Byrnes, FQHCs are required to provide basic primary and preventive services, including oral health, as well as “supplemental services,” which include mental health and substance abuse services. In addition, FQHCs must provide case management services to consumers in order to link them with needed community resources. This can pose a significant challenge for behavioral health providers who often have little experience integrating with other services. Byrnes said that contracting with other providers could be a good alternative, although having “that provider in the health center for some amount of time per week” is essential. In addition, Byrnes noted that “[focusing] in on the core primary care services” is a good start for providers who lack comprehensive offerings, and told participants to keep in mind that there are different required services for different populations. Making services accessible. Along with the provision of sliding-fee discounts based on consumer income, accessible locations, convenient hours of operation, and discharge planning, Byrnes made the requirement of after-hours coverage for FQHCs quite clear. “A recording telling folks to go to the ER does not cut it,” she stated in bold, red lettering on her accompanying PowerPoint slide. In order to provide this continuous, round-the-clock care, Byrnes noted that it is expected that the FQHC will establish linkages with other community-based services. However, she added that FQHCs must “assure that whatever linkages are developed do not affect [their] integrity.” Competing with other FQHCs. Members of the webinar audience voiced concern that with other FQHCs nearby, their chances for receiving funds were slim. However, Byrnes adamantly disagreed, and pointed out that Austin, T.X. alone had 26 FQHCs. “Why?” she asked the participants, answering, “Because they all serve different medically underserved populations.” Though she admitted that the competition will be fierce for the 350 New Access Point grant recipients, she reiterated that achieving FQHC status is not impossible, no matter where you are. “[You can] demonstrate adequate unmet need, or that you’re responding to a need another FQHC is not, or justify why more services are necessary,” she said. “There is no ownership of service areas.” Byrnes suggested that providers can “get started by contacting state primary care associations and neighboring FQHCs to see where [they] fit in.” To view the webinar in its entirety, visit The National Council for Community Behavioral Healthcare’s Webinars . It is available at no cost to viewers. Tue, 17 Aug 2010 00:00:00 EST C49E32DA23FE4BC6990380C10E82D213 http://www.behavioral.net/ME2/dirmod.asp?type=Publishing&mod=Publications%3A%3AArticle&mid=64D490AC6A7D4FE1AEB453627F1A4A32&tier=4&id=0A5C52DBA58B4CAF9F0562B3A2809E19 These days, it’s tough to find a social service agency that is adding services rather than cutting them. But the Cook County Sheriff’s Office, serving the Chicago metro area, has found a way—and for less than $2,000. Through its newly developed Alumni Association outreach program, the Cook County Jail’s Day Reporting and Pre-Release Centers (DRC/PRC) network substance users, either on probation or awaiting trial for non-violent crimes, with program alumni committed to recovery.  Though the jail has several programs dedicated to substance use treatment, including a 449-bed intensive inpatient program, Bob Mindell, director of Treatment Contract Services in the Department of Community Supervision and Intervention at the Cook County Sheriff’s Office, says that there are few accessible aftercare services. Once men complete their three- to six-month stay, they are released back into the community, and back to old circles of friends. “For guys who have been involved with what our guys have been involved in, they have a negative social network; it’s a gang or apparatus for selling drugs,” Mindell says. “So if they come out and their only resource is that social network, they’ll go back to doing what they were doing before.” Role models for re-entry After noticing a strong bond among six participants who had successfully completed the program and achieved recovery from substance use problems, program directors sought to extend their recovery success to new participants. The new program invites successful alumni to network with recovering participants, helping them to build more positive social circles. Though it has informally existed for years, the DRC/PRC Alumni Association was formed in late 2009 to begin planning the outreach program, which was launched at a ceremony last Friday.   Cook County Sheriff Thomas J. Dart speaks at the kick-off ceremony for the Alumni Association.   “We looked at the Alumni Association as the support group that could help men make the transition from the treatment program here back into the community,” Mindell says. “It’s really that first month or two that’s going to determine whether people are successful, and if they’re not able to make that bridge, it’s very easy for them to fall back into old patterns.” Since its formation, alumni have returned to the DRC/PRC to meet with participants, helping them to continue good habits developed in treatment following their release. Often, this includes invitations to local to AA and NA meetings that alumni regularly attend in the community. “When I went to 12-Step meetings at first I didn’t really understand it,” says Lee McClain, a DRC/PRC alumni of 11 years and counselor at the Cook County Jail. “What encouraged me was the alumni, the same guys that were coming to talk to us and I had learned to trust, saying, ‘Come with us.’” Through the new program, the DRC/PRC hopes regular interaction with alumni will not only support participants are they prepare to reenter the community, but as they attempt to achieve another goal of recovery: finding gainful employment. The Cook County correctional system offers vocational services to help participants secure jobs or training post-treatment, but Mindell has found his program’s “social network” model to be much more effective. “We know from surveying people that most of those who come out of this program and find work [do so] through relatives or other people they know, not through some sort of vocational service,” he says. “Particularly people who might consider themselves middle class, they’re more likely to be reaching out to their network than going to a vocational program.” McClain agrees, and notes that his own job hunting efforts were ineffective after leaving the DRC/PRC. “All the jobs I got came from alumni members and word of mouth,” he says. “They gave me hope, which is what I really needed.” In the future, the DRC/PRC also plans to extend the Alumni Association’s work into family and relationship support—an area of concern for many in current programs. While reinitiating ties with parents, spouses, or children that have suffered as a result of substance use may be difficult, alumni can serve as role models to help ease tensions or share first-hand experience. “We’re increasingly trying to plan activities around this,” Mindell says. “It’s important for these guys at some point to show their family they’re doing well and are committed to doing well.” Low cost, high credibility Mindell points out that the idea of relying on a social network for recovery support goes against the traditional social services model of referring those in need to public services. But to him, it’s just as effective—if not more so. Members of the Alumni Association accept certificates from Sheriff Dart.   “[Social services] is becoming a more difficult model for everybody to operate, partly because of shrinking public dollars,” he says. “But even when there is a lot of money, that’s not the only tool available.” Through a small amount of funding—about $2,000 total—from grants and vendors, the DRC/PRC has been able to fund the alumni outreach program, along with a kick-off cookout for 600 people. “It’s basically a free program,” he says. Recent and long-time alumni are recruited to the program through monthly mailings and e-mailings, as well as informal “phone tree” networks, while current DRC/PRC participants are brought in through informational meetings prior to re-entry. In all, there are about 45 active alumni, and as the association grows, committees will be modeled in the structure of a 12-Step program for referral, recreation, bylaws, and the like. While all in the Alumni Association are volunteers, they are just as effective as full-time staff, says Mindell. “Alumni who have been through the program and have become successful have high credibility with guys struggling with the same issues. When [alums] who have come from where they come from talk to them about recovery, it’s believable to them and those guys are role models.” September will mark the program’s inaugural weekly open support meeting, where DRC/PRC participants will meet with alumni to talk about personal issues and essential skills for successful community re-entry. These will be similar to 12-Step meetings, and in the future, the Alumni Association hopes to schedule support meetings throughout the Cook County area. Other social development activities, such as sober family parties, are also in the planning stages. “This is not just a cheap program but a very effective program,” Mindell says. “People are used to thinking we can’t do anything because we don’t have any money, but that’s not the only way help is given to people.” Thu, 12 Aug 2010 00:00:00 EST 0A5C52DBA58B4CAF9F0562B3A2809E19 http://www.behavioral.net/ME2/dirmod.asp?type=Publishing&mod=Publications%3A%3AArticle&mid=64D490AC6A7D4FE1AEB453627F1A4A32&tier=4&id=F3D2273DCEAC4690806FFA9E4BD672BA Shortly after noon Thursday, the U.S. Senate passed an amendment to an earlier House-approved measure to extend a temporary increase in the Federal Medical Assistance Percentage (FMAP), the federal match for hard-hit state Medicaid programs. As part of the American Reinvestment and Recovery Act, Congress temporarily boosted the FMAP by 6.2 percent from fiscal year 2009 through the first quarter of FY 2011, which ends in December. Upon House approval of the amended Senate measure, a $16.1 billion appropriation will fund extension of a “phased down” 3.2 percent increase in FMAP funding to states through the first quarter of 2011, and a 1.2 percent increase through the end of June. House approval is expected soon, since House Speaker Nancy Pelosi yesterday asked House members to cut their summer recess short and return to Washington, where a vote on the measure is scheduled for Tuesday, August 11. While state governors originally hoped for a six month extension of the full 6.2 percent FMAP enhancement, budget hawks in the Senate would not support it, says Michael Bird, federal affairs counsel for the National Council of State Legislatures. “We got the six month extension we had hoped for, but we got a lower matching rate, to make the bill affordable to those on the other side of the aisle.” While the money will make a dent in cumulative state budget gaps that exceed $80 billion for FY 2011, states that face balanced budget requirements continue to “do what they’ve got to do to make up the rest of the shortfall,” says Bird. “We’re talking about three consecutive fiscal years of very sizable budget gaps that have taken nearly every state way beyond the low hanging fruit, right into the muscle of their biggest ticket programs—Medicaid, public health, education, public safety, human services—where the bulk of their budget goes.” At the state level, “it’s a ‘shark tank’ situation—who’s going to get hurt the worst, or are cuts going to be shared more equally?” He notes that Nevada, California, New York, Florida, Wisconsin, and Rhode Island are among the states with “the worst numbers.” The outlook is improving, but only slowly. “In terms of financial recovery, the states are usually 12-24 months behind the national picture,” says Bird, with some recovering faster, others slower. “What we’re reporting as good news now is that the revenue numbers [for FY 2011] don’t seem to have deteriorated below the FY 2010 numbers, for the most part.” While this may indicate a “bottoming out on the revenue side,” Bird says that there’s a lot of trouble left behind, from all of the cutting and revenue raising that has already taken place. “A FY 2011 number that’s equal to FY 2010 may be ‘good news,’ but the FY 2011 number now may be equal to what you had in ’06 or ’07, and you’re still expected to be doing all of the same things.” He sees “another year or two” of budget cutting, revenue raising, capital project delays, furloughs, and other painful adjustments at the state level.  “It’s going to take a lot to come out of this.” Thu, 05 Aug 2010 00:00:00 EST F3D2273DCEAC4690806FFA9E4BD672BA http://www.behavioral.net/ME2/dirmod.asp?type=Publishing&mod=Publications%3A%3AArticle&mid=64D490AC6A7D4FE1AEB453627F1A4A32&tier=4&id=56254010C1624D4FA084AF4868182989 Behavioral Healthcare , the professional journal serving the executive, clinical, and operating leadership of mental health and substance abuse centers nationwide, is pleased to announce its list of 2010 Behavioral Health Champions: • Franklin D. Lisnow, Executive Director, CeDAR (the Center for Dependency, Addiction, and Rehabilitation) at the University of Colorado Hospital, Aurora, Colo. • William J. Sette, President and CEO, Preferred Behavioral Healthcare of New Jersey, Lakewood, N.J. • Denise Bertin-Epp, President and Chief Nurse, Brighton Hospital, Brighton, Mich. • Robert E. Whaley, Executive Director, Southeast Behavioral Health Group, LaJunta, Colo. • Gary Van Nostrand, President and CEO, SERV Behavioral Health System, Inc., Ewing, N.J.     The 2010 Behavioral Health Champions (from left to right): Gary Van Nostrand, Denise Bertin-Epp, William J. Sette, Robert E. Whaley, and Franklin D. Lisnow These champions, nominated by their peers and selected by the editorial team of Behavioral Healthcare magazine, rank among the most active and accomplished executives and leaders in the fields of community mental healthcare and substance abuse treatment and recovery. Each will be recognized at an awards luncheon in Washington, D.C. at the National Conference on Addiction Disorders (NCAD) on September 10, 2010. “These champions, and the organizations they lead, continue to make great contributions to all those struggling to recover from serious mental illness, mental trauma and substance use disorders across the United States,” says Dennis Grantham, senior editor of Behavioral Healthcare magazine. “Each has played an important role in leading, or reinventing, approaches that help thousands, from young children and teens to adults and military veterans, to recover and reclaim their lives.” Programs led by the 2010 Champions have: • Blazed new trails in recovery-oriented services for those suffering from serious mental illnesses, including effective, community-based treatment; • Expanded the reach of behavioral health services into the realm of law enforcement, providing youthful offenders with the guidance and support needed to set a positive course;   • Built supported-housing, education, and employment programs that have helped thousands to recover their lives, families, and ability to live independently in their communities; • Developed integrated approaches for substance-use disorder treatment that have helped thousands of people achieve and maintain sobriety; and • Influenced the selection and adoption of key measures of quality and treatment effectiveness, as well as their measurement through the use of health information technology. Profiles of the 2010 Behavioral Health Champions will be available in the July/August issue of Behavioral Healthcare or in the BH Champions menu tab found at www.behavioral.net .  Thu, 29 Jul 2010 00:00:00 EST 56254010C1624D4FA084AF4868182989 http://www.behavioral.net/ME2/dirmod.asp?type=Publishing&mod=Publications%3A%3AArticle&mid=64D490AC6A7D4FE1AEB453627F1A4A32&tier=4&id=BF7960A774914332AADB5572A35E146A Torn between fear of voters and fear of deficits, the Senate this week passed a $30 billion, 99-week extension of unemployment benefits for jobless Americans. However, the bill, which is awaiting President Obama’s signature, was amended by the Senate to remove a provision that would have continued to provide states with even a scaled-down version of the “enhanced” federal medical assistance percentage (FMAP).  “I expect that FMAP is dead for now, at least until after the election,” said Ron Manderscheid, executive director of the National Association of County Behavioral Health Directors, in an exclusive interview with Behavioral Healthcare. He predicted that state governors, dozens of whom have counted on an extension of the enhanced FMAP payments to narrow unprecedented budget shortfalls in FY 2011, will continue to press Senators on the issue, hoping to win an extension of enhanced FMAP funding in the Senate’s post-election lame duck session.  The enhanced FMAP, which at present boosts the percentage of federal matching funds paid to states based on their Medicaid expenditures by at least 6.2 percent (more for high-unemployment areas), started in FY 2009 to help cash-strapped states meet the expenses of their Medicaid programs during the recession. Without Senate support, this additional funding will expire on December 31, 2010.   Would the loss of enhanced FMAP funding in 2011 have an effect on your behavioral health organization? Let us know in the comments section below. Thu, 22 Jul 2010 00:00:00 EST BF7960A774914332AADB5572A35E146A http://www.behavioral.net/ME2/dirmod.asp?type=Publishing&mod=Publications%3A%3AArticle&mid=64D490AC6A7D4FE1AEB453627F1A4A32&tier=4&id=F67985CAC6BF49BF97E14BCB4D173C76 Before a crowd of about 800 at this year’s State Associations of Addiction Services (SAAS) and NIATx Summit, three key officials—SAMHSA administrator Pamela Hyde, ONDCP deputy director Tom McLellan, and NIDA division director Wilson Compton—highlighted federal efforts and initiatives that will impact funding, care methodologies, care delivery, and technology implementation for providers of behavioral health and substance use treatment services now entering into what Hyde called “the brave new world” shaped by national health reform and parity. Now, Part II—continued from last week’s online exclusive .  Compton calls for “medicalizing addiction” Noting the huge disparity between the estimated 23 million Americans who meet diagnostic criteria for substance use disorders and the 2.3 million currently in treatment, Compton outlined a new vision for mainstreaming addiction into general medicine, or as he said, “medicalizing addiction.” “We’ve got to go there or we will be left behind in terms of improving public health and making an impact on the wide range of social costs and consequences of addiction,” said Compton.  At present, however, two problems stand in the way: a lack of awareness among individuals with substance use problems and a lack of follow-up by physicians. “People don’t think they’re addicted, even though they meet diagnostic criteria.  But they’re showing up somewhere—emergency rooms, for example—and doctors aren’t picking it up,” said Compton.  “ER and primary care doctors often see addiction as more of a social disease, not a medical problem.” McLellan agreed, stating that doctors could pick up on substance use issues through brief screening and interventions.  “Just two or three questions can help a doctor identify patients who are drinking too much or using too often.  Although these patients represent just 20 percent of the primary care population, they represent 50 percent or more of the visits to ERs and trauma centers.” The key, he added, is to “let doctors know that they can do it” and to support additional screening and intervention by simplifying paperwork and increasing payments.  “If they look carefully, they’ll see that it’s often the excess alcohol use that’s screwing up their treatment for diabetes; the undiagnosed marijuana use that’s screwing up treatment for asthma; so it is very much in the interest of better healthcare.” Compton presented study results that showed even modest interventions could have health impacts.  One study showed that, among patients presenting with substance use concerns, a 10-minute peer intervention helped significantly reduce substance use rates over a six-month period.  Even a visit to primary care—without the peer intervention—led to improvements over the longer term.  “It’s clear that SBIRT and similar approaches can make a difference in all kinds of settings, all over the world.”  For that reason, Compton said that NIDA has been increasing funding for SBIRT-related studies since 2008. McLellan: Serve the 90 percent who are now unserved Both speakers agreed that primary care providers must expand their role in first-level addiction treatment.  Despite a wide range of available therapies—CBT, MBT, community reinforcement/family training—and medications, McLellan says that many addiction treatment providers lack the professional personnel (doctors, psychiatrists) and range of training necessary to administer these more complex treatments.  To help fill this gap, McLellan said that the government is turning to 7,000 federally qualified health centers (funded by HRSA), and 250 more centers funded by the Indian Health Service.  “They have the people, the infrastructure, and the EHR systems to implement this approach.  Now, we’re asking that they focus on it.” McLellan pointed out that “they’re not going to be taking your funding, your treatment opportunities, or your business referrals.”  He said that they would “bring in new patients” from among the 90 percent who remain unserved. “If this program works, then primary care doctors who do not now know how to treat substance use disorders will learn.  And if they’re unsuccessful in first-level treatment, they’ll make referrals to specialty care centers like yours—that is, if you have a relationship with them, if you can bill Medicaid, if you have the ability to handle electronic health records and, therefore, to meet their needs.  It’s a new line of business, folks; you’re not losing anything, you’re going to gain.  And what the country’s going to gain is whole lot more access and availability of care where the rest of healthcare is delivered.  That’s the plan.” Wed, 21 Jul 2010 00:00:00 EST F67985CAC6BF49BF97E14BCB4D173C76 http://www.behavioral.net/ME2/dirmod.asp?type=Publishing&mod=Publications%3A%3AArticle&mid=64D490AC6A7D4FE1AEB453627F1A4A32&tier=4&id=D1E24AF445F74AA5968000514DA60C00 After the Louisiana Department of Health and Hospitals (DHH) twice asked BP for $10 million in funding to support expanded mental health services in Gulf Coast areas affected by the Deepwater Horizon oil spill and received no reply, the National Alliance on Mental Illness (NAMI) added its voice to DHH’s request in a letter to BP’s Chief Operating Officer last week. “We needed to speak out and say very pointedly to BP, ‘It’s time for you to take responsibility,’” says Michael Fitzpatrick, MSW, NAMI’s executive director. Now, the oil giant is in conversations with the federal government regarding financial support for what both the DHH and the Institute of Medicine have identified as “the primary health issue of this disaster”: the need for mental health services in affected areas. “We’re very pleased,” says Fitzpatrick, “and we ask that they continue to negotiate in good faith.” After almost three months of oil continuously leaking into the Gulf, the damage done to homes, businesses, and livelihoods has added to the already heightened stress levels brought on by the recession and ongoing recovery from Hurricane Katrina and Hurricane Ike. This has created what Fitzpatrick calls “a wave of crisis washing over the region”—a crisis that needs an immediate and ongoing response. “What you have in [Louisiana’s] public mental health system on a good day is relatively minimal, [and then] you put additional stress on top of it because you have people in need of support who have not been in the system before,” he says, adding that Louisiana received a “D” in NAMI’s 2009  Grade the States survey of state mental health services.  “We feel that BP has a legal and moral obligation to help finance the increased need for mental health services, support for families, for individuals, for people who may need to relocate.”   Michael Fitzpatrick, MSW, NAMI's executive director The DHH’s requested $10 million will fund a six-month outreach initiative led by the Louisiana Spirit program, which provides therapeutic and psychiatric services through human services districts and community-based organizations. “The speed with which we can fully implement these services will greatly affect the longer-term behavioral health needs and reduce the long-term costs of what is certain to be an ongoing challenge,” wrote DHH Secretary Alan Levine in a letter to U.S. Health & Human Services Secretary Kathleen Sibelius. Effects on CMHC services As in Louisiana, mental health services in the other affected Gulf states of Alabama, Florida, and Mississippi are also severely strained by budget cuts and an increased demand for services. It’s unlikely that community mental health centers (CMHCs) in the region are equipped to service both their continuing care populations and those populations experiencing trauma as a result of the oil spill. According to the National Council’s Project Helping Hands , an emergency mental health initiative, CMHCs can expect to experience the following challenges in the wake of disasters such as the oil spill: • Staffing shortages due to trauma and burnout; • A need for additional resources such as technology and transportation, along with damage to current resources; • An influx of new consumers with no medical records or histories; • Access to funding for new patients; • Medication shortages; • Lack of supportive and transitional housing, whether due to damaged properties or an increased population of displaced consumers; and • Increased hospitalizations due to loss of continuous support services. Lakeview Center, a Pensacola, Fla.-based CMHC, is currently planning to meet those challenges that lie ahead. Though it has not experienced as much increased need as the states to the west, according to director of workforce development Marvin Chaffin, LMHC, Lakeview is leading prevention efforts to ensure the community is prepared for the psychological aftereffects of the spill. “I believe that we’re going to see the beginning of increased services probably after the summer season is over here and they’ve tallied up all the revenue that was lost on the beaches and by fishermen,” Chaffin says. “Then we’ll start to see some real impact and folks who are depressed and anxious, and I fully expect that the need for services will mature over the next three months to a year.”   Clean up crews at work on the beaches of Pensacola, Fla. © BP p.l.c. To prepare, Lakeview has developed intervention training for potential volunteers and fact sheets for public distribution. There is some talk, Chaffin says, of AmeriCorps VISTA supplying volunteers to the area through multiple human services organizations. Long-term efforts essential While BP negotiates funding to support the Louisiana’s current mental health needs, history has shown that disasters such as the Deepwater Horizon oil spill can have long-term effects. These effects will be felt for generations, as evidenced by the 1989 Exxon Valdez oil spill in Alaska, where clean-up efforts are still needed to completely rid the region of oil. “BP needs to realize that this has a long-term impact,” Fitzpatrick says. “The reality is when you’re taking away the occupation of people whose family may have been in that occupation for generations and it was your error or your mistake, you have the responsibility for it.” At Lakeview Center, considering the long-term effects of the spill is an everyday task. While prevention and increased service efforts are being developed and implemented to meet the community’s near-term needs, daily meetings are conducted to develop a “plan that matures on a daily basis” as the situation in the Gulf changes. “Our greatest concern at this point is that if the well stays capped, the national spotlight will begin to fall off of the area and the political heat will also move away from the area,” Chaffin says. “Because of that, there really won’t be a lot of will to make sure the folks who have been affected are really taken care of.” Chaffin hopes that the state and federal governments, as well as private organizations, will help to fund CMHCs that “have been taking a pounding” from the oil spill’s effects. “We are collecting the information and data currently on all of our efforts with the hope that perhaps we may see some money come that would help us offset our cost,” he says. “Otherwise, we’ll be forced to absorb it, and we will because that’s our mission.” Wed, 21 Jul 2010 00:00:00 EST D1E24AF445F74AA5968000514DA60C00 http://www.behavioral.net/ME2/dirmod.asp?type=Publishing&mod=Publications%3A%3AArticle&mid=64D490AC6A7D4FE1AEB453627F1A4A32&tier=4&id=35A0252458974B1C85F4991BB1861763 Before a crowd of about 800 at this year’s State Associations of Addiction Services (SAAS) and NIATx Summit, three key officials—SAMHSA administrator Pamela Hyde, ONDCP deputy director Tom McLellan, and NIDA division director Wilson Compton—highlighted federal efforts and initiatives that will impact funding, care methodologies, care delivery, and technology implementation for providers of behavioral health and substance use treatment services now entering into what Hyde called “the brave new world” shaped by national health reform and parity. Because 50 percent of adult mental health issues manifest symptoms before the age of 14 and 75 percent manifest before the age of 25, the trio emphasized the need to build a “system of prevention” implemented locally and focus community-based supports on children, adolescents, and young adults. “Our number one priority is prevention,” asserted Hyde, who asked, “How can we develop emotionally healthy kids?” The key, she explained, is to reach them early by fostering the development of “prevention prepared communities,” or PPCs. McLellan remarked that such communities would foster coordinated programs among multiple groups—parents, schools, law enforcement, and local governments, for example—with the goal of surrounding young people with “relevant, age appropriate messages and interventions that span the timeframe of risk.” “The antecedents are the same for the things that harm our young people—dropping out, bullying, depression, family issues,” he explained. “Yet, there is evidence that if you employ a practice that reduces even one of these factors, you can help to reduce all of them. Think of the policy implications: If you can get to age 21 without developing an alcohol or substance use problem, you probably won’t get one.” At present, McLellan said that 164 agencies are working together to coordinate the goals, performance requirements, RFPs, and purchasing/grant processes used to drive the development of many types of PPCs. These groups are guided by five demand-reduction priorities developed by the ONDCP through a 35-agency workgroup that sought to link research, policy, and practical implications to guide programs:    1. Prevention    2. Screening and early intervention    3. Expanded access to treatment    4. Special SUD programs for offenders    5. Common means of performance management While the federal government can provide strategic direction areas such as prescription drug abuse, suicide prevention, and grants for PPCs, Hyde emphasized the importance of local government action, noting—to a round of applause—that “the two most effective measures against alcohol abuse among youth are to raise alcohol taxes and get rid of happy hours.” Interagency cooperation will also be critical to implementation of the many pieces of healthcare reform, said Hyde, noting that the effort will pan out in four ways:    1. Implementation of the Affordable Care Act;    2. Work with CMS to coordinate the addition of 16 million new Medicaid patients, five to six million of whom are expected to have significant behavioral health and substance use issues;    3. Evolution of SAMHSA’s block grant structure; and     4. Incorporation of parity requirements, which require that mental health and substance use treatments are managed and funded in a manner equal to other medical services.  “These are going to change the way we do business, who is eligible, and the nature of the services we provide,” says Hyde, adding that a major effort is now underway to define a range of services. “We’re looking at what ought to be provided across the continuum, then trying to define how the services will be paid for—what Medicaid must or will not pay for, what insurance will or will not pay for, and what block grants will or will not pay for.” She also made plain the implications of these changes for providers in terms of operating income, referral structure, and technological capabilities. “For those of who don’t have a good means of billing Medicaid, I’d suggest that you develop it. For those of you who don’t have really good relationships with your FQHC and your primary care providers—I’d suggest that you get them. There are tremendous changes coming.” Coming up next: How “medicalizing addiction” can make a difference—and what it means for providers. Thu, 15 Jul 2010 00:00:00 EST 35A0252458974B1C85F4991BB1861763 http://www.behavioral.net/ME2/dirmod.asp?type=Publishing&mod=Publications%3A%3AArticle&mid=64D490AC6A7D4FE1AEB453627F1A4A32&tier=4&id=A472C0A1033E416BA389C11B89A4288B Fresh from a day of policy briefings, some 500 behavioral health advocates joined National Council leaders on Capitol Hill on June 30 to press Congress on four key issues: extension of enhanced FMAP funding, funding equality for behavioral health information technology, federal status for behavioral health clinics, and increased federal grants for mental health and substance use treatment. According to Linda Rosenberg, CEO of the National Council, advocates were “looking for leadership, not politics” as they tried to bolster the courage of legislators worried about rising federal deficits and determined opposition in upcoming mid-term elections. Two of the advocates’ goals involved Medicaid, which she says provides 70 percent of the nation’s funding for services to individuals with serious mental illness. At the top of the list was the continued fight for a “desperately” needed continuation of “enhanced” Federal Medical Assistance Percentage (FMAP) funding for state Medicaid programs. This enhancement began with an $87 billion allocation in the ARRA stimulus bill that boosted the federal share of state Medicaid funding from a normal range of 50 to 76 percent up to 56.2 to 80 percent in the period from October 2008 to December 2010. Rosenberg says that, despite the fact that the reasons for the original FMAP enhancement—recession, high unemployment and falling state revenues—persist, Congress balked at a $25.5 billion FMAP extension this spring and hasn’t yet mustered support for a scaled-down, $15 billion measure. “There are people who believe that [FMAP] is dead, but I am hoping that now that Congress has finished passing the financial [regulation] bill, the dip in the stock market combined with bad jobs reports will offer Congress some cover to do the FMAP extension,” Rosenberg says. “If jobs don’t pick up, state revenues don’t pick up, and the states are in such desperate shape. We can’t allow people with serious mental illness to get the short end of the stick. They’ve got no other resources, no other choice. We’ve got to keep the heat on.” Rosenberg joined advocates in hailing Rep. Doris Matsui (D-CA) and Rep. Eliot Engel (D-NY) for introducing a new bill, The Community Mental Health and Addiction Safety Net Equity Act of 2010 (HR 5636), that would permanently strengthen the Medicaid safety net for behavioral health consumers. She explained that the bill resurrects the concept of Federally Qualified Behavioral Health Centers (FQBHCs) that passed the House version of health reform last fall, but was lost with approval of the Senate version in March. “What that does is help to protect [consumers] from the kind of cuts that are now devastating states. It would create equality in safety net services for those with serious mental illness and substance use disorders,” she says, noting that “although hospitals and health centers already get cost-based reimbursement, behavioral health organizations do not.” The bill would make such reimbursements available to the FQBHCs while creating national standards and reporting that she says will improve care and provide more consistent and stable services. With three House co-sponsors, Rosenberg says that the National Council is seeking a Senate sponsor to introduce a companion bill. Hill Day advocates clearly boosted support for another House bill, The Health Information Technology Extension for Behavioral Health Services Act of 2010 (HR 5040), as 18 co-sponsors were added in recent days to the 29 that already signed on with Reps. Patrick Kennedy (D-RI) and Tim Murphy (D-PA), who introduced the bill. This measure would extend the electronic health record funding incentives provided in ARRA’s HITECH Act to licensed providers of mental health and substance use treatment and inpatient psychiatric and substance use treatment facilities. Though ongoing work is needed, Rosenberg asserts, “We have an opportunity to move this bill. Right now, the only objection that Congress has to anything is money. So, the only real question is: If this were to pass, is there enough money in the HITECH ACT to compensate behavioral health organizations the way they do with the others? We think so.” She adds that “there’s no doubt that people know [EHRs] will save money in the long run and in the short run. Transparent medical records cut down on fraud and abuse and certainly save lives and money in terms of medical errors. There’s also the parity argument—the idea that behavioral health must not be treated differently than other health issues.” Advocates also argued for increased block grant funding for mental health and substance use treatment, and expressed continued support for housing and homeless programs. Says Rosenberg, “These funds become more vital than ever with the kind of cuts that are happening in the states and if, God forbid, FMAP is not extended.”   Additional information as well as the National Council’s Hill Day policy presentations are available at: http://www.thenationalcouncil.org/cs/hill_day/2010_review . Thu, 08 Jul 2010 00:00:00 EST A472C0A1033E416BA389C11B89A4288B http://www.behavioral.net/ME2/dirmod.asp?type=Publishing&mod=Publications%3A%3AArticle&mid=64D490AC6A7D4FE1AEB453627F1A4A32&tier=4&id=EB63DF7C3FE44F5DBA1819163369EFDD One of the most important and enjoyable responsibilities I have as editor is to participate on the team that reviews the dozens of nominations that we receive for possible recognition as Behavioral Health Champions. Personally, it gives me the opportunity to speak with these executive leaders and understand the influences, motivations, and circumstances that led them to devote their heads, hearts, and lives to improving the availability, quality, and impact of behavioral healthcare nationwide. As we recognize our 2010 Champions, let us remember that there is more than one meaning for the word “champion.” This recognition isn't about being first. It's about an older ideal: People whose lives, examples, and efforts offer understanding for the misunderstood, direction for those who might otherwise be lost, treatment and resources for those sapped by illness, and the hope of a better life—a life in the community—for all who seek it. We hope that these stories offer continued inspiration, hope, and strength, not only as you remember the many difficulties and obstacles that you and our 2010 Champions have overcome, but also as you recall the boundless intelligence, imagination, and passion shared within the field-a resource against which no future obstacle can stand for long.   2010's Behavioral Health Champions are:      - William J. Sette    - Gary Van Nostrand    - Denise Bertin-Epp    - Franklin D. Lisnow    - Robert E. Whaley More online: To read about past years' Behavioral Health Champions, visit http://www.behavioral.net/champions . Don't forget to visit the organizational Web sites of our Champions and to nominate other worthy senior executive leaders, starting next spring, for recognition in 2011. Behavioral Healthcare 2010 July-August;30(7):16-21 Fri, 02 Jul 2010 00:00:00 EST EB63DF7C3FE44F5DBA1819163369EFDD http://www.behavioral.net/ME2/dirmod.asp?type=Publishing&mod=Publications%3A%3AArticle&mid=64D490AC6A7D4FE1AEB453627F1A4A32&tier=4&id=EE6D9FA9FF044FA7913529D206FD6DCD In the 1980s and ‘90s, managed care companies first sought to use “disease management” strategies as a way to deliver better healthcare at lower costs. But these early approaches never caught on with customers for two reasons. First, they failed to meaningfully “engage” the customers in the process and second, their “disease only” focus missed the fact that people struggling with serious or chronic conditions like obesity, heart disease, diabetes, asthma, or cancer often experience anxiety, depression, or other behavioral health issues that can interfere with adherence to medical treatment. Quadir “JJ” Farook, president and CEO of InfoMC (Conshohocken, Pa.), a developer and provider of payer-focused health analytics and disease management software, explains, “If you had cancer, you would have a cancer disease manager from one company. If you were diabetic, you would have a diabetes disease manager from another. You had a manager for every condition, each treating a separate person. There was no one to coordinate the care, to look at the whole person and really engage that person in treatment.” Schooled by these earlier failures, major health insurers are investing in a new generation of “population health management” (PHM) technology. PHM programs continue to depend on the latest predictive analytics, but now leverage a range of knowledge, tactics, and technologies to engage individuals, track and record progress, and generate more positive and better-measured outcomes. Health plans look for consumer engagement “Medicine is catching onto the idea that behavioral health approaches can engage the individual and promote the positive behavior changes needed to make medical interventions successful,” says Farook. He notes that two-thirds of healthcare spending, which now averages about $9,000 per person in the U.S., goes to treat individuals with chronic diseases. Most of the depression that occurs in this group is treated by primary care physicians with medication-a good start-but, Farook adds, “these people aren't getting exposed to behavioral health services, which provide a better long-term outcome.” The key to the most effective PHM approaches, he says, is in identifying chronically ill individuals and linking them up-as part of their chronic disease treatment-with behavioral health resources. For any plan or large employer, the analytics process is the same: Run mountains of data to segment the population into groups-well, at-risk, or chronic, for example. For chronic groups, plans typically adopt more engaging, interactive approaches, such as the use of personal coaches-trained in behavioral health-to establish relationships, then engage the individual regularly through calls or more current technology-such as e-mails, text messages, and mobile applications-to encourage participation, monitor progress, and “keep them in the loop.” “I'm seeing a lot of this ‘med-psych integration,’” says Farook. “There's an understanding that health coaching models can make the difference in cost containment.” As managed behavioral health organizations develop new products and services aimed at both chronic and well populations, Farook says that businesses like his are moving beyond analytics and measurement to expand the “back-office” capabilities needed by payers and plans to support engagement through the latest communications devices. Expand data collection, employ decision supports to improve outcomes As payers and plans refine their analytical tools and customer engagement tactics, behavioral health experts, like those at Polaris Health Directions (Langhorne, Pa.) offer tools that enable behavioral healthcare providers to individualize treatment, improve outcomes, and increase program effectiveness. Linda Toche-Manley, PhD, vice president at Polaris, says that providers can improve outcomes by: Collecting additional client diagnostic data; Providing that data to clinicians so they can select and plan the optimal service mix for treatment; and Making “risk-adjusted” evaluations of the quality and effectiveness of programs that target specific populations. She cites a typical example: An individual reporting severe depression presents and requests treatment. He is asked to fill out personal history forms. But he does so selectively, omitting information about a chemical dependency problem. “This is not unusual,” says Toche-Manley, who adds that “the initial course of treatment is typically determined by the information [caseworkers] are given, in combination with the caseworker's educational backgrounds and experiences in the field.” As a result, “rarely are recommendations based on empirical data that is linked to potential outcomes.” She suggests a different process, which supplements the forms with a computer-based personal assessment-a tool more likely to get a truthful result. With the individual's permission, his wife and family members also complete an assessment. This additional information on the individual's behavior, risks, and strengths-backed by the use of a clinical decision support tool-provide the caseworker with greater insight, measures of the relative severity of the individual's symptoms, and a set of evidence-based treatment approaches matched to the individual's symptoms. Every few weeks during the course of treatment, the individual takes computer-based assessments that track his progress. So, what's the difference? Toche-Manley points to three important differences. First, she says “the voice of the patient, as well as standardized data, are used to build the treatment plan.” Second, additional information regarding the individual's risks and strengths-information that empirically affects long-term prospects for recovery-is documented. And third, the cycle of measurement and feedback drive better communication and progress evaluation between the individual and the clinician. In addition to impacting the clinical process, Toche-Manley says that significant program-level improvements can be realized by analyzing key individual risks, strengths, and other factors. “Many program directors wonder, ‘What programs work best with what types of clients?’ Treatment populations are not homogeneous, and what succeeds for one client may fail for another,” she explains, citing a multi-county study of the effectiveness of wraparound care program outcomes for nine types of youth. Through analysis of various combinations of clinical and service data, she says that “what does and does not work for specific youth and adults began to be revealed.” When applied program wide, these analytical insights are improving outcomes by over 30 percent. “Real cost savings are often realized by better initial matching of services to specific clinical subgroups, and not by elimination of service types,” says Toche-Manley. “Systems can afford to give the best services-even the most costly ones-when their service decisions are supported by empirical observations that probable success is high.” Behavioral Healthcare 2010 July-August;30(7):22-23 Thu, 01 Jul 2010 00:00:00 EST EE6D9FA9FF044FA7913529D206FD6DCD http://www.behavioral.net/ME2/dirmod.asp?type=Publishing&mod=Publications%3A%3AArticle&mid=64D490AC6A7D4FE1AEB453627F1A4A32&tier=4&id=529AC6DB8B674839AD94F94891052A50 Ideally, the enthusiasm that mental health and addictions counselors bring to their jobs and populations would never fade. But as Eileen O'Mara, EdD, core faculty at Capella University and professor emeritus at Hazelden Graduate School of Addiction Studies, and Thomas Durham, PhD, LADC, CCS, executive director of The Danya Institute, know too well, burnout is an eventual certainty for many counselors. O'Mara and Durham will lead two workshops at this year's inaugural National Conference on Addiction Disorders (NCAD). O'Mara will present “Burnout Prevention: An Individual and Management Challenge,” while Durham will present “Clinical Supervision: An Important Resource for Self-Care.” When left unaddressed, burnout can result in anything from low morale to high staff turnover. Affected staff members may come in late or call off sick more than usual, find ways to spend less time with patients, make professional errors, develop cynical attitudes, or begin substance abuse themselves. And all of these things ultimately lead to a reduction in the quality of care that patients receive. “It's an ongoing issue to be aware of,” says O'Mara, who has studied burnout and its effects for over 25 years. “Companies must be prepared to be on top of situations among staff as they arise.” To effectively address the threat of burnout among staff members, organizations must provide three things: A supportive working environment that acknowledges staff stressors; Comforting and encouraging clinical supervisors; and Therapeutic resources for counselors. Reduce staff stressors Though burnout prevention and coping skills are essential for all counselors, O'Mara asserts that organizations also must address the on-the-job stressors that can lead to staff burnout. “It's really pretty simple,” O'Mara says. “If the organization is committed to supporting staff and giving them the resources they need to do their jobs, that will reduce the level of burnout.” She recommends that organizations include burnout-prevention resources in their strategic plans, such as: Ample, paid time off to recuperate from work stressors . Although it can be difficult to provide counselors-who typically have weekly obligations to clients and groups-with vacation time, O'Mara says that organizations should supply a substitute for a vacationing counselor. “And personally, I don't think a week is enough,” she says. “People need at least two weeks.” Health and wellness initiatives . Along with vacation time, health initiatives encourage counselors to take care of their bodies so they are less prone to stress-related illnesses. O'Mara cites Hazelden's employee retention program-which awards employees $50 every time they complete a healthy activity, such as walking a certain distance or choosing a healthy meal from the cafeteria-as an ideal example. “That kind of stuff really makes a big difference,” O'Mara says. “People like to know that their stress is acknowledged and is being helped.” Professional growth and learning opportunities . Organizations should also be prepared to support counselors' professional needs as well. “Having the company's support of professional development is critical to a counselor's growth and competence,” O'Mara says. “Bringing in a national speaker, sending people to a conference-like NCAD-and supporting that growth is a major part of keeping people engaged in the organization.” So, too, is career growth. Often, burnout can be remedied by challenging counselors with new roles or responsibilities. For example, O'Mara says the chance to “switch populations, do case management, work in admissions, or do something a little less intense” can help counselors to “get their balance back,” rather than exit the field altogether. Vital relationships A supportive environment is important, but counselors also need a safe relationship in which they can express needs, feelings, and frustrations. This relationship is often provided by their clinical supervisor. Effective clinical supervision “requires the supervisor to develop a good collegial working relationship with the supervisee, which doesn't always happen,” says Durham. “Some organizations are more concerned with the bottom line and may not be staffed appropriately to provide good supervision.” He says that effective clinical supervisors function as mentors and sources of support. “The supervisor relationship is key” in helping counselors develop a strong sense of self-confidence and deliver the best possible care. Such support begins at the top, with an administration that understands what clinical supervision is, he says. Supervisors, in turn, “are responsible for developing a relationship with the counselor to ensure they grow as a clinician and have someone they feel comfortable discussing certain issues with.” These issues, such as compassion fatigue and secondary PTSD developed by working with traumatized patients, must be dealt with in clinical supervision, or they could lead to burnout. Durham suggests that clinical supervisors meet with counselors to address such issues at least one hour each week in a group or one-on-one setting, depending on the counselor's level of experience. Warning signs Clinical supervisors should watch for three warning signs of counselor burnout. If noted, these signs call for additional attention beyond the weekly meeting: Irritability and escape thinking; Reported feelings of countertransference; and Abandonment of a spiritual practice, such as meditation or church attendance. “I usually counsel people that if you have countertransference that is similar in nature and occurs three times in a row, then you need to go to therapy and figure out what the root of it is,” O'Mara says. Because of this, O'Mara insists that all organizations need to provide their employees with an EAP that offers three to six free sessions. Durham agrees. “A supervisor can suggest the counselor go to the EAP, and they'll do a confidential evaluation and refer them somewhere,” he says. “It makes it a lot easier because the EAP takes the referral away from the supervisor.” In the event that an EAP is not available, Durham suggests that supervisors offer counselors a list of resources to choose from. Supervisors should not make referrals unless “it's the only thing and there is no other means available.” While the organization and clinical supervisors can identify warning signs of burnout, it is up to the individual counselor to figure out what prevention strategies work and to maintain them over time. NCAD 2010 NCAD, to be held Sept. 8-11 in Washington, D.C., is produced by Vendome Group, publisher of Behavioral Healthcare . The inaugural conference offers educational sessions on treatment, administration, design, and technology. Vendome founded the event in conjunction with NAADAC, the Association for Addiction Professionals and the National Association of Addiction Treatment Providers (NAATP). To register for the conference, visit http://www.ncad10.com . Behavioral Healthcare 2010 July-August;30(7):24-25 Thu, 01 Jul 2010 00:00:00 EST 529AC6DB8B674839AD94F94891052A50 http://www.behavioral.net/ME2/dirmod.asp?type=Publishing&mod=Publications%3A%3AArticle&mid=64D490AC6A7D4FE1AEB453627F1A4A32&tier=4&id=BDC1F0EADD8A4844A60A7665756822C4 Nearly one in five Americans suffers from an anxiety disorder in any given year, according to the National Comorbidity Survey Replication Study reported in 2005. And the majority of them are seeking care in general medical, rather than specialty behavioral health, settings. “Often, these persons do not understand what's wrong, and when they go to their family doctor, these treatable illnesses are frequently missed,” says Bradley N. Gaynes, MD, MPH, professor in the department of psychiatry at the University of North Carolina. The consequences of this reality are dire. “Untreated anxiety disorders result in disability and generate increased costs because the physical manifestations of anxiety often prompt expensive diagnostic procedures,” says Dr. Peter Roy-Byrne, professor and vice-chairman in the department of psychiatry at the University of Washington at Harborview Medical Center. But the consequences also offer an opportunity for clinicians and organizations in the behavioral health camp wishing to enhance their practice profile by collaborating with their colleagues in primary care. For many complicated reasons, the linkages between these two camps have been slow to come by. Recent advances in the ability to detect and manage anxiety disorders in the primary care setting should strengthen and promote linkages between the two camps. Recognizing anxiety disorders in primary care: the M-3 Screener Gaynes is the lead author of a recent study validating a new screening tool called My Mood Monitor (M-3), a one-page, web-based checklist that can be completed in a few minutes and indicates whether a patient has an anxiety disorder or other behavioral conditions. 1 Their study included 647 patients from his university's Family Practice Medicine Clinic. Each subject filled out the 27-question M-3 checklist and then participated in a follow-up interview with a clinician who had no access to the results of the M-3. “The M-3 was effective in screening for any mood or anxiety disorder 83 percent of the time and for a specific disorder in 76 percent of cases,” said Gaynes. “Its diagnostic accuracy equals that of presently-used single-disorder screens but with the additional benefit of being combined into a one-page tool.” The M-3 also screens for suicide risk and substance abuse, urging users who might be at risk for these and other conditions to seek follow-up care. What distinguishes the M-3 from other screening tools is that it includes multiple psychiatric disorders, rather than focusing on a single disease such as depression or anxiety. It is also readily accessible at a Web site ( http://www.mymoodmonitor.com ), where an individual can anonymously answer 27 questions that identify his/her risk for depression, anxiety, PTSD, and bipolar disorder. After answers are recorded, the individual can then generate a “total score” in each of several categories that gauges the severity of their condition at the current time. A score of 33 or more (on a 0 to 100 scale) in any category indicates an increased probability that the individual is being affected by the condition. The tool then suggests appropriate follow-up care. While the M-3 is a screening scale developed in a primary care setting, I have used it in my psychiatric practice with new and long-term patients. I find it to be a quick and accurate way to focus on critical symptoms and behaviors. My patients go to the Web site, complete the tool (without violating their HIPAA rights) and send results to me that quickly inform my clinical diagnostic impression. The ratings can be kept on file using Microsoft's HealthVault to help in assessing the risk-benefit ratio of each patient's treatment over time. According to Michael Byer, co-author of the M-3 checklist, “There are opportunities for primary care clinics and practices to receive reimbursement funds for administering mental health/health risk assessment screens via CPT Code 99420.” Treating anxiety in primary care: the “CALM” model Once a psychiatric problem has been identified in a primary care setting, how does it get treated? Roy-Byrne and his colleagues have just published a study describing a flexible treatment delivery model called Coordinated Anxiety Learning and Management (CALM). 2 Their study, funded by NIMH, compared the effectiveness of CALM to “care as usual” (UC) at 17 clinics in four U.S. cities. Together, the clinics provided more than 780,000 visits to over 35,000 patients annually, along with a diverse clinician, patient and insurance mix. The CALM Model addresses the four most common anxiety disorders, even when they co-occur with depression. Following diagnosis, each patient in the CALM approach selects pharmacotherapy, cognitive behavioral therapy (CBT), or both. The study was conducted as follows: Physicians identified subjects eligible for the study. This group, which included 120 internists and 28 primary care physicians, received a half-day of training from a local psychiatrist who offered: A three-step medication-management algorithm; As-needed follow-up consultation by telephone or e-mail; and Face-to-face assessments for complex or treatment-refractory patients. The treatment algorithm included first-line use of selective serotonin reuptake inhibitor (SSRI) or serotonin norepinephrine reuptake inhibitor (SNRI) antidepressants (see table ), dose optimization, and adverse effect monitoring. For treatment-refractory patients, second- and third-level medications included combinations of two antidepressants or an antidepressant and benzodiazepine. Anxiety Clinic Specialists (ACSs) included six social workers, five RNs, two master's-level psychologists, and one doctoral-level psychologist who received six half-day training sessions. The ACSs were critical to coordinating the study because they: Finalized subject selection and randomization into CALM and UC study groups; Provided CBT to patients in six to eight weekly sessions; and Tracked patient outcomes through a treatment period of three to 12 months, then followed at six, 12, and 18 months after baseline. Ongoing treatment was monitored in a web-based system based on the research group's “Improving Mood-Promoting Access to Collaborative Treatment” (IMPACT), modified for anxiety conditions. “We found a significantly greater improvement with CALM vs. UC for global anxiety symptoms as well as better response and remission rates,” said Roy-Byrne. “In our study, depressive symptoms improved as much as anxiety symptoms. I think there is reasonable data for the opposite as well. Primary care clinicians prefer to address a range of common mental disorders rather than just one, and it appears the CALM model allows just that.” So what is keeping the CALM model from wider use in primary care? There are three things: As usual, reimbursement mechanisms are not yet in place to cover the care management involved. So, while the results of the Roy-Byrne et al study may help influence new reimbursement policies or legislation, they unfortunately will have little effect on current practice. Second, because CALM was developed as an “in house” model for large clinics with available staff, its use in smaller primary care practices may require some ingenuity. Third, none of the web-based support materials are available for public use. Behavioral healthcare stakeholders are “on deck” “The bottom line is that we've demonstrated the feasibility of a model that addresses multiple common mental disorders in the context of one delivery system in the primary care setting,” said Roy-Byrne. And according to Gaynes, “Hospitals, doctors, and patients are preparing to use electronic medical records (EMR) systems to document all healthcare interactions, and the M-3 is the first validated application to use EMR technology for mental healthcare.” With the appearance of tools like the M-3 and the CALM model, it is now only a matter of time until primary care physicians grow in their ability to identify, diagnose, and treat anxious or depressed patients. Behavioral healthcare providers need to understand how screening and diagnostic methodologies are evolving in primary care and be ready to collaborate with primary care providers in offering those suffering from these disorders the full range of treatment.     William M. Glazer, MD, is President of Glazer Medical Solutions ( http://www.glazmedsol.com ) of Key West, Fla., and Menemsha, Mass. He is a clinician, researcher, lecturer, and consultant, and has been a member of faculty of the departments of psychiatry at the Yale and Harvard schools of medicine. References Gaynes BN, et al. Feasibility and Diagnostic Validity of the M-3 Checklist: A Brief, Self-Rated Screen for Depressive, Bipolar, Anxiety, and Post-Traumatic Stress Disorders in Primary Care. Annals of Family Medicine. 2010; 8:160-169. Roy-Byrne P, et al. Delivery of Evidence-Based Treatment for Multiple Anxiety Disorders in Primary Care: A Randomized Controlled Trial. JAMA. 2010; 303 (19): 1921-1928. Behavioral Healthcare 2010 July-August;30(7):38-39 Thu, 01 Jul 2010 00:00:00 EST BDC1F0EADD8A4844A60A7665756822C4 http://www.behavioral.net/ME2/dirmod.asp?type=Publishing&mod=Publications%3A%3AArticle&mid=64D490AC6A7D4FE1AEB453627F1A4A32&tier=4&id=4A30A78B167345F98F283BE161E58D2C In such harsh economic times, a behavioral healthcare organization might be hard-pressed to find a professional willing to take on the tough job of leading a fundraising campaign. But Linda Garceau-Luis understands that even tough times bring new opportunities for success, and she plans to tap into these sources as Centerstone Foundation's new CEO. In this new role, she is responsible for development efforts for the Foundation in both Indiana and Tennessee, as well as for those in support of the Centerstone Research Institute (CRI). “My role is to connect individuals, foundations, and corporations to Centerstone's mission,” she says. But the economy wasn't the greatest obstacle in Garceau-Luis' way when she took on her new role in April. Rather, the flooding of Nashville, Centerstone's headquarters location, in early May presented an entirely different kind of challenge. The floods caused destruction in Middle Tennessee that could take years to rebuild. “In some of our locations, we do have a lot of cleanup to do, including one of the locations near where I am, which was totally flooded out,” she says. “But I think we're fortunate overall not to have been affected too much.” While dealing with the relocation of several of its own facilities, Centerstone also supported the rest of the community as a resource, offering its case managers for assistance at local Disaster Information Centers and encouraging community members to utilize its crisis services. “I think we're in recovery mode now,” Garceau-Luis says. Well prepared for the challenge ahead Having spent most of her career working for academic healthcare centers, Garceau-Luis led development efforts at Dartmouth Medical School before relocating to the Nashville area to continue her career at Vanderbilt Medical Center and the University of Tennessee Health Science Center. She points out that Centerstone, which became the nation's largest provider of community-based behavioral healthcare after its merger with CBH and Quinco in 2008, is also an academic medical center, not unlike the others for which she has worked in the past. “As with my previous positions, Centerstone has a four-pronged mission: patient care, research, education, and outreach,” she says. “I am excited to be joining Centerstone at this critical time when the recent mergers have occurred and the organization is positioned to emerge as the premier academic behavioral healthcare organization in the world.” Centerstone is not Garceau-Luis' first venture into the behavioral health field, either. After graduating from Plymouth State College of the University of New Hampshire, she accepted a job with the Dartmouth-Hitchcock Mental Health Hospital in Hanover, N.H., working closely with physicians in the field treating behavioral health conditions. “I developed an appreciation for the complexity of this area of medicine,” she says. “I believe that Centerstone has changed the paradigm in behavioral healthcare … and I am passionate about Centerstone's mission to ‘prevent and cure mental illness and addiction.’” Centerstone's financial priorities are well aligned with this mission, according to Garceau-Luis, who says that the organization will focus on raising funds for three key areas. First, development efforts will focus on Centerstone programs that support uninsured individuals in Indiana and Tennessee. “Typically, these programs are not fundable by any means other than through private support from individuals, foundations, and corporations,” she says. Second, Centerstone will focus on raising funds for the growing CRI, which has attracted $50 million in federal, state, and private grants since 2003. “Research is the key to unlocking the clues to who gets mental illness, what treatment works best for which individuals, and what are the most effective ways to alleviate symptoms and cure mental illness,” Garceau-Luis says. Last, Centerstone plans to enhance its funding in support of returned military service members and their families. Through its partnership with Not Alone-a confidential, online community providing support and local-service links to service members affected by combat stress and PTSD-Centerstone will fund Project Safe Return, which will expand behavioral health services to veterans, active members of the armed forces, and military families. Little known advantages With philanthropic donations down in just about every industry, Garceau-Luis knows that she has her work cut out for her. “Donors give when they're ready,” she says, “not on our timetable.” But she also knows her field well enough to have a few strategies up her sleeve. “Planned giving is popular in any economy but especially in down economic times,” she says. “Life income gifts provide the donor a current income tax deduction and a stream of income for life, and bequests allow a donor to make a commitment for the cause about which they are passionate without feeling they are jeopardizing their current financial stability.” Because of this, Garceau-Luis says that she plans to focus on growing Centerstone's endowment “to affect more lives now and provide for future generations,” as 80 percent of all endowment funds come from planned gifts. For behavioral health providers lacking in resources and Garceau-Luis' fundraising expertise, she suggests that board members can often create opportunities to engage with philanthropists. “Our board members are critical to our success,” she says. She also encourages development professionals in the behavioral health field to “be fearless,” while keeping a plan ready on hand. “Without it, you will not know how to proceed.” Behavioral Healthcare 2010 July-August;30(7):40 Thu, 01 Jul 2010 00:00:00 EST 4A30A78B167345F98F283BE161E58D2C http://www.behavioral.net/ME2/dirmod.asp?type=Publishing&mod=Publications%3A%3AArticle&mid=64D490AC6A7D4FE1AEB453627F1A4A32&tier=4&id=4B5AD7B445E4487886B9E27B78B0326E “When I retire, I'll know that I did what my parents asked of me: I gave back.”   Position: Executive Director   Organization: Center for Dependency, Addiction, and Rehabilitation (CeDAR) at the University of Colorado Hospital   Location: Aurora, Colo.   Services: Comprehensive diagnostic assessment and treatment services to help individuals and their families overcome addiction and co-occurring disorders, including residential treatment, extended care programs, family programs, and alumni and aftercare support groups   Staff: 50   Raised in Brooklyn by parents who “always saw people for what they were,” Frank Lisnow had three gifts that would shape his life: A desire to “give back,” an ability to see the best in people, and a pragmatic, street-wise approach to solving problems.   After earning a business degree, Frank quickly found that work as an industrial engineer “didn't seem to fit.” With his wife, he moved to Vermont, taking a job at a men's correctional center in St. Johnsbury. Despite a lack of formal training, he got a job protecting and counseling these troubled individuals “because I was a big guy.” Before long, “A light went off. This is what I want to do,” he recalls. “I want to work with people who are in trouble.”   After seeing the impact of drugs and alcohol, “by far the largest source of problems for the men at the correctional center,” Frank sought a job in community drug and alcohol counseling 18 months later. Again, despite a lack of formal training, he fit in easily at Northeast Kingdom Mental Health, impressing director Vernon Barry with his street skills. “I grew up on the streets of Brooklyn,” he says. “I understood the street and understood people who had those types of problems.”   Looking back, he acknowledges, “I couldn't get a job today with what I had then.” But it didn't matter. “[Barry] saw something in me that he was willing to take a risk on. He taught me the ropes.” Inspired by Barry's confidence and his own passion for the field, Frank completed formal professional training, earning MEd and MAC degrees.   His 16 years with Barry—from 1972 to 1988—not only taught him management skills, but an eclectic, consumer-focused approach to mental health and chemical dependency treatment. Frank sees it as a combination of recovery and mental-health approaches (12 Step, pharmacology, behavioral therapies, and more) tuned to an individual's needs. He continues to practice this “person first” approach today.   Noting that 12-Step fellowship is vital, for example, Frank suggests that an anxious person needs other tools-perhaps medication and behavioral approaches-to make that fellowship successful. “Let's put the best of both worlds-recovery and behavioral health-together,” he asserts. At Northeast, Frank became active in NAADAC, ultimately serving as its president from 1986 to 1988. At the time, he got to know Dave Lombard, a NAADAC board member associated with Clearbrook, a 100-bed chemical dependency center in Wilkes-Barre, Pa.   Lombard brought him to Clearbrook, where, in 16 years, Frank learned “how to run a business, when you've got to make money to pay salaries, meet expenses, and continue the mission of the organization—which is to help people.” He observes that “too many non-profits run like non-profits and wonder why they've gone out of business,” adding, “Compassion and good business are not incompatible.”   Frank made what he calls his “final” move to the Center for Dependency, Addiction, and Rehabilitation (CeDAR) in 2005. Created by the University of Colorado Hospital, CeDAR gave Frank “the chance to practice what I thought was quality behavioral health treatment in a quality chemical dependency center. It's a place where people can get everything they need to turn their lives around.” Since his arrival, CeDAR has aspired to be a top treatment center for chemical dependency and co-occurring disorders. “We can deal with more difficult patients-patients that not every facility can handle.”   Calling CeDAR his “swan song,” Frank reflects, “This was an opportunity to leave my mark. When I retire, I'll know that I did what my parents asked of me: I gave back.” Photo by Don Weule Thu, 01 Jul 2010 00:00:00 EST 4B5AD7B445E4487886B9E27B78B0326E http://www.behavioral.net/ME2/dirmod.asp?type=Publishing&mod=Publications%3A%3AArticle&mid=64D490AC6A7D4FE1AEB453627F1A4A32&tier=4&id=1CF5CF8FFD8840D1B56B6B7835E5C864 “Leave the world a better place as a result of your contributions.” Position: President and CEO Organization: Preferred Behavioral Health of New Jersey Location: Lakewood, N.J., serving 13 counties at 50 locations Services: 60 mental health and substance abuse programs including outpatient therapy, day treatment programs, integrated case management, medication monitoring, residential services, supported education, vocational services for adults, specialized services for seniors, and children's services including an adolescent shelter, school-based programs, supervised visitation, and foster care support Staff: 450   Like many young people in the 1960s, Bill Sette grew up with a social conscience and a desire “to do something” with his life. After graduating from Rutgers with an MSW degree in 1969 (he also holds an LCSW credential), he got involved in social services work in Ocean County, which-then and now-is one of New Jersey's fastest-growing counties. By 1977, the county still had only one mental health service provider, a long waiting list for services, a dearth of inpatient beds, and one of the highest admission/readmission rates to state psychiatric facilities. Additional services were desperately needed. Sette, seeing the problems, seized the opportunity, and with the assistance of others, established a new center, now known as Preferred Behavioral Health of New Jersey (PBH). Over the 33 years under his direction, PBH expanded and developed new services to meet community needs and now employs 450 staff, operates in over 50 locations in 13 counties, and has a budget of over $24 million. Bill is president and chief executive officer of Preferred Behavioral Health of New Jersey and its affiliates-Preferred Children's Services and Preferred Behavioral Health Consulting Group-and serves on the board of Preferred Behavioral Health Foundation. Bill is also a founding member of Peer Partners LLC, the group that developed the Peer Collaboration model, a guide for executive-level peers to help each other find solutions to the things that “keep them awake at night.” This process is being used by over 40 organizations nationally and internationally, encouraging leaders at all levels to learn from each other by sharing their knowledge and experience. Known for his camaraderie and sense of humor, Bill has also been instrumental in establishing and supporting other community organizations, and he serves on many of their boards. He encourages his staff to participate at all levels of government and in all the major community institutions to improve the health of the communities and consumers they serve. “Working in the non-profit sector requires business acumen, leadership skills, and a passion for a mission that can leave the world a better place as a result of your contributions,” says Bill. “That passion drives my commitment and has led to a career filled with the rewards of serving others.” Bill cites the influence and support of others as a critical factor in his success. Through his involvement with public policy on the state and national level, he came to know Debra Wentz, PhD, president and CEO of the New Jersey Association of Mental Health and Addiction Agencies (NJAMHAA), whom he thanks “for her leadership, encouragement, and support.” He also thanks Donald Hevey, president and CEO of the Mental Health Corporations of America (MHCA) for his support and for “developing an unparalleled membership of entrepreneurial leaders,” along with PBH's administrative team and staff “for their loyalty, support, encouragement, and tireless efforts to fulfill our mission.” A longtime member of The National Council, Bill commends Linda Rosenberg and her staff “for their advocacy at the national level on behalf of the community behavioral health system.” Bill serves as president of the New Jersey Mental Health Institute, as a member of the Board of Directors of NJAMHAA, and as a member of MHCA's Board of Directors. He is certified as a trainer in the Ken Blanchard model of High Performance Teams.   Photo by Keith Woods Thu, 01 Jul 2010 00:00:00 EST 1CF5CF8FFD8840D1B56B6B7835E5C864 http://www.behavioral.net/ME2/dirmod.asp?type=Publishing&mod=Publications%3A%3AArticle&mid=64D490AC6A7D4FE1AEB453627F1A4A32&tier=4&id=99A0554989154B8EBCBB8CDFA5D863EB “We found a 29 percent reduction in hospitalizations compared with the period immediately preceding the change to recovery-focused programs.”   Position: President and CEO   Organization: SERV Behavioral Health System, Inc.   Location: New Jersey   Services: Residential mental health, residential developmental disability (support for co-occurring disorders), day programs, outpatient treatment programs   Staff: 750   As a high-school student, Gary Van Nostrand watched friends and family members struggle with mental health and addiction problems and wondered, “How do these things come to be?” Through college and graduate studies in clinical neuropsychology at Tulane University, the University of Florida, and the Mayo Clinic, his curiosity grew into a fascination-and a career.   While he published his would-be doctoral thesis, Dual functional asymmetry of the brain in visual perception, Gary never finished his doctorate. Instead, he gained many of the professional skills he would depend on every day on the job, administering multi-county drug and alcohol counseling services in Iowa, then West Virginia, before moving to a similar program at Princeton Medical Center. He even left the field for stints in HR consulting and home healthcare services, though he kept ties through a board chair at SERV Behavioral Health System, Inc.   His business acumen made him a natural choice to participate in SERV's CEO search effort in the late 1990s and then, following a leadership crisis, to step in as the organization's CEO in 2002. There were painful changes as the organization's “silos” were dissolved in favor of a team approach and voices, including his, challenged what he describes as SERV's “authoritarian” model for delivering services-especially residential services.   “We told residents when to get up, when to go to bed, when to eat, and how to behave. Every residence had a long list of ‘House Rules,’” Gary recalls. “Our professional staff had the attitude that they knew best and residents should do as they were told in order to get ‘better.’” Quickly, however, Gary realized that the culture wasn't working for residents. “I didn't see people developing the way I thought was possible, taking responsibility for their own lives. And I don't think you can be well and not be responsible.”   With the support of board members, Gary and his team “did some research into how recovery-focused changes worked” and developed a plan and evaluation methods for a two-year shift to recovery-focused programs, starting in 2005. They got results-including one result that Gary calls “totally unexpected.”   “The most interesting finding [of the recovery-focused program] was one we hadn't expected. We found a 29 percent reduction in hospitalizations compared with the period immediately preceding the program. The hospitalization rate was not a focus of our study-more of an after-thought. Clearly, however, something changed.”   Gary speculates that the new focus fostered stronger relationships. “One of the major problems [for our consumers] is isolation: ‘Nobody understands me.’ Yet if the individual is connected to an individual or a team of individuals, there's a feeling that ‘they know what's going on with me’ and a trust that the team can be there at tough times.”   Among the hundreds of consumers who were, or are, involved in SERV programs that transition them from illness to recovery and isolation into successful educational or employment experiences, these findings offer reassurance, says Gary.   “As some people get better, they get jobs, but then face the challenge of keeping them. They don't have the right habits,” he says. “When they're having a bad week, someone can come in and help them by providing an example and offering support. It's the kind of thing that prevents an occasional setback from being a major setback.” Photo by Michael Mancuso Thu, 01 Jul 2010 00:00:00 EST 99A0554989154B8EBCBB8CDFA5D863EB http://www.behavioral.net/ME2/dirmod.asp?type=Publishing&mod=Publications%3A%3AArticle&mid=64D490AC6A7D4FE1AEB453627F1A4A32&tier=4&id=4E82F5A0A2744F94893BE43EFA5EE89A “We've got to measure so that we can look at chronic illness outcomes on a quality continuum, much the same way they do in the manufacturing world.”   Position: President/Chief Nurse   Organization: Brighton Hospital   Location: Brighton, Mich.   Services: 132-bed substance use rehabilitation hospital offering inpatient programs for individuals (co-occurring disorders, medical and legal professionals, adolescents) plus outpatient, life-long recovery, education, and research programs   Staff: 135 “We've got to measure so that we can look at chronic illness outcomes on a quality continuum, much the same way they do in the manufacturing world.”   Though she's becoming known for her leadership in quality and process improvement in one of the country's leading substance abuse rehabilitation hospitals, Denise Bertin-Epp's most valuable training occurred outside healthcare. After leaving Greenbrook Recovery Center to become Brighton Hospital's director of nursing in 1999, Denise found that her desire to drive change was at odds with Brighton's paper-based culture. At the time, she says, it was “a bad fit.” So for two years, the ISO-certified, Six Sigma Green Belt (she also holds a bachelor's in nursing and a master's in healthcare administration) served as a quality consultant to Michigan's automotive, electronics, and manufacturing industries.   “I worked in a couple of startup companies and became an ISO auditor. I was able to look at the process improvement methods used at a lot of non-healthcare companies. My husband Jack, who's an industrial engineer, used to talk about quality indicators like scorecards, benchmarks, or process improvement methods like kaizen exercises and fishbone (problem solving) diagrams. Ten years ago, those weren't things we used in healthcare. Yet, we use them now.”   Denise got a chance to put her knowledge to work at Brighton in 2003, when in the face of a declining census and growing financial concerns, she returned to take on the dual post of chief operating officer/chief nurse. The falling census led to falling revenues and pressure to cut programs. Not exactly a recipe for growth, Denise recalls. With board approval, she led efforts to stabilize operational, financial, and clinical indicators; implement creative clinical programs; revamp the hospital's organizational infrastructure; integrate medical and administrative leadership; affiliate with a nearby hospital system; and, finally, to drive 20 percent growth in each of two years.   Today, as president/chief nurse, Denise's process improvement and quality focus extend even further at Brighton, which has now implemented ISO, Lean, Six Sigma, and JCAHO certification facility-wide. “If we believe that this [addiction] is a disease, behavioral healthcare has to adopt the same standards that acute care uses-things like fall risk or suicide risk, for example. We've got to measure those indicators so that we can look at chronic illness outcomes on a quality continuum, much the same way they do in the manufacturing world. My leadership team here at Brighton are all Green Belts in Six Sigma. They've got to be able to do it.”   When it came time for Brighton to develop an electronic medical records system, Bertin-Epp and her team used the same approach. “We picked an ISO-certified vendor, one that used the same quality parameters [and] the same process improvement methods that we did.” While developing the EMR system, her team took on a host of concerns, including medication errors and the expense of clinical dictation. Targeted teams, using kaizen exercises, analyzed possible errors and inefficiencies, then designed processes to prevent them. With the system, which the Brighton team implemented $1.2 million under budget, medication errors fell 65 percent while template-based dictation cut clinician time dramatically. Just three years later, Brighton Hospital and Medical Communications Systems are now launching ebhr, an electronic behavioral health record system, to the behavioral health industry.   In this era of reform, when many in behavioral healthcare look warily to a future dominated by unfamiliar concepts and new terminology-EHRs, EBPs, comparative effectiveness, and more-champions like Denise show us that we have much to master, but little to fear.   Photo by Judith Anderson Thu, 01 Jul 2010 00:00:00 EST 4E82F5A0A2744F94893BE43EFA5EE89A http://www.behavioral.net/ME2/dirmod.asp?type=Publishing&mod=Publications%3A%3AArticle&mid=64D490AC6A7D4FE1AEB453627F1A4A32&tier=4&id=6CF220D198314A00980C05F5763B6B26 “Until then, I hadn't realized that recovery was such a big deal. Then it hit me: We had a responsibility to make this work.”   Position: Executive Director   Organization: Southeast Behavioral Health Group   Location: La Junta, Colo., serving six southeastern counties   Services: Comprehensive outpatient mental health, substance abuse, wellness services, early childhood services, and nursing home services   Staff: 75   After 11 years as chief financial officer at Southeast Behavioral Health Group, Bob Whaley earned consideration for the job of executive director when it opened up in the late 1990s. Though he was trained in accounting and finance along with his MBA credentials, he had learned much about how the organization operated, its clinical programs, and had gotten to know dozens of the consumers that it served.   Bob got the job, but then realized something was wrong. “This agency was in trouble. We knew we were spending most of our resources on a small population of individuals affected by serious mental illness,” he recalls. “Our community was saying, ‘You don't have outpatient services, you don't have children's services, there's nothing for substance abuse treatment.’”   Together with his staff and board, he looked for a better way forward-a way to better balance the financial needs of consumers' care with those of the community. Research led Bob and his staff to a new approach called “recovery” that would place empowered consumers into the community, but with a framework of support.   Financially, it was perfect. It would reduce the cost of care and free up resources for other tasks. But, Bob wondered: “Was it right? Was it a responsible thing to do?” He found the answer one evening, sitting in a shopping mall, where he noted that more than a few of the shoppers looked familiar. Finally, he realized: They were consumers from the agency, accompanied by case managers. “If it weren't for the case managers,” he says, “I wouldn't have known them from anyone else.”   “They are just like me,” he thought. “They have their days when they need support, but then, so do I. Our role is to support them in the lives they choose.” With help from Ed Knight, PhD, a schizophrenia survivor and recovery advocate, Bob and his staff built a recovery-focused plan. Bob won board approval for agency-wide training and set a date for program launch in 2000.   “We figured that we could move our [120] people into the community within two years. But when they found out what we were going to do, everyone was asking, ‘Can I be next?’” The moves were done in three months.   Bob says that shortly thereafter, someone asked, “Are community leaders concerned?”   “I replied that ‘they really didn't notice.’ And that was true. We worked with six counties, six different sheriffs, different communities, and the consumers never had problems. Our case managers kept in contact and provided help when needed, but most consumers got along fine.” Today, they still do: 80 percent of those who returned to their communities in 2000 remain in them-living independently, owning their own homes, many in relationships, some married, and virtually all working or volunteering their time. “It's not your life or mine, but it's a life that works,” says Bob. “It's their life.”   The value of the program-beyond its immediate financial sense and consumer appeal-didn't occur to Bob until, at Ed Knight's suggestion, he presented at a conference in 2002. But it wasn't just any conference-Bob spoke to the “coercion and control” track of a national consumer conference. The response was immediate, Bob recalls. “They could see there was a better way.”   “Until then,” he says, “I hadn't realized that recovery was such a big deal. Then it hit me: We had a responsibility to make this work for our clients and to communicate it to others, so they could benefit, too.” Joining other recovery advocates, Bob and his staff have made countless presentations since, with their own organization's success to offer as proof.   Photo by Jeanne Ballard Thu, 01 Jul 2010 00:00:00 EST 6CF220D198314A00980C05F5763B6B26 http://www.behavioral.net/ME2/dirmod.asp?type=Publishing&mod=Publications%3A%3AArticle&mid=64D490AC6A7D4FE1AEB453627F1A4A32&tier=4&id=B1341CB3785C4027BD284221C9AEA80C When it comes to the safety of patients in a behavioral health facility, there is “no one-size-fits-all solution,” according to James Hunt, AIA, NCARB, an architect and consultant for the building and design of such facilities. Each population comes with its own risks and each organization must decide just how far to go to incorporate safety into design. The patient bedroom is a particularly high-risk area, since patients are unsupervised for the longest periods of time in this space. When furnishing a patient bedroom, staff should consider each item carefully. Beds . Hunt identifies “platform beds with no storage drawers or exposed wires, springs, or restraint loops” as the best choice. Facilities can minimize the institutional look and feel of these beds by selecting the bed's finish. Hunt suggests choosing a wood or wood-appearing finish, such as synthetic materials with a surface made to look like wood, as long as it is well-sealed and durable. Facilities may also choose to select plastic beds, rather than wood, as these can be more durable ( figure 1 ). “These have the advantage in that they … have no joints into which liquids can penetrate,” Hunt says.     Figure 1. Plastic, platform beds are a safe and durable choice for facilities (mattress not shown. Photo by Norix Group, Inc. Whatever the bed choice, Hunt advises facilities that these beds be anchored firmly to the floor “to reduce the likelihood of patients using them to barricade” bedroom doors leading out into the corridor. Dressers, armoires, and closets . According to Hunt, “clothes poles and hangers have been a significant issue” for patient safety for many years. Patients have commonly used these features as ligature attachment points from which to hang themselves. To reduce this risk, the Facility Guidelines Institute eliminated space for hanging clothes as a requirement for facilities, effective this year (see FGI Guidelines for the Design and Construction of Health Care Facilities , 2010 edition). Instead, Hunt recommends a sloped, open-front cabinet with fixed, shallow shelves ( figure 2 ). The selection of this type of product: Ensures that patients cannot easily sit or climb on the top of the cabinet's sloped surface; Eliminates cabinet doors, which are “often used as an attachment point,” and reduces the risk of hanging; Reduces the risk that the secured, shallow shelves can be used for climbing or removed for use as weapons; and Eliminates drawers, which can also be broken, used as attachment points, or removed and used as weapons.   Figure 2. Shallow shelves and a sloped top reduce climbing and hanging risks from shelving units. Photo by Norix Group, Inc. Hunt insists that, like beds, these cabinets should be securely anchored to walls or floors. Nightstands, desks, and chairs . Because these furnishings are typically light in weight, Hunt says that facilities may need to eliminate the potential for patients to stack or throw nightstands, desks, and chairs. This can be done by anchoring them to the floor. The presence of drawers should also be eliminated by replacing them with open shelves. For desk chairs, Hunt suggests choosing products that are lightweight plastic, as they “are not easily broken” and “do not make good weapons.” Windows and window coverings . Windows are highly susceptible to abuse by patients, according to Hunt. Because of this, adequate selection of durable glass is essential for the patient bedroom. The FGI Guidelines refers facilities to specific American Society for Testing and Materials (ASTM) tests at http://www.astm.org for window glazing impact resistance ratings. Some facilities choose to use clear polycarbonate (Lexan) for windows in patient areas because it is very difficult to break. However, it is susceptible to being scratched. There are some mar-resistant and abrasion-resistant coatings available that will help reduce this problem. In the event that patients scratch the polycarbonate windows, Hunt suggests keeping replacement panels on hand. Window coverings pose a potentially high safety risk for patients, as blinds, draperies, curtain rods, and cords or chains for adjustment could be used for hanging. To prevent this, Hunt identifies “mini-blinds sealed between layers of the exterior window glazing” as the best selection for window coverings, provided that “the device used to adjust the position of the blind [does] not provide a ligature attachment point.” For facilities that cannot afford or use such window coverings, Hunt makes another suggestion: a flush-mounted track with break-away drapes ( figures 3 and 4 ). This track is directly mounted to the ceiling, reducing the risk that patients can hang from it. The fabric selected for the drapes should be “breathable, to reduce the risk that patients use it to suffocate themselves.” Facilities should also be sure to eliminate any and all cords, chains, and wands typically used to adjust drapes.   Figures 3 and 4. Flush-mounted curtain tracks are secured to the ceiling (left) and lined with safety tabs for breakaway drapes (right). Photos by Imperial Fastener Company, Inc. Doors . Hunt asserts that the selection of doors and door hardware for patient bedrooms remains “a complex issue without a clear solution at this time.” However, he does have several recommendations that he has found to be effective in his own facility design projects. His first recommendation is to select an “in-swinging” door for the bedroom. However, he notes that this could pose a potential opportunity for patients to barricade themselves in their rooms. To reduce this risk, Hunt presents several options: A “door within a door,” or “wicket.” Hunt says that this “smaller panel in the center of the primary door” should be hinged to swing outward into the hallway, but should be locked at all times, except in emergencies. An unequal pair of double egress doors. “This involves a primary door of the required width that swings into the room and an adjacent door that is approximately 18 inches wide that swings into the corridor,” Hunt says. “The narrow leaf should be locked at all times, except in emergencies.” Similarly, facilities could also choose an unequal pair of doors divided by a mullion-or vertical frame-that separates two doors. “[This] provides a more secure attachment of the smaller leaf,” Hunt says. A double-acting door with an emergency stop. “This door normally swings into the room and can be swung out if a device in the jamb is depressed to allow movement in the outward direction,” Hunt says. “This solution requires the use of center pivot hinges which present some potential hazards.” Anchored furniture, which reduces the possibility of the barricade hazard. Hinges on all door selections should be continuous (piano hinges) with sloped “hospital tips,” according to Hunt. All applicable code and regulatory officials must be consulted before deciding on any of these suggestions. Door locks may also present an opportunity for patient suicide or self-harm, as they provide attachment points from which one could hang a ligature. Because of this, Hunt says that “standard knob or lever locksets should never be used on any patient accessible door.” Instead, he suggests the following options: Anti-ligature levers with a conical rose ( figure 5 ); Push/pull locksets, also known as paddle handles, that resist downward pressure; and Crescent handle locksets, which resist upward, downward, and transverse attachment.   Figure 5. The conical shape of Stanley Patient Safety Levers (SPSL) prevents patients from securing attachments to them. Photo by Stanley Security Solutions, Inc. An over-the-door alarm can alert staff if a hanging attempt is being made by a patient. These pressure-sensitive strips are avail-able from at least three companies, Hunt says. Flooring . Floors of patient bedrooms pose less of a safety risk than other components. However, patients may be inclined to damage or urinate on floors, according to Hunt. To secure flooring and prevent it from being picked or pulled loose, Hunt suggests sheet vinyl or broadloom carpet. “Both of these materials provide a minimum of seams at which patients can tamper,” he says. Solution-dyed yarn and moisture-resistant backing for carpet is also preferred. If urination is a high concern, Hunt suggests seamless, resinous flooring-which is durable, resistant to chemicals, and easy to clean-and an integral base. According to the Joint Commission, 75 percent of suicides occur by hanging in a patient bedroom or bathroom. Because of this, facilities should take as many precautions as they find necessary to protect their patients from self-harm or suicide in these environments. “Each facility must evaluate its patient population, staffing, and other issues to determine the level of risk it is willing to accept,” Hunt says. In a later article, Hunt will outline the strategies and components facilities may utilize to reduce risks in patient bathrooms. Designing a new market When James Hunt, AIA, NCARB, first began planning and designing behavioral health facilities, he says that product manufacturers wouldn't give him the time of day regarding the development of new products for the behavioral health population. After working in the industry as an architect and consultant for several decades, Hunt teamed up with long-time colleague David Sine, ARM, CSP, CPHRM, in 2003 to write the Design Guide for the Built Environment of Behavioral Health Facilities, one of the few resources for organizations on building a safe, but still visually pleasing, environment. The guide is currently in its fourth edition and available for free online at http://www.naphs.org . Hunt says that the design guide has, hopefully, helped raise awareness of hospitals, designers, and manufacturers that the behavioral health market is unique and must be designed for carefully in order to achieve a high level of safety for both patients and staff. Behavioral Healthcare 2010 July-August;30(7):32-34 Thu, 01 Jul 2010 00:00:00 EST B1341CB3785C4027BD284221C9AEA80C http://www.behavioral.net/ME2/dirmod.asp?type=Publishing&mod=Publications%3A%3AArticle&mid=64D490AC6A7D4FE1AEB453627F1A4A32&tier=4&id=644B08AFC8FC48D08C53C86A99C47E64 Get ready to squirm in your seats because we need to have a talk with you about spirituality. Spirituality is a topic we behavioral health types have shied away from: Professionals are taught to avoid it in their practices, and organizations have concerns about the separation of church and state. Many of the people who use our services, however, tell us that some form of spirituality plays a key role in their recovery process. So, since we're all trying to create opportunities for people to recover, we'd better get over ourselves and figure out how to talk to people about this. We've asked Rev. Laura Mancuso, a psychiatric rehabilitation counselor and interfaith minister, to help us discover ways of including spirituality in program planning and initiate conversations with people that will help them develop spiritual competence. Laura worked in the public mental health field at the local, state, and national levels for 15 years before her own journey of health challenges and personal losses culminated in a calling to become ordained. As an interfaith minister, she strives to honor all faith traditions, as well as the beliefs and life philosophies of those who do not adhere to any religion. Laura observes that “spirituality is highly personal, very central to a person's inner life, and oftentimes inseparable from one's cultural identity. It seems to me that if mental health programs can figure out how to respect and support the spirituality of the people we serve and the people we employ, we will have figured out how to respect and support their very essence as human beings. That's why spirituality should be included in programs that intend to be holistic, culturally competent, and recovery-oriented.” The Joint Commission's Standards and Elements of Performance require healthcare organizations-including accredited behavioral health organizations-to assess how a person's spiritual outlook may affect his or her care, treatment, and services. The February 2005 issue of the Joint Commission's newsletter, The Source , states: “Spirituality can be defined as a complex and multidimensional part of the human experience-our inner belief system. It helps individuals search for the meaning and purpose of life, and it helps them experience hope, love, inner peace, comfort, and support.” 1 Aren't those things we could all use more of? Then why is it so hard for mental health programs to “go there”? There are many reasons. Although it's now shifting (see Milestones in the recognition of spirituality in mental health wellness and recovery ), professional training programs warned students for decades not to discuss religion or spirituality with clients, as it was thought to foster delusions. Publicly-funded programs must be careful not to promote religion, or to favor one religion over another. Incidents of discrimination and violence on the basis of religious beliefs create more fear. The drive to improve the credibility of our interventions through scientific evidence causes us to turn away from concepts and processes that are more difficult to measure. Given these challenges, the most common response is to avoid the topic altogether. The challenge before us is to wade into these murky waters with our eyes and hearts open, meet myths and misconceptions with facts, and listen to what service recipients have told us over and over: Spirituality is often a valuable resource in the recovery journey. Here are a few things to avoid while wading in: Avoid proselytizing. Exploring one's spirituality is a very personal experience. Each of us needs to discover our own way of relating to spiritual issues. Programs should not favor one religion over another. Service eligibility should not be conditional on expressions of faith or participation in religious ritual. Humanists, agnostics, atheists, and other secularists should not be excluded-directly, indirectly, or even subtly. These are basic premises of welcoming spirituality at non-discriminatory workplaces and service sites. Following these core practices still leaves a whole lot of room for dialogue about spirituality. Now that we know what not to do, what can we do to help people develop spiritual strength that supports their recovery journey? One approach is to talk about spirituality as one of the three parts of our basic makeup: body, mind, and spirit. Most of us know how to take care of our bodies, and in our business, we talk a lot about how to manage our minds. Since we've largely avoided conversations about spirit, we haven't given people much support to develop competencies in this area. Next month we will wade deeper into this subject and explore more approaches to supporting this important aspect of recovery. In the meantime, here are some ideas that can create an opening for a supportive, recovery-based conversation about developing spiritual competencies: A good place to start is just listening to what people have to say about spiritual issues. As simple as this may sound, it's a step many of us haven't yet taken since we have not been open to having this conversation. We can ask how people understand the words “spirituality” and “religion,” and if they view them as distinct. Listen deeply to what they say. We can ask what gives their lives purpose and meaning. For example, the following questions were developed for use by physicians: “What do you hold on to during difficult times?” “What sustains you and keeps you going?” “What aspects of your spirituality or spiritual practices do you find most helpful to you personally?” “Is there anything I can do to help you access the resources that usually help you?” 2 If people express interest in gaining spiritual competencies, we can describe some practices that many others have found helpful, such as: prayer, meditation, contemplation, reading inspirational books, journal writing, spending time in nature, taking part in religious services, or volunteering services to others. We can show interest in and provide support for their spiritual findings and encourage them to stay with practices that support their recovery, and to let go of those that don't. Spirituality is different from religion. It has less to do with organized approaches and is more individualized. But since there is a strong connection between the two, let's look at what the national polls reliably indicate about religion. They say that religion is an important facet in the lives of the vast majority of Americans. In 2009, Newsweek stated that polls since 1992 have consistently found 85 percent of Americans say religion is “very important” or “fairly important” in their lives. 3 Research also indicates that faith, religion, and spirituality play important roles in coping with stress, trauma, and illness. 4,5 Why would we assume that people with psychiatric conditions are any different? Anything that can support the resiliency of the people we serve should definitely be our business. We must move beyond our ambivalence about including spirituality in mental health programs if we intend to provide holistic, culturally competent, and recovery-oriented services. Lori Ashcraft, PhD, directs the Recovery Opportunity Center at Recovery Innovations, Inc. in Phoenix. She is also a member of Behavioral Healthcare's editorial board. William A. Anthony, PhD, is director of the Center for Psychiatric Rehabilitation at Boston University. Rev. Laura L. Mancuso, MS, CRC, serves the mental health community in California as an interfaith chaplain, and was director of the California Mental Health and Spirituality Initiative from 2008-2010. References The Joint Commission. The Source ,February 2005, 3 (2),p. 7. Anandarajah Gowri and Hight Ellen. “Spirituality and Medical Practice: Using the H.O.P.E. as a Practical Tool for Spiritual Assessment”. American Family Physician, 63 (1),January 2001 ,pp. 81-89.Available at: http://www.aafp.org/afp/2001/0101/p81.html . Stone Daniel. “One Nation Under God?” Newsweek, September 20, 2009.Available at: http://www.newsweek.com/id/192915 . Lukoff David. “Spirituality in the Recovery from Persistent Mental Disorders.” Southern Medical Journal, 100 (6),June 2007.Available at: http://www.smajournalonline.com . Peteet John “Selected Annotated Bibliography on Spirituality and Mental Health0.” Southern Medical Journal, 100. (6),June 2007.Available at: http://www.smajournalonline.com . Behavioral Healthcare 2010 July-August;30(7):7-8 Thu, 01 Jul 2010 00:00:00 EST 644B08AFC8FC48D08C53C86A99C47E64 http://www.behavioral.net/ME2/dirmod.asp?type=Publishing&mod=Publications%3A%3AArticle&mid=64D490AC6A7D4FE1AEB453627F1A4A32&tier=4&id=33F29C50ECAC4E3C85195418692D4FBA According to the Mental Health Risk Retention Group (MHRRG), the most common liability claims made against community mental health centers (CMHCs) are related to sexual misconduct, patient violence, suicide, and medication errors. These claims can lead to expensive lawsuits, patient injuries, and damaged reputations. Many underfunded and understaffed CMHCs, damaged by national budget constraints, don't have the necessary resources or manpower to implement company-wide quality improvement initiatives that can lessen or eliminate these risks. But Lakeside Behavioral Healthcare, based in Orlando, Fla., has created a company culture built upon quality improvement, which has led to their receipt of two Negley Awards in 2009 and 2010. Lakeside's award-winning initiatives-“Minimizing Medication Errors” and “Preventing Sexual Misconduct in the Workplace”-are just small pieces of a broader quality improvement program, one that is rooted in Lakeside's organizational values and instilled in new staff members the moment they begin their careers at the CMHC. Creating a system of quality care When Diana Lee “D.” Jackson, vice president of quality and risk management, began her career at Lakeside in 1989 as the executive assistant to the executive director, Lakeside's 30 individual programs operated independently. These silos developed their own practices, processes, and standards for delivering care. Jackson took over the quality and risk management department in 1992, just in time to spearhead Lakeside's accreditation process with the Commission on Accreditation of Rehabilitation Facilities (CARF). “I went through all the offices and procedures for CARF, and I identified that every little program area did its own very unique thing,” Jackson says. “It was very repetitive for programs. They never communicated with each other.” She recognized that the key to developing a system of care was to unite the different program areas under one company-wide approach, with one way of monitoring “what we did and how we did it.” Jackson created the Performance Improvement Committee (PIC), a strategic, governing body to oversee Lakeside's company-wide quality standards and practices. With the PIC in place, Jackson established five additional standing committees (see figure ). Each would oversee a specific aspect of the company and ensure organizational commitment to Lakeside's six Pillars of Excellence (Environment of Care, Professional Staff, Services to Clients and Families, Corporate Leadership, Resource Development, and Community Awareness) and to Lakeside's foundational values, or “Rocks” (Accountability, Customer Service, Communication, Teamwork). These five tactical committees are:   Figure. Lakeside Behavioral Healthcare's quality improvement structure Consumer and Environmental Safety Committee. Representing the Environment of Care pillar, this committee is made up of representatives “from front-line staff to the vice president,” as well as the risk manager, says Jackson. Infection Control and CLIA/Waived Testing are sub-committees reporting to the Safety Committee. Clinical and Ethical Practices Committee. This committee, made up of clinical supervisors, directors, and managers, represents the Services to Clients pillar and oversees company-wide practices for providing treatment. The committee evaluates each practice and then develops staff-education projects to improve them. Pharmacy, Training, Peer Review Teams, and the Psychiatric Emergency Interventions (PEI) Review Team are subcommittees reporting to this committee. Compliance Committee. The Compliance Committee represents the Resource Development pillar, ensuring that contract regulations and rules are followed throughout the organization. Its subcommittees include the Service Event Review Team, the Contract Review Team, and Document Imaging. Staff Relations Committee. This committee is responsible for maintaining the welfare, morale, and health of Lakeside's employees and holding up the organization's foundational values, or “Rocks.” Privileging Committee. The Privileging Committee represents the Professional Staff pillar and oversees the privileging and credentialing process for all new, independent practitioners for Lakeside's hospital unit. All tactical committees and sub-committees meet regularly, usually once a month. They review trends, identify problem areas, and recommend improvement activities, which are then reported back to the PIC monthly. “One of the things that goes along with the PIC is the performance assessment system, which is a very intricate plan for how we measure outcomes for each of our clinical programs and the processes of each program,” Jackson says. “Each program has established a plan for their area, and they measure those on a monthly basis.” From those measurements, the PIC creates detailed reports. Then, using data from the reports, the PIC identifies areas for strategic improvement. The result is a company-wide initiative, such as the “Minimizing Medication Errors” program. All-line staff involvement Though some committee assignments are position-driven, Lakeside opens up its committees to all staff members on a volunteer basis. With over 600 staff members and 30 program areas, the organization has found that this integrated committee system improves communication, keeps staff informed, and maintains a sense of togetherness. “Staff are basically educated from orientation on about our performance improvement process and our pillars of excellence,” says Randy Hawkins, LMHC, NCC, director of quality health information services. “We never have to struggle to get people interested because it's an opportunity for them to voice their opinions and be part of the bigger picture.” Staff are also encouraged to make quality improvement suggestions even if they are not involved in the PIC structure. Whenever a problem or opportunity for improvement is noticed, staff members are able to take these concerns directly to the appropriate committee for consideration. When warranted, ad-hoc, short-term performance improvement teams made up of front-line staff are then formed to assess the process in question and recommend improvements. The appropriate committee then approves the team's findings. “The front-line staff, especially if they have a concern that really touches what they're doing, love to be on the performance improvement team,” Hawkins says. “They're able to really make a difference in their own work and the organization as a whole.” The involvement of line staff in its quality improvement programs helped Lakeside's medication management and sexual misconduct programs stand out among the applicants for the Negley Awards, according to MHRRG president Nicholas Bozzo. “They had a good diversification in both [2009 and 2010] in the level of people in the organization who were involved in making that best practice come to fruition,” he says. “It was not just senior management driving it down, nor was it people at the bottom of the organization trying to convince senior management they had to do it. It was a nice blend of both.” This kind of ongoing, organization-wide improvement effort forms a solid defense against errors and litigation. Though Lakeside has not had a medication ordering error in three years nor any founded sexual misconduct allegations in the past two years, Jackson knows that it only takes one minor mistake to create a larger problem for any organization. “You can do everything right and still end up having a problem,” she says. “But when you're defending yourself in litigation, the fact that you've done your due diligence and taken all these actions really does show to those judging the case that you've done everything you could to prevent this.” Behavioral Healthcare 2010 July-August;30(7):29-30 Thu, 01 Jul 2010 00:00:00 EST 33F29C50ECAC4E3C85195418692D4FBA http://www.behavioral.net/ME2/dirmod.asp?type=Publishing&mod=Publications%3A%3AArticle&mid=64D490AC6A7D4FE1AEB453627F1A4A32&tier=4&id=12465E5D4F9A451F8C7E38C3F3E20E9F The HITECH provisions built into last year's American Recovery and Reinvestment Act (ARRA) promise billions in incentives for healthcare providers who would upgrade to electronic health records (EHRs) as part of a long-term strategy to improve healthcare quality and reduce costs. Now, with the implementation of parity for mental health and substance use disorders plus the major reforms promised in the Patient Protection and Affordable Care Act, behavioral health providers and organizations are confronted with a huge agenda for change: more payers, more consumers, more collaboration with other caregivers, and the prospect of full integration with the medical community. With the help of research into public documents and timely guidance from industry experts-including members of SATVA- Behavioral Healthcare dove into the EHR incentive provisions of the HITECH Act, looking at the implications specific to behavioral health providers. Where is the EHR money, and when is it available? The government, through the HITECH provisions of ARRA, is offering financial incentives to eligible professionals (EPs) and hospitals that participate in the Medicare and Medicaid programs. The incentives are intended to help them pay for EHR systems that are needed as a part of ongoing quality improvement and payment reforms. For hospitals, the HITECH Medicare and Medicaid EHR incentives will become available as early as October 2010. Note that for hospitals, meaningful use reporting requirements and incentive payment years are tied to federal fiscal years, which start October 1 and end on September 30. Thus, hospital incentives under both programs become available in federal fiscal year 2011, which begins on October 1, 2010. EHR incentives for EPs under both the Medicare and Medicaid EHR incentive programs are tied to calendar years. Incentives for EPs become available in January 2011. (Because states administer Medicaid-funded programs, all states were asked by CMS to submit plans under which they would qualify and administer Medicaid EHR incentive funds. These plans are subject to CMS approval, which could cause some delay in the start dates in some states.) Are behavioral healthcare professionals and facilities now eligible for this money? At present, many behavioral health professionals are not yet eligible and most facilities are excluded. Yet, passage of a new bill could change that soon. Here's what happened: The original ARRA legislation specifically identified physicians and nurse practitioners as eligible professionals, but excluded other licensed behavioral health providers as well as psychiatric hospitals from the definitions of those who would qualify for EHR incentives. A bill to “fix” these disparities, The Health Information Technology Extension for Behavioral Health Services Act of 2010 (HR 5040), was introduced in the U.S. House of Representatives by Congressmen Patrick J. Kennedy and Tim Murphy in April 2010. This bill specifically includes typical behavioral health professionals including clinical psychologists and clinical social workers in the EP definition used for incentives, and specifically includes psychiatric hospitals and behavioral health/addiction treatment centers in its “hospital/organizational” definition. What's a “certified” EHR system or EHR system upgrade? To qualify for the initial year of incentives, an EP or hospital must use an EHR that is “ARRA Certified.” The certification means that the EHR incorporates the features required to support current, or Stage 1, “meaningful use” requirements released by the Office of the National Coordinator (ONC). A “temporary” EHR certification rule became effective on June 24, 2010. Temporary certification is intended to fill the gap until organizations who apply to be Authorized Testing and Certification Bodies (ATCBs) are approved to participate in the permanent certification process. According to the ONC, the goal is to have the ATCBs operational in summer 2010 and certifying EHRs sometime in the fall according to Stage 1 (2011) meaningful use requirements. (It is expected that the “temporary” certification program will sunset at the end of 2010.) In 2013 and 2015, respectively, EHRs certified under the Stage 1 requirements must be recertified in a similar manner to demonstrate that they offer the functionality needed by users to meet Stage 2 (2013) and Stage 3 (2015) meaningful use requirements. If I buy a certified EHR system or upgrade, will I (or my hospital/organization) meet meaningful use requirements? No. The idea that “certified” software alone is sufficient to demonstrate meaningful use is a misconception, explains Michael Morris, president of Anasazi Software. “People sometimes think that if they buy a certified EHR, then [meaningful use] is on the vendor. That's not the case. Certification is on the vendor, but meaningful use is on the EP or hospital.” In other words, after the vendor installs the EHR software, users must do the hard work of adapting people and processes to the EHR so that they are meaningfully using the EHR as a part of their routine business activity. That will take planning, process analysis, process redesign, software training, and a lot of adjustment. What are meaningful use criteria? Generally, “meaningful use” criteria are performance criteria that HHS and ONC have decided will demonstrate that an EHR system is capable of meeting the data, security, networking, interchange, and other requirements needed to support national healthcare reforms that strive to improve quality, ensure safety, and reduce costs. There are actually three sets, or stages, of meaningful use (MU) criteria envisioned by the ONC: Stage 1 MU criteria focus on data capture and sharing and are available today. Stage 2 MU criteria will focus on advanced clinical processes and are still being developed. Stage 3 MU criteria will focus on improving outcomes, but are not yet in development. We'll cover the evolving stages of meaningful use criteria in upcoming issues of Behavioral Healthcare . How do EPs and hospitals qualify to start the incentive payments? EPs or hospitals become eligible for the first and largest EHR incentive payment in one of three ways: Declaring a “non-binding intention to participate in the incentives program.” This enables receipt of the first year's incentive even before the EHR purchase or implementation takes place. Purchasing or starting implementation of a “certified” EHR system. For those who already own an EHR, a “certified” EHR system upgrade also qualifies for funding. Demonstrating meaningful use requirements for that payment year. While Medicare EPs and hospitals must demonstrate meaningful use for a 90-day period of the first year in which they receive payment, it does not appear that there is a similar requirement for Medicaid EPs and hospitals in the first year. However, it is clear that all EPs and hospitals must demonstrate meaningful use throughout the year following their first payment year. The goal of the regulations is to put all EPs and hospitals on track to achieve Stages 1, 2, and 3 of meaningful use by January 1, 2016, with the stages scheduled as shown in figure 1 . This figure makes clear that EPs and hospitals who adopt early can qualify for up to two years of funding for both Stage 1 and Stage 2 meaningful use requirements. Later adopters will face a shorter implementation timeline and a steeper adoption curve.   Figure 1. Stage of meaningful use criteria by payment year What happens if an EP or hospital/organization fails to meet meaningful use requirements? Medicaid EPs and hospitals can keep the first year's incentive-there's no penalty involved. What happens to Medicare EPs and hospitals who take the first year's incentive up front, yet fail to meet the 90-day meaningful use demonstration required in their first payment year is not entirely clear. (Possibly a claw-back mechanism could be used, since their incentive would have, if received in advance, been paid out as a percentage of their Medicare billings.) Beyond the first payment year, the rules are clear: Any EP or hospital that fails to meet meaningful use requirements will lose the chance for subsequent EHR incentive payments in all years that the requirements are not met. How do the Medicaid and Medicare EHR incentive programs compare to each other? As seen in figures 2A and 2B , the programs have similar requirements for meaningful use and EP/hospital participation. But they differ in other areas, including program duration, available incentives, administration and payment, and penalties for non-participation.   Figure 2A. EHR incentives for eligible providers (EPs)   Figure 2B. EHR incentives for hospitals/organizations How long are the Medicaid EHR incentives available? How are they calculated? The Medicaid EHR incentive program offers EPs and hospitals up to six years of payments over a 10-year period. Medicaid incentives for EPs : EPs may take advantage of the program for six years in the period starting in calendar year 2011 through the end of calendar year 2021. EPs must qualify to receive their first payment by or before calendar year 2016, then meet meaningful use requirements to receive the maximum incentive payment of $63,750 by the end of the program, as shown in figure 3 .   Figure 3. EHR incentives for Medicaid eligible professionals (EPs) Medicaid incentives for hospitals/organizations : Hospitals can participate in the program for six years from the start of fiscal year 2011 (October 1, 2010) through the end of fiscal year 2021. (For states still awaiting CMS approval of their Medicaid EHR incentive administration plans, the start date could be later.) Medicaid EHR incentives for hospitals/organizations are calculated as shown in figure 4 . Hospitals may participate in both Medicare and Medicaid EHR incentives, provided they meet the patient population and timing requirements.   Figure 4. EHR incentives for Medicaid eligible hospitals/organizations How are the Medicare EHR incentives calculated? Medicare incentives for EPs : The Medicare EHR incentive program for EPs begins in calendar year 2011 and extends through the end of calendar year 2016. Within that period, Medicare EPs may qualify for up to five years of payments to a maximum of $44,000. To qualify for the maximum level of payments, Medicare EPs must receive their first year's incentive payment during or before calendar year 2012, and then qualify for additional payments by meeting meaningful use requirements for subsequent years. Medicare EHR incentive payments for EPs equal 75 percent of Medicare allowable charges for services provided by the EP in the qualifying year, up to the maximum annual level shown in figure 5 . Incentive payments are increased for EPs who serve in “health professional shortage areas” (an additional 10 percent payment).   Figure 5. Medicare EHR incentives for eligible professionals (EPs) Incentives are reduced for Medicare EPs who are “late adopters” or who fail to achieve meaningful use before or during 2012 by reducing the size/number of payments available in 2013 and 2014. The Medicare incentive program also penalizes Medicare EPs who do not adopt EHRs or do not meet meaningful use requirements by the end of 2015. They will face “payment adjustments” as soon as 2015 or 2016, which will appear as deductions by Medicare from the payment allowed for their services. Medicare incentives for hospitals/organizations : Medicare hospitals can qualify for up to four consecutive years of EHR incentive payments under the incentive program, which starts in fiscal year 2011 (October 1, 2010) and concludes on September 30, 2016. The formula used to calculate Medicare EHR incentives for hospitals is very similar to the one used for Medicaid incentives, which is shown in figure 4 . The differences are: 1) Medicare program information is used in step two of the formula shown in figure 4 , and 2) transition factors for Medicare hospital payments are reduced for those who participate after 2013. If Medicare hospitals do not adopt EHRs, or fail to meet meaningful use requirements by the end of fiscal year 2015, Medicare may begin making “payment adjustments” of one percent or more from the payment allowed for their services. What are the advantages of going forward right away? EPs and hospitals that are able to proceed with EHR implementation and upgrade programs in the near term will have a longer timeframe in which to successfully demonstrate the three successive stages of meaningful use, which are due by 2016. Those who start by 2011 will have five years, while those who wait until 2013 will have just three. Those who begin in 2014 and 2015 will lose not only implementation time, but also funds, since a reduced transition factor applies to their incentive payment. How much will accomplishing meaningful use cost? No one can predict exactly what an EHR implementation will cost or exactly what it will require to succeed as planned, but a good program manager and a reputable vendor are important to the process. EHRs are being offered because achieving the nation's vision of a reformed health system won't be easy, and it won't be cheap. Morris suggests a rough rule of thumb for costing a system implementation: If, within a five-year period, external costs for an EHR implementation (software, license, development, services, support paid to consultants/vendors) costs X , Then internal costs for the system will equal 2X for the same five-year period (planning, project management, staff/clinician training, process changes, administration, etc.). A rough estimate of total system cost is 3X . So, while the available HITECH incentives are substantial, they probably won't do the job. “The fact is, even the maximum level of EHR incentive funding is unlikely to cover a provider's cost of procuring, installing, administering, training, and achieving Stage 1 of meaningful use with an EHR system,” says Morris. There's also likely to be a time crunch if you apply for the first year's incentive before you've made substantial progress in implementing the EHR, because meaningful use has to be demonstrated by Medicare EPs and hospitals for 90 days in the same calendar year the first payment is received. For payment year two and all subsequent years, all EPs and hospitals must demonstrate meaningful use throughout the year to qualify for incentives. Morris says that the challenge isn't so much about knowing what the meaningful use requirements are, but rather in implementing the process changes, training, measurement, and follow-through needed to accomplish, measure, and demonstrate them-while maintaining other daily work activities. He expects that small providers will have the best chance to implement quickly, while medium-sized and large providers will likely take more time. Timeframes for implementation may range from less than one year to several years, again depending largely on the size of the organization. Behavioral Healthcare 2010 July-August;30(7):10-15 Thu, 01 Jul 2010 00:00:00 EST 12465E5D4F9A451F8C7E38C3F3E20E9F http://www.behavioral.net/ME2/dirmod.asp?type=Publishing&mod=Publications%3A%3AArticle&mid=64D490AC6A7D4FE1AEB453627F1A4A32&tier=4&id=59150ED4B1544C9A9E7BEB7D3D5CDC6C On June 9, the major associations representing the mental health and substance use fields assembled in a historic gathering to affirm that they will speak with one voice in implementing national health reform. Those gathered unanimously agreed to combine the efforts of the Whole Health Campaign and the Coalition for Whole Health into a single entity-represnting 110 organizations-with the latter name, all in support of implementing the provisions of the Patient Protection and Affordable Care Act of 2010. This action is remarkable, given a past in which the mental health and substance use care and prevention fields have often been at odds over issues ranging from resource allocation to clinical control. Points of fissure have also formed around differences including public vs. private, treatment vs. prevention, state vs. county/local, managed care vs. provider, and more. Both the Campaign and the Coalition have worked to bridge these differences so that the fields can speak with a united voice. Effective consensus was reached more than two years ago around three principles developed by the Whole Health Campaign: good health insurance coverage for persons with mental health and substance use conditions; good, integrated care that spans mental health, substance use, and primary care; and good prevention services for mental health and substance use conditions. On these principles, the Campaign produced eight policy papers, and the Coalition advocated for the major mental health and substance use provisions in the new reform legislation. Several years of vital work lie ahead. This work will involve close collaboration with the Secretary of HHS; participation on boards, commissions, and taskforces; review of draft regulations; and communication with the field so its views are reflected accurately and it is informed of current developments. The reform legislation represents a once-in-a-lifetime opportunity to make the mental health and substance use fields fully equal participants in healthcare, where we can and must succeed. What are the reform-related issues that will be addressed? Insurance reform . More than 32 million adult Americans will receive health insurance coverage through these provisions. This will occur through expansion of the Medicaid program for all who are at 133 percent of the Federal poverty level or less and the creation of State Health Insurance Exchanges. Both of these provisions will go into effect in 2014. About 10.5 million of these newly insured persons will have a mental health or substance use condition. My personal estimate is that the newly insured will bring $68 billion per year in new resources to our fields. Coverage reform . Coverage reform has many features: elimination of pre-existing condition provisions in current plans; extension of parental coverage for adult children to age 26; elimination of annual and lifetime limits on coverage; and elimination of co-pays for prevention and promotion interventions. Each of these provisions will serve to expand access to mental health and substance use care. We need to begin to prepare now for these new coverage features. Quality reform . The Secretary of HHS has been directed to address quality reform. This will involve development of demonstrations of patient-centered medical homes, including behavioral health medical homes; development of approaches and demonstrations for accountable care organizations that reintegrate care for the whole person; implementation of evidence-based practices; and implementation of quality measures. Because there cannot be good health without good mental and addictive health, we must work hard to influence the quality agenda. Payment reform . This reform will be designed to improve the efficiency of our payment systems. Most state Medicaid systems use a costly, inefficient, encounter-based payment system. The Secretary of HHS will be designing episode and case-rate systems that adjust for performance, improve efficiency, and promote improved quality. We must pay particular attention here, since episode and case rates are likely to include mental health, substance use, and primary care. Information technology reform . Financial incentives for adoption of electronic health records and personal health records encourages use of these tools to support better reporting and quality improvement. Today, more than ever, the mental health and substance use fields must speak and act with unity as we participate in the implementation of health reform. I invite you to engage fully in the effort, every step of the way.     Ron Manderscheid, PhD, worked for more than 30 years in the federal government on behavioral health research and policy. He is the Executive Director of the National Association of County Behavioral Health and Developmental Disability Directors as well as a member of Behavioral Healthcare 's Editorial Board.   Behavioral Healthcare 2010 July-August;30(7):9 Thu, 01 Jul 2010 00:00:00 EST 59150ED4B1544C9A9E7BEB7D3D5CDC6C http://www.behavioral.net/ME2/dirmod.asp?type=Publishing&mod=Publications%3A%3AArticle&mid=64D490AC6A7D4FE1AEB453627F1A4A32&tier=4&id=427F8BE3E4BA45E089A4963BBD4CFF8B Staffing/Recruitment Services FasPsych, LLC FasPsych, LLC represents a group of licensed psychiatrists and psychiatric nurse practitioners who are able to provide ongoing coverage, via video teleconferencing and other web-based platforms, to behavioral health agencies in need of prescribing clinicians. FasPsych's mission is to provide immediate, innovative solutions to the ever-growing demand for behavioral health services and decreasing pool of qualified professionals. All FasPsych clinicians have extensive behavioral health experience and are skilled in providing services to diverse clients. Visit http://www.faspsych.com for more information.   PsychPros PsychPros matches qualified, credentialed job candidates to temporary, temp-to-hire, direct hire, and executive search assignments across the U.S. PsychPros is owned and operated by behavioral healthcare professionals. PsychPros provides organizations with access to an exclusive set of search strategies, such as: PsychSearch, a national databank with over 25,000 active job seekers; sourcing networks of colleagues across the country; Internet postings and advertising on job boards; and expert recruiters. Personnel offered are executive staff, clinical staff, and support staff. For more information, contact Holly Dorna at 513-333-4770 or visit http://www.psychpros.com .   Personal Health Records (PHRs) Afia, Inc. Afia's innovative approach to helping organizations design and implement PHRs employs a user-centric methodology to develop progressive features and gain support from behavioral health staff and consumers. Regardless of the vendor, a successful PHR requires a delicate balance of privacy and transparency. Afia meets directly with consumers and staff to determine the most effective system design and adoption strategy for each unique organization. Including both groups assures that the PHR becomes an effective clinical tool. For more information, visit http://www.afiahealth.com or contact Jeremy Nelson ( jeremy@afiahealth.com ).   Caring Technologies, Inc. Behavior Imaging ( http://www.caringtechnologies.com ) enables health and education professionals and their organizations to remotely interact with patients, specialists, and other staff members while building a library of shareable assets and a continuous health record. Features include a shared digital library, secure messaging, administration tools, fax/scan solutions, paperless forms, video capture, and Excel-compatible reporting. Behavior Imaging is used by behavioral health centers, over 500 U.S. classrooms, the U.S. Air Force, and universities around the world.   E*HealthLine The VITAL PHR enables real-time, secure access to up-to-date personal health records. With VITAL, consumers have the ability to retain, capture, exchange, review, update, track, and control their health records, and provide real-time communications with their providers for prescription refill and consultation. With VITAL, the consumers have the ability to store their health data within a health bank that can be accessed and shared with family members and/or healthcare providers, anytime and anywhere. Visit http://www.ehealthline.com .   Sigmund Software Supporting a long-term vision of a single, comprehensive patient health record for each patient, Sigmund's solution includes a web-based, health information exchange system, powered by InteHealth. The patient health record provides a patient-centric approach, empowering the patient to manage their health, and provide access to their complete health record from all sources to those who need it. For more information, visit http://www.sigmundsoftware.com or contact Cory Valentine, director of client development, at 800-448-6975 or CValentine@SigmundSoftware.com . The next issue's product/service center will focus on Online Education and Financial/Billing Software. To participate in these sections, e-mail lbarba@vendomegrp.com . Behavioral Healthcare 2010 July-August;30(7):35 Thu, 01 Jul 2010 00:00:00 EST 427F8BE3E4BA45E089A4963BBD4CFF8B http://www.behavioral.net/ME2/dirmod.asp?type=Publishing&mod=Publications%3A%3AArticle&mid=64D490AC6A7D4FE1AEB453627F1A4A32&tier=4&id=8F177AB6C11F42FDBE6704465017C116 Just a few years ago, Georgians in crisis or in need of behavioral health services had two options: find a provider on their own or call one of 25 “single-point-of-entry” lines serving portions of Georgia to get provider information. Both options required individuals to make their own appointments, which often weren't immediately available. Many who sought help ended up in hospital emergency rooms, state hospitals or local jails, significantly increasing the cost of care, or not receiving care at all. Efforts to improve this system were limited by the lack of quantifiable information about ease and speed of client access to services. And, in 2005, the problem got worse as Georgia's resources were further stretched by the arrival of over 120,000 Hurricane Katrina survivors, many of whom were suffering from serious depression, PTSD, or addictive disorders. In response to these challenges, the Georgia Department of Behavioral Health and Developmental Disabilities (DBHDD) used a competitive bid process in 2006 and selected Behavioral Health Link (BHL) to develop and manage a statewide toll-free crisis and access line, now called the Georgia Crisis and Access Line (GCAL). Statewide, GCAL would provide a “no wrong door” approach to access, offering telephonic crisis intervention, 24/7 service scheduling with consumer choice, real-time data and reporting for strategic planning, and a new degree of consistency and transparency. BHL is a private, Georgia-based company whose approach to integrated crisis intervention coordinates brief screening, triage/linkage, mobile crisis, and disaster outreach. GCAL was launched statewide on July 1, 2006, with a tagline of “A Crisis Has No Schedule.” To date, it remains the only statewide crisis and access line in the U.S. that can actively link callers, 24/7, to service providers. GCAL was the first U.S. crisis line to integrate the Substance Abuse and Mental Health Services Agency's (SAMHSA) Suicide Risk Assessment Standards (SRAS) into its call center protocols, enabling staff to view SRAS protocols on database screens during a call to help determine the appropriate level of care. It also earned the Commission on Accreditation of Rehabilitation Facilities' (CARF) first-ever accreditation as a Crisis and Information Call Center. Because BHL provides no direct services, GCAL operates as an honest broker, offering consistency, support, and service choices to those who call for help. GCAL referral outcomes Referral outcomes, by fiscal year 2007 2008 2009* (Projected) 2010 *In FY 2009, about 128,000 referrals were made. Agency referrals (routine appointments) 78% 76% 79% 80% Mobile crisis referrals (statewide) 5% 11% 10% 9% Intensive services referrals Private psychiatric hospitals Crisis stabilization programs State hospitals   17% 13% 11% 11% More than a hotline: a crisis safety net GCAL's services go beyond those of a “hotline” because it offers callers standardized, statewide access to a comprehensive and coordinated system of care. It functions as a safety net for individuals, communities, and the state by linking people to routine mental health, addiction treatment, and other services while providing emergency intervention when needed. Thus, it functions as an integral component of Georgia's comprehensive mental health system, ensuring access to and continuity of care. The recent economic downturn, which drove budget cuts for a variety of behavioral health and substance abuse prevention services even as demand for services increased, highlighted GCAL's value. For many, it was the only place they could turn to for help. Strong connections to mental health, substance abuse, and related providers across Georgia are critically important to the ability of GCAL staff to link callers to appropriate services. At present, relationships have been established with over 140 public or private agencies at about 240 sites. These include six inpatient state hospitals, 26 crisis stabilization programs, many law enforcement and 911 access centers statewide, three sub-acute detoxification programs, 30 private inpatient psychiatric hospitals, mobile crisis teams that serve 40 of Georgia's 159 counties, and 141 hospital emergency rooms. At times, GCAL staff will dispatch a mobile crisis team directly to a hospital ER when, based on established relationships and practices, ER staff wish to “divert” a patient seeking admission for services to community-based crisis or behavioral care.  On average, GCAL staff and systems manage more than 1,000 calls daily. To accomplish its mission, GCAL's operations coordinate knowledge, data, technology, and tracking systems to support licensed clinical staff (LCSWs, LPCs, and RNs) who provide callers with prompt, first-line triage and emergency/crisis support as well as other support staff who manage caller access and referrals to routine or non-emergency services. Through the process of handling a single phone call, GCAL staff: Conduct screenings to quickly assess callers' needs and risks, while engaging them, offering them choices, and using the least invasive interventions possible. Link callers, in real time, to routine services or crisis services (including mobile crisis response, when required). Day or night, callers can be scheduled with an appointment date and time at community mental health providers across the state, based on a schedule of routine and “emergent” appointments supplied in advance by the provider location. GCAL's personalized approach is supported by an interactive, flexible suite of call center software applications and databases. The software supports call triage by licensed clinical professionals, while helping support personnel manage non-emergency service needs by prioritizing the best, closest, or fastest available providers. Electronic call center boards provide staff with immediate performance feedback, helping them to track open cases and pending referrals. Additional software is available for intensive service providers to track waiting referrals and access real-time triage information. Dashboard reporting Beyond daily operations, GCAL's technology and operations are able to track, capture, and present-in dashboard form-key utilization data collected from GCAL callers-the kind of data that state officials had sought for years before. Generated monthly and available online, these real-time rolling updates present key state- and county-level indicators (e.g., abandonment rate, average speed of answer, hospital diversions) to state contract managers, community agencies, private partners, and the public at large. These reports provide decision makers with the data they need to improve services and operate more cost-effectively, show outcome data from state and county behavioral healthcare agencies, and improve GCAL's coordination with community stakeholders.  The same approach-dashboard-based reporting-has helped in addressing previous system issues as well. In 2008, when GCAL callers experienced delays in obtaining dispositions into inpatient psychiatric hospitals and crisis stabilization programs, BHL managers added staff and worked with Georgia DBHDD and other system stakeholders to develop an “Average Minutes Till Disposition” metric to track and improve disposition times. More recently, BHL developed an electronic interface, shared with DBHDD management staff, that monitors referrals to state facilities and associated wait times. This interface enables state staffers to track referrals, wait times, and acceptances to state facilities. GCAL facts Based in Atlanta, Ga. Serves all 159 counties 75 full-time employees and three shifts $4+ million operating budget (FY 2010), funded by Georgia DBHDD Call volume: About 1,000 calls per day and approximately 350,000 calls per year Service linkage: In FY 2009, 128,000 callers were linked directly to community-based mental health services. Suicide prevention: In FY 2009, GCAL staff supported 14,079 callers with suicidal desire; 12,915 with suicidal capacity; and 6,086 with suicidal intent. GCAL helps save lives At its core, GCAL is not about technology or innovation. It is about crisis intervention and a human interaction that engages and helps people. One example was 12-year-old Julie who sat home alone, struggling with ongoing depression but too anxious to talk to anyone about it. She considered ending her life by using her father's rifle. Instead, Julie called the hotline and spoke with a GCAL clinician who provided support. A GCAL staff member then stayed on the line for over an hour until the parents could be contacted and return home. The mother was not aware her daughter was depressed. Julie and her parents were willing to engage in treatment services and she was given an urgent appointment for the next day. This outcome was possible because GCAL's staff was equipped with the ability to schedule the appointment on a Sunday afternoon when local services were closed. She had the fastest, closest, best quality providers available at her fingertips through a sophisticated algorithm, and Julie's parents could make an informed choice of a community mental health provider agency. Efficiencies of a statewide approach In its nearly four years of operation, GCAL has: Saved over $70 million by diverting callers to community-based services, preventing the inappropriate use of emergency rooms and state hospitals (“hospital diversions”). Cut average patient time for intake to services by up to 60 percent. Saved $1.2 million/year in operating costs compared to the previous 25-line system. Cut the cost of handling a call-a cost borne by Georgia's DBHDD-to about $15 (FY 2009), while providing direct scheduling, linkage, and patient follow-up capabilities not available with other call-system alternatives. Removed barriers to service, simplified the appointment process, and reduced patient wait times for service. Enforced statewide consistency in the identification and use of appropriate and least-invasive treatment interventions. Provided a continuing source of performance data that supports continuous system improvement. Pamela Schuble, MSSW, ACSW, LCSW, is CEO of Behavioral Health Link, the provider of integrated crisis and access services that was contracted to operate the Georgia Crisis and Access Line. Gregg Graham, MA, MBA, is a partner in Behavioral Health Link and a member of Mental Health America's national board of directors, with 25 years experience in managing behavioral health and managed care organizations. David Covington, MBA, LPC, is a Behavioral Health Link partner, vice-chair of the SAMHSA National Suicide Prevention Lifeline Steering Committee, and currently serves as chief of adult services for Maricopa County Regional Behavioral Health Authority. Behavioral Healthcare 2010 July-August;30(7):26-28 Thu, 01 Jul 2010 00:00:00 EST 8F177AB6C11F42FDBE6704465017C116 http://www.behavioral.net/ME2/dirmod.asp?type=Publishing&mod=Publications%3A%3AArticle&mid=64D490AC6A7D4FE1AEB453627F1A4A32&tier=4&id=AC417C8F7421459D9FEF3B13350C06C1 A recent CDC study found that while 89 percent of adults agreed with the statement that “treatment can help persons with mental illness lead normal lives,” just 57 percent agreed that “people are caring and sympathetic to those with mental illness.” Though study authors speak of the need for continued efforts, activities, and media relations to boost these numbers still higher, I took comfort in the findings. In my 25 years as a writer, explainer, and persuader, I've found that people can be “educated” about something, but that they become “convinced” through the often random, coincidental, or accidental experiences of life-things that we would say “get you where you live.” That brings me to a short story: Some years ago, the house across the street from my family's home was sold. All the neighbors were, of course, curious and glad to observe the investments made by the new owner, seen in the stream of trucks and workmen going in and out for several weeks, making improvements indoors and out. As the work neared conclusion, my doorbell rang. I was visited by a longtime neighbor, a kind and compassionate person, who lived next to the sold property. With a note of concern, he told me that the property's title had been transferred and that a “a group home” was moving in. He had asked our city councilman to look into the matter. “Is it legal,” he wondered, “for such a home to be set up in a residential neighborhood?” The fact that it was indeed legal did not entirely resolve his concerns. Our conversations continued as he articulated issues that other neighbors and I wondered privately: “Who will be ‘in charge’ at this home?” “What kind of people will be living here?” “Who will we, our spouses, and our kids meet when we go to the mailbox?” We soon found out: three 30-something women and one young man, with a small team of social workers and caregivers who work regular shifts. At the residents' open house, we met their parents along with others who took an interest in the county's growing network of group homes. We saw the visits of their friends and relatives, the group of their peers that does landscape and maintenance work every week, the bus driver who picks up two of the residents every day. But one group we never saw at the home was the local police. Not once, though they have visited the homes of other neighbors on the street. I've come to know Beverly, the home's supervisor, who visited me to smooth over a concern about on-street parking. I know Veronica, a social worker who ran over to use the phone when she locked herself out, worried that she'd momentarily left a resident alone inside. And, I've come to know Roxanne, a pleasant, friendly woman whom I met on my way to the mailbox. On occasion, we catch up through a brief conversation. And, I see her signature next to those of the other residents on the holiday card that accompanies the plate of cookies they prepare for neighbors each holiday season. Though it seemed important at one time, I've never again wondered about the kind of people these are. Experience brought me the only answer that my family and the others on our street really need: They're our neighbors. Dennis G. Grantham, Senior Editor Behavioral Healthcare 2010 July-August;30(7):6 Thu, 01 Jul 2010 00:00:00 EST AC417C8F7421459D9FEF3B13350C06C1 http://www.behavioral.net/ME2/dirmod.asp?type=Publishing&mod=Publications%3A%3AArticle&mid=64D490AC6A7D4FE1AEB453627F1A4A32&tier=4&id=E928B1228BA64BE18B8EDC1F18F3D35D Despite consistently higher rates of depression, suicidality, binge drinking, and marijuana use among lesbian, gay, bisexual, and transgender (LGBT) individuals, a new SAMHSA report from the Substance Abuse and Mental Health Services Administration (SAMHSA) finds that few substance abuse treatment and behavioral health facilities offer programs tailored to LGBT consumers. The SAMHSA report  found that only six percent of addiction treatment facilities and seven percent of facilities treating both mental health and addiction offered such programs. Yet, according to a 2009 study by the Massachusetts Department of Public Health, The Health of LGBT Persons in Massachusetts , LGBT consumers face poorer health outcomes overall than their heterosexual counterparts due in part to ongoing stigma and lack of access to insurance and services. Of the facilities offering special programs for LGBT clients, private facilities were in the majority, with “for profit” facilities providing twice as many LGBT programs than government-run facilities (seven percent vs. 2.6 percent). SAMHSA has been working since 2001 to remedy these shortcomings, partnering with the National Association of Lesbian, Gay, Bisexual and Transgender Addiction Professionals and Their Allies (NALGAP) to develop a free, introductory guide and training curriculum, facilitated by the ATTC Network, for staff providing LGBT programs. NALGAP is also working with SAMHSA to develop a standard for LGBT-specific programs. “When you say you do culturally-specific programming, like a women’s program or serving ethnic minorities, there’s a standard that people follow,” says Joseph Amico, MDiv, CAS, LISAC, president of NALGAP and national marketing coordinator for Sante Center for Healing. “NALGAP has been really trying to work with SAMHSA and saying we need to do the same for LGBT folks as well.” But whether a program standard exists or not, there are still several challenges that could prevent organizations from adopting a LGBT-specific program in the first place—especially community-based programs. For starters, Amico says, many organizations haven’t even recognized the need for these types of programs yet. “Every organization has LGBT clients whether they realize it or not,” he says. “But I don’t think folks have adopted it; administrators and boards haven’t embraced it and said this is an issue that needs to be addressed.” Amico also cites the eight-year tenure of the Bush administration as a challenge for LGBT programs, as that administration did little to encourage the need for LGBT-specific services in behavioral health. “We had eight years of administration that pushed faith-based programs, and there are certain faith-based programs that are not going to treat LGBT issues in the warm, caring way we would advocate,” Amico, who is also an ordained Christian minister, says. “It was quite counter-productive.” Once community-based programs have accepted that they do, in fact, need to develop programs tailored to LGBT consumers, funding the program is always a challenge. While Amico acknowledges that publicly-funded organizations are very limited in the services they can provide, he says that this challenge may actually work in favor of LGBT programs. “If we can get the states to say to the publicly-funded organizations, ‘This LGBT program is now a standard of care, you need to do this,’ that will make a huge difference,” he says. “The organizations will then turn around to the state and say, ‘Fund the training for us.’ And that’s the only way it’s going to happen.” Since the release of the SAMHSA’s LGBT treatment training curriculum in 2008, the ATTC Network has trained 170 individuals from around the U.S., who then provide training in their own organizations or geographic areas. The ATTC Network is currently working to educate enough trainers so they are available nationwide. In the meantime, Amico says that it’s important for organizations lacking in LGBT-specific services to recognize that “we can’t be all things to all people.” He encourages community-based programs to refer LGBT consumers with needs beyond their scope of services to other programs with more expertise. For those organizations looking to develop a LGBT service or training program, SAMHSA’s written companion to the LGBT-treatment curriculum, A Provider’s Introduction to Substance Abuse Treatment for Lesbian, Gay, Bisexual, and Transgender Individuals , is available for free. Joseph Amico, MDiv, CAS, LISAC, president of NALGAP, will lead the workshop “What Everyone Needs to Know When Working With Sexual Minorities” at this year’s inaugural National Conference on Addiction Disorders (NCAD). In this presentation, he will cover the basics of meeting the needs of LGBT consumers, such as making your intake process and office more LGBT-friendly, understanding the politically correct terms for sexual minorities, and helping LGBT consumers heal from cultural victimization associated with sexual orientation. For more information on NCAD, visit www.ncad10.com . Wed, 30 Jun 2010 00:00:00 EST E928B1228BA64BE18B8EDC1F18F3D35D http://www.behavioral.net/ME2/dirmod.asp?type=Publishing&mod=Publications%3A%3AArticle&mid=64D490AC6A7D4FE1AEB453627F1A4A32&tier=4&id=0C17FA73726142A6B12597FA570F28F4 In a new FAQ document, “Applying the Substance Abuse Confidentiality Regulations to the Health Information Exchange,” SAMHSA and the Office of the National Coordinator (ONC) for Health Information Technology, address recent questions about the applicability of 42 CFR Part 2 in light of healthcare reform and the nation’s vision for interoperable electronic health records.  Concerns about the limitations of 42 CFR Part 2 confidentiality protections, raised by groups including the Patient Protection Coalition, were captured in the article, Confidentiality law: Time for change? , authored by nationally-known privacy advocate Renee Popovits, JD, in the April issue of Behavioral Healthcare magazine.  The 42 CFR Part 2 law and regulations are intended prevent stigma and discrimination by protecting the confidentiality of persons involved in treatment for drug or alcohol abuse. 42 CFR Part 2 restrictions apply to any personally identifiable information (PII) that would, directly or indirectly, “identify a patient as an alcohol or drug abuser” and ban the release of that information, with limited exceptions, without a signed patient consent. The Q & A document, whose complete text is found at www.samhsa.gov/HealthPrivacy/ , affirms that although “the consent requirement is often perceived as a barrier to the electronic exchange of information, it is possible to electronically exchange ... treatment information while meeting the requirements of 42 CFR Part 2.” Other highlights of the document include: Patient consent on a 42 CFR Part 2-compliant consent form is always required for the release of PII associated with the purposes of treatment, payment, or healthcare operations, except in situations of medical emergency or when the Part 2 (treatment) program has entered into a Qualified Service Organization Agreement (QSOA) with an entity that needs the information to provide covered services. Patient consent is required for exchange of PII to or through an HIO regardless of the HIO’s operating model (i.e., opt-in, opt-out, or “no consent”). Patient consent is also required to allow the HIO to “redisclose” PII to other HIO affiliated members. Consent for initial disclosure to an HIO and subsequent redisclosure to HIO affiliates may be obtained using a single 42 CFR Part 2-compliant consent form, provided the consent form specifically lists each affiliated member organization or provider and the purpose of the disclosures remains the same. Patient consent forms do not require an original “wet” signature. Facsimiles, photocopies, or electronic consent forms may be used, provided the Part 2 program, provider, and patient act with “reasonable caution” in their use. The document also outlines requirements for compliance with 42 CFR Part 2 for medical personnel, HIOs, and Part 2 programs in the event of a medical emergency that requires access to PII in the absence of patient consent. In such an event: Medical personnel: - Must “use their professional judgment” to determine that there is an emergency that “poses an immediate threat to the health of any individual and which requires immediate medical intervention.” - Must document the “circumstances surrounding the medical disclosure” to the HIO or other vehicle of disclosure in its request for the 42 CFR Part 2 information. Specifically, this involves documenting, in the patient’s electronic record, the name and affiliation of the medical personnel receiving the information and treating the patient, the name of the individual making the disclosure, the date and time of the disclosure, and the nature of the emergency.   - May download and store the PII used to treat the emergency in their own medical records and redisclose it without patient consent to others, provided the redisclosure “is limited to the information necessary to carry out the purpose of the disclosure.” HIOs: - Must document, in the patient’s electronic record, the name and affiliation of the medical personnel receiving the information and treating the patient, the name of the individual making the disclosure, the date and time of the disclosure, and the nature of the emergency.   - Must notify the Part 2 program and inform it that a disclosure has occurred. HIOs can automate this notification with data systems that automatically notify and provide the required information to the Part 2 program when a “break the glass” disclosure occurs in a medical emergency. Part 2 programs must: - Document, in the patient’s electronic record, the name and affiliation of the medical personnel receiving the information and treating the patient, the name of the individual making the disclosure, the date and time of the disclosure, and the nature of the emergency.   Additional discussion about 42 CFR Part 2 will take place on Aug. 4 in a meeting hosted by SAMHSA and ONC. For those unable to participate on Aug. 4, a SAMHSA webcast on the topic is planned, though timing has not been announced. Thu, 24 Jun 2010 00:00:00 EST 0C17FA73726142A6B12597FA570F28F4 http://www.behavioral.net/ME2/dirmod.asp?type=Publishing&mod=Publications%3A%3AArticle&mid=64D490AC6A7D4FE1AEB453627F1A4A32&tier=4&id=575E995EFBFB4AF48FBF88509FC989B8 It’s been said that laughter is the best medicine. And with the therapeutic benefits of laughter ranging from enhanced immune system function to lower stress hormones and the release of natural pain-relieving endorphins, it’s hard to argue otherwise. But can laughter lead to recovery from mental illness? David Granirer, founder and artistic director of Stand Up for Mental Health (SMH), would say “yes.” After all, he’s seen it firsthand. In 2004, Granirer—a registered counselor, mental health consumer, and professional stand-up comic—was teaching a regular comedy clinic at Langara College in Vancouver. When his students pointed out how therapeutic his classes were, a lightbulb went off in his head: Comedy would be great therapy for his patients, too. From that, the SMH program was born. “It’s a simple premise,” says Pat Bayes, executive director of SMH. “What starts out as rehabilitation and recovery becomes empowerment and enables students to go out and de-stigmatize, entertain, and educate audiences.” SMH classes consist of 10 or so “students,” who gather once a week with Granirer to learn how to write and deliver jokes based upon their own mental health journeys. After studying the fundamentals of comedy and performance—including delivery, timing, and stage presence—for three months, students make their comedic debut—performing for the community.   SMH's Vancouver 2010 Comedy Debut Benefit, featuring the Class of 2010 (pictured here with David Granirer, center), took place May 31 at the Stanley Industrial Alliance Stage. Throughout the year-long program, students nurture, encourage, and challenge each other through the creative process. The graduation showcase marks the end of the program, but also a new beginning for the alumni comics, now armed with a fresh outlook on life. “It’s enabled them to go back into the world with a sense of purpose and an alternate way to deal with tough issues,” Bayes says. “A lot of our students have gone back to school, started new careers, or begun new relationships.” Graduates may also stay on with the SMH program to mentor incoming comics, perform with new classes, and work on new material. SMH has trained graduates across Canada and, because of its success, maintains a long waiting list of interested consumers. But the national attention hasn’t just attracted students to Granirer’s classes; it’s also attracted members of the community to SMH’s showcases. “Most people would never want to come out and listen to a talk about mental illness by a doctor or a head of a mental health agency,” says Bayes  “But our branding—‘Are you crazy about comedy?’—gets the general public interested. They come out for a great evening of comedy, but we also slip in the anti-stigma message.” Because SMH’s comics come from every walk of life, ranging in age from 12 to 78, the program is constantly seeking out new and diverse populations in need of its anti-stigma message. Programs tailored to college students and members of the Canadian military, two groups gravely affected by stigma, are now underway. SMH is also working to develop programs geared toward those in prisons, as well as toward native peoples like the Inuit, whose suicide rate among youth is 10 times higher than the national average. CBC's Passionate Eye documentary "Cracking Up" focuses on SMH. “The stories and comedy that they share help break down stigma,” Bayes says. “We say that we’re ‘changing hearts and minds, one laugh at a time.’ Audience members see it’s OK to talk about mental illness and seek out help.”   In the fall, SMH will expand to the U.S., bringing its comics to the Campus Day program at the University of Rochester’s School of Medicine. Other stops are being considered, including visits to Harvard, Yale, UCLA, and Dartmouth.   Wed, 16 Jun 2010 00:00:00 EST 575E995EFBFB4AF48FBF88509FC989B8 http://www.behavioral.net/ME2/dirmod.asp?type=Publishing&mod=Publications%3A%3AArticle&mid=64D490AC6A7D4FE1AEB453627F1A4A32&tier=4&id=64BDD6189F4A4C35B16F5DEB720C3803 By the year 2020, the National Council expects that its Mental Health First Aid program will be just as well-known as CPR and First Aid. But for now, the program is becoming increasingly popular with law enforcement in the state of Rhode Island. After a series of unfortunate incidents involving mentally ill individuals and local police officers who were ill-equipped to deal with them, Carole Bernardo, MS, training coordinator at LifeWatch EAP, suggested integrating the 12-hour Mental Health First Aid program—which she had just been certified to teach—into Rhode Island’s Municipal Police Training Academy curriculum. “I was observing a stress management training that was taking place at the academy and just got to talking to them,” Bernardo says. “I went over the lesson plan and they were very interested.” That was nearly two years ago. Since then, the academy has filled every one of its Mental Health First Aid classes. But it took a bit of effort to shape the program to meet the needs of police officers, who have substantially different needs and concerns than those of other typical Mental Health First Aid audiences, which include private-sector employers, hospital and healthcare workers, and the general public. “My recommendation was that it sounded like a decent program, but that any training program involving just a practitioner, without a police officer to relate it to police work and procedural issues, may flop,” says Lt. Joseph Coffey, who now joins with Bernardo as the program’s co-trainer. In order to increase the relevance of the training to law-enforcement personnel, the pair revamped the program’s materials to fit their target audience. “She focused more on the signs, symptoms, and response suggestions and I made sure that everything we covered related to current police concepts regarding safety, use of force, discretion, handcuffing, and transportation,” Coffey says. Coffey and Bernardo use their tailored program to teach new and veteran officers alike how to: • Recognize a person struggling with mental illness (This may involve recognizing and identifying medications the person might possess or individual behaviors typical of mental illness.); • Weigh their options when responding to incidents (This might involve making referrals to community resources or decisions to transport suspects to care, whether voluntarily or involuntarily.); and • Understand the requirements of mental health law and how they relate to police procedures (This might involve understanding issues of personal privacy and managing them throughout the process of reporting or writing up an incident.) The training is facilitated through lectures, PowerPoint slides, interactive exercises, and videos. One exercise requires officers to think and perform tasks while wearing headphones that beep loudly or make other distracting sounds. This exercise simulates the difficulty experienced by individuals with a mental illness who are expected to respond to an officer’s questions or react calmly in tense situations even as they hear voices or hallucinate. “We also have videos they watch and then critique what the officers in the video did or what they could have done better,” Bernardo says. “It’s interesting because a lot of them will share situations that have happened to them, and this opens up a great dialogue with everybody in the classroom.” While raising awareness of mental illness, the program also helps to strengthen relations between law enforcement and local providers, who are invited into the classroom to receive the Mental Health First Aid certification alongside the officers. “Police and clinicians alike talk to us about the relevance of what we’re saying and how surprised they are by the amount of equally shared frustrations,” Coffey says. “We’re presenting a program, but at the same time building more positive relationships between groups that sometimes clash.” The program is helping to redefine historical trends in other ways, too. According to Coffey, police have not been widely known as a community resource in the past, but their new skills have helped to establish them as such. “Now you have a police resource at your fingertips to enable these people to get help,” Coffey says. “That’s key for any community because if the person doesn’t get help, the police may be responding to a crisis-type situation in the future that nobody benefits from.” The increased awareness will not only help to identify and meet mental health needs in the community, but alleviate the high costs associated with housing individuals with mental illness in the criminal justice system. According to a study by the Technical Assistance and Policy Analysis (TAPA) Center for Jail Diversion in 2005, mentally ill inmates cost the justice system up to seven times more than other suspects to accommodate. “I’ve been in public safety for over 30 years, and I can tell you that probably for every dollar we’re putting in, we’re saving tens of thousands,” says Chief Anthony Silva, executive director of the Municipal Police Training Academy. “Not only in medical costs, but for the police department, it’s got to be [saving] hundreds of thousands.” Other police departments have followed suit, recognizing the high value—both fiscal and moral—of preparing their officers for mental health crisis situations. The Seattle Police Department announced last month that it will hire a full-time, grant-funded mental health counselor to respond to incidents alongside officers, while several departments across the nation—including Seattle—offer mental health crisis training to their officers. Wed, 02 Jun 2010 00:00:00 EST 64BDD6189F4A4C35B16F5DEB720C3803 http://www.behavioral.net/ME2/dirmod.asp?type=Publishing&mod=Publications%3A%3AArticle&mid=64D490AC6A7D4FE1AEB453627F1A4A32&tier=4&id=77774DFEBA1F4EB2963E88923B40745A In 2002, Congress directed HUD to work with local communities to establish a system for collecting and reporting homeless data that would better illustrate the scope of homelessness and help to evaluate the effectiveness of HUD McKinney Act programs. Based on this requirement, HUD created a specification for Homeless Management Information Systems (HMIS) and, as of 2004, required all continuum of care (CoC) communities that received McKinney Act funding to collect the required data and utilize an HMIS to communicate it to state and national officials. Following a series of discussions, several state of New Jersey entities-the Housing and Mortgage Finance Agency (HMFA), the Department of Human Services (DHS), and the Department of Community Affairs (DCA)-decided to create an HMIS collaborative that would offer each of their departments, along with the state's 21 counties-or CoC communities-access to a shared reporting system. The system was to be developed and administered by the HMFA, through its Supportive Housing and Special Needs Division, which is based in Trenton and headed by Division Director Pamela McCrory. Development of the HMIS collaborative program posed several challenges, she recalls: meeting HUD and HMIS requirements, bringing together diverse community agencies within each CoC community around a shared system, and providing the state of New Jersey with HMIS data sufficient to bolster its efforts to renew and increase its share of federal housing funds. “We created an advisory group with representatives from many different communities to identify the requirements needed to support a joint RFP, which was drafted by an IT consultant.” Among the key requirements for the NJHMIS software package were the ability to collect and store HUD-HMIS mandated data elements, generate HUD-HMIS mandated reports, and accommodate future growth. Another key requirement was that the NJHMIS be web-based. This application service provider (ASP) approach to software acquisition would eliminate the burden of network management, the costs of software maintenance/upgrades, and limit the need for hardware, network, or other capital investments. Then, armed with the RFP, McCrory and the other departments entrusted the statewide HMIS implementation to a new HMIS project manager, Abram Hillson, who joined the project in May 2004. Throughout a busy summer, Hillson led the product selection process, which was staffed primarily by a team of individuals representing NJHMIS collaborative partners. Because of hardware and bandwidth variables throughout the state, the selection team realized that they would probably make some tradeoffs, especially regarding the user interface. “There were a lot of graphical interfaces offered by the vendors that were beautiful,” says Hillson. “But we had to ask ourselves: ‘With a statewide implementation, do we really want to put out a package like this over the web?some of our community agencies-especially those in more rural areas-may still be using older hardware and dialup lines?’” He adds, “If we had specified an HMIS package that required all the latest bells and whistles to operate properly, the first thing we would have had to do would be to buy a lot of new hardware. And we weren't doing that.” Knowing that a package that offered a “100 percent solution” could not operate on the mix of available hardware, Hillson and his team of HMIS partners decided that “any package that met 85 percent or better of our needs would probably be in the finals.” As they considered the many offerings submitted in response to the RFP, they evaluated vendors in terms of support, customization capabilities, responsiveness, and performance on similar projects. After narrowing the finalists to three, the team then upped the ante. “We asked each of the three finalists for an on-site presentation and a ‘hands-on’ user training/demonstration session, conducted with actual end users,” he says. The group, consisting of individuals from the agency partners who planned to use the software, logged in on a range of hardware and network connections, accessing the HMIS packages through a secure (https:) web interface. “We really beat up on the systems-entering, compiling, and transmitting data. We tried to simulate the whole process and we looked at everything: How user friendly was the package? What was the system response time over the web' What were the pop-up screens like? Were the screen questions being asked in the proper sequence?” Benefits of NJHMIS collaborative model Application services provider (ASP) model: Delivers software via secure web interface (https:) Makes data accessible in virtually any location, on a range of web-capable computers or devices Cuts capital costs for software and database (upgrades/maintenance), servers, and network hardware Reduces software-, network-, and hardware-related staffing needs Easy, secure data access: All data stored centrally, with high security and redundancy Confidentiality of personal protected information (PPI) supported via multiple levels of user access Collects, stores, and delivers data for multiple programs (HMIS, HPRP, PATH) using a common record, configurable forms, and a variety of program-specific report formats Supports upload and download of data using common, tab-delimited SQL files; routine uploads of HMIS data are made regularly by 225 of 230 NJHMIS collaborative partners They also evaluated the configurability of the systems. “For example,” Hillson asks, “how flexible would the intake consent form be in terms of allowing additions or changes to the fields on the forms, plus new functionality to benefit the collaborative?” And, experience told Hillson and the team that the selected vendor had to be responsive-not only for the short-term configuration changes needed to adapt the software to meet HUD and NJHMIS requirements, but also for long-term training, upgrades, and technical support. After a nationwide search, Hillson and his partners recommended AWARDS, an enterprise package developed for human services agencies by application services provider Foothold Technology of New York, N.Y. Beta testing of the new NJHMIS started in October 2004 with a 90-day system trial at 15 agency sites throughout the state. “Our statewide rollout began in January 2005. Each quarter, for the next two and a half years, we would bring up a given number of sites,” Hillson explains, noting that the site-launch process involved deployment of the software, training of two principal users, and a post-deployment visit by a HMFA technical assistant from Hillson's deployment team. Each site's users would have multiple levels of support. First, they would be trained by one of the site's two “principal” users, who received NJHMIS training from Hillson's team and who would act as first-level support. Next level support was provided by technical associates and a “help desk” in Trenton, while any vendor support was provided through a Foothold Technology systems integration manager. Completed in mid-2006, the NJHMIS collaborative “provides licensing, access, training, and technical assistance for 230 provider agencies, 20 of 21 CoC communities, and state partners who support efforts to renovate housing, provide rent support, and related services,” says McCrory. The flexibility of the system has enabled it to grow, she says, noting that the collaborative now supports over $30 million in federal funding, not only from the HUD McKinney Vento program, but also from two other programs. First, there's the community-based, federally-funded PATH (Project to Aid Transitional Housing) program, which provides statewide outreach to individuals living with mental illness and helps them to obtain transitional and supported housing. More recently, the system has also been adapted to support Homeless Prevention and Rapid Re-Housing Program (HPRP) funds provided by Congress through the American Reinvestment and Recovery Act (ARRA). The mechanism is relatively simple, Hillson explains. “There's one basic type of client record in the system. Based on the program being accessed (HMIS, PATH, HPRP, etc.), the system offers the appropriate variation of the form to the user, who provides the form data that is needed.” Adding support for the New Jersey Department of Human Services' PATH program, for example, involved modification/addition of forms and questions used for data input, then “some back-end customization” to support differing PATH agency data reporting requirements. Today, HUD officials consider NJHMIS as a “model” HMIS system, while SAMHSA officials have held it up as a model for PATH program reporting, which will become mandatory in 2011. New Jersey officials say that its capability to deliver comprehensive outcomes data has helped the state not only to renew HUD funding for current programs, but to win federal funding for other, related programs. Perhaps just as important, NJHMIS has won the respect of its user community, where it displaced locally developed work processes and procedures at over 200 locations. At one agency, where a manager once rejected the system, the team later got a second chance. Now, 40 users at the site use not only the HMIS features, but also the enterprise features of the AWARDS software to do everything from staffing, transportation, and janitorial schedules to site administration and case management. “They put everything into it,” says Hillson. “It's a tremendous tool for case management-it's a great way to track individual needs, treatment plans, and other details.” At another site, “despite efforts to involve many people, we did find that there was a community that said they weren't going to get involved with the system because it ‘wasn't how we do business.’ Locally, they had developed an Access database system, but it did not offer a complete service plan, updates, reminders, or quality checks. We didn't push them at the time,” says Hillson, “but when they were ready to try, we supported them. Once they started using the system, they quickly appreciated what we were doing and have since become great supporters. They said that the versatility of the system ‘broke down silos between programs and showed a much broader scope of information.’” Behavioral Healthcare 2010 June;30(6):37-38 Tue, 01 Jun 2010 00:00:00 EST 77774DFEBA1F4EB2963E88923B40745A http://www.behavioral.net/ME2/dirmod.asp?type=Publishing&mod=Publications%3A%3AArticle&mid=64D490AC6A7D4FE1AEB453627F1A4A32&tier=4&id=47F42FB67C3D45908BDC3133244A4D27 AdCare Hospital is a 114-bed inpatient facility with six outpatient sites. The hospital admits approximately 5,000 inpatients and provides over 85,000 outpatient treatment sessions per year, which represents 100,000 initial claims that must be processed for payment. Collaboration across departments in problem identification and resolution can improve access to information and increase the effectiveness of the revenue cycle. Over the past several years, with an increase in the number of patients and service locations, AdCare experienced difficulties in revenue collection. A Controllable Events Committee was formed and included stakeholders from various disciplines to identify and address the root causes of these problems. The team has addressed not only ongoing issues-such as the use of mutually understood terminology and standardized communication-but has also assessed our structure and practices for process improvement from a systems perspective. Through this approach, we examined the capture, use of, and access to non-clinical documentation to improve the revenue cycle. The prior system was to create a manila folder of patient information upon admission of a patient, containing a face sheet for their account, a copy of their insurance card, and insurance verification on that date. This folder was retained in a file room. However, copies of authorization letters, inpatient case management review forms, outpatient case management forms, and appeal letters were retained in files at inpatient, outpatient, or billing office locations. As a result, comprehensive reviews of these documents were time-consuming and inefficient. Solution Access to non-clinical documentation during the revenue cycle process is essential to ensure accurate and efficient processing of patient accounts and proper reimbursement for services provided. Important non-clinical documentation may include patient identification, insurance card and eligibility verification, and other registration materials, as well as payer authorization correspondence, tracking, and appeal letters. Document imaging-via scanning-of these patient-specific materials provides a centralized information resource for registration and billing functions. The same resource simplifies document referral and tracking by case management and clinical departments who must communicate with insurance reviewers. Components of the document imaging solution include: Registration documents . The revenue cycle process begins at pre-registration, which requires retention of verified identification, insurance eligibility and benefits information, and pre-certification or authorization documents. Scanning these materials at initial registration or when updated ensures availability of the most current, applicable documentation as well as a dated record of all previous information in a convenient, centralized location. Centralized image storage enables corroboration of a patient's identity during the entire span of care, ensures treatment integrity, and protects against the risk of identity theft. Federal and state provisions and provider standards call for a comprehensive approach to mitigating any chance of identity theft or compromised privacy of patients. Proper verification and protection of personal identity information (PII) and personal health information (PHI) are essential elements of this process. Insurance eligibility and benefit confirmation is crucial in determining a patient's available benefits and making appropriate case management decisions. Administratively, such documentation simplifies coverage reviews and the process of identifying and correcting errors made by registration or billing staff. Post-billing provides a supporting record for eligibility and other, related payer appeals. While paper copies of these materials could be retained in files, their availability is either limited to that file or, if duplicated, at multiple locations. However, they may not be uniformly updated upon subsequent service dates. The centralized storage of current materials-via imaging-solves the problem of redundant and inaccurate paper records that can result in data-entry errors. Case management documents . Initial pre-certification materials may consist of an online-generated response from a payer or, if verbal, a form indicating the reviewer, time, authorized level of care, and other essential data. These provide a reference for case management staff and for the central billing office in claims submission and denial management, as well as data for following up with appeals. Insurance companies have become increasingly inflexible when conducting post-service reviews for authorization, or when the information in their systems regarding pre-certification or pre-admission contact is incorrect. By tracking the date/time, reviewer, level of care discussed, and any comments from the review in a standard format, the case manager has the supporting record to more successfully argue a disputed authorization. Assisted by centralized electronic storage, case managers at different locations-within the same department or at different inpatient and outpatient locations-can review essential materials, understand the progress and flow of contacts with insurers, and more effectively coordinate care. Similarly, the billing office, when confronted with a denial or question about a billed level of care, can tap the same resource to more effectively perform its role in the revenue cycle process. Insurance correspondence . Insurance companies send numerous documents to providers regarding payment for services. Some of these are relevant to both treatment coordination and segments of the revenue cycle. As confirmation of the services are pre-certified by their utilization review department, payers issue authorization letters to providers indicating the level of care, units, and date range for the patient's treatment. Access to these communications assists staff in care planning and further authorization reviews. Any disputes or denials of requested treatment authorizations must be retained for reference in developing treatment plans and concurrent or retrospective service appeals. Scanning in appeals and appeal responses from insurance utilization reviewers to the appropriate accounts provides us with reference information for subsequent action or trending. Security . Stratified systems' access to imaged documents is important to ensure that only designated staff are able to access certain documents. As with all aspects of the PII and PHI, availability of materials must be limited to only those items needed for specific staff functions within the organization. Challenges As with any new process or technology, some staff members were uncomfortable adjusting to the use of electronic images in place of paper. Through a phase-in, education, and feedback process, the system has been adapted to fit the needs and understanding of those who need to use the documentation. They are now able to access it from a single electronic file. Positive outcomes With proper implementation and systems adaptation, document imaging in the revenue cycle improves efficiency and effectiveness in securing reimbursement for rendered services. It also ensures the integrity of patient identity and provides a valuable reference for case management and clinical staff in ongoing contact with insurance reviewers and pre-certification departments. Centralized, electronic access to these documents ensures the most current, relevant information is available to staff who interact with payers; promotes clear understanding of coverage and benefits for treatment planning; and offers the comprehensive records needed to resolve payment issues for services provided. While assisting in these operations, document imaging also serves as a stepping-stone to implementing electronic medical records (EMR) and complements the information that will be captured in EMR applications. Collaborative application of this technology and process reduces staff time for documentation storage and retrieval, reduces the risk of lost revenue, and supports and improves the revenue cycle process. Nathan F. Moore received his BA from the University of Massachusetts at Amherst and MPA from the California State University at Hayward, concentrating in organizational change and assessment. He has worked for 15 years in the healthcare field, six of which were as a revenue cycle consultant in the Northeast. He is currently director of revenue cycle operations at AdCare Hospital in Worcester, Mass. Behavioral Healthcare 2010 June;30(6):35-36 Tue, 01 Jun 2010 00:00:00 EST 47F42FB67C3D45908BDC3133244A4D27 http://www.behavioral.net/ME2/dirmod.asp?type=Publishing&mod=Publications%3A%3AArticle&mid=64D490AC6A7D4FE1AEB453627F1A4A32&tier=4&id=81CDDE2A61D0490C973C1A4F81063847 The fight for equality-what many have called the civil rights fight for our field-is now coming to fruition. Parity in insurance coverage for mental and addictive disorders has become law. In 2009, the State Children's Health Insurance Program (SCHIP) was reauthorized with mental health parity. This year federal parity regulations were issued that are both pro-provider and pro-consumer. After years of debate and discussion, healthcare reform is also now law (P.L. 111-148, P.L.111-152), with strong provisions that build on the federal parity law. For example, health exchanges will be required to provide behavioral health benefits at parity. As we've made strides in putting behavioral health where it belongs-as a routine part of health-we need to build on this momentum to remove remaining vestiges of discrimination. For individuals coping with some of the most severe disorders who may need hospitalization, there are two particular areas that a group of national associations are now working to change within Medicare and Medicaid: Elimination of the Medicare 190-day lifetime limit Implementation of the Medicaid Emergency Psychiatric Care Demonstration Project Act of 2009, or IMD/EMTALA Demonstration End Medicare's 190-day lifetime limit When people are seriously ill and at their most vulnerable, there is no time for them to be worrying about their health insurance coverage. But if you are a Medicare beneficiary experiencing a severe mental disorder, you may find your coverage disappears just when you need it the most. A little-known provision in the Medicare law limits Medicare beneficiaries to 190 days of inpatient psychiatric hospital care during their lifetime . This restriction is applied only to individuals with mental illnesses who receive care in a psychiatric hospital (the limit does not apply to psychiatric units in general hospitals). There is no such lifetime limit for any other Medicare specialty inpatient hospital service . Congressional action is needed to address this limitation, since it was not addressed in recent healthcare reform legislation. More and more Americans facing complex, chronic, and disabling mental illnesses are hitting this Medicare lifetime limit and losing access to essential crisis hospital stabilization services when they are most needed. Like other diseases such as diabetes, mental illnesses can be chronic and require brief, but recurring, hospital visits for stabilization and medication management. For Medicare beneficiaries, these short stays help them to remain active in their communities, but can quickly add up to 190 days-a worry that people with chronic physical disorders never have to think about. The impact of the arbitrary 190-day lifetime limit (which was put into law decades ago) is particularly painful because Medicare beneficiaries include not just the elderly, but also the disabled. Over eight million Medicare beneficiaries, or about 17 percent, are under age 65 and disabled. 1 More than a quarter of Medicare beneficiaries (29 percent) have a cognitive/mental impairment. 1 Low-income seniors and younger persons with disabilities who are enrolled in both Medicare and Medicaid (“dual eligibles”)-accounting for some 8.8 million Medicaid beneficiaries-have substantial health needs. Over half are in fair or poor health (twice the rate of others on Medicare). Dually eligible individuals are also more likely to have mental health needs compared to other Medicare beneficiaries. 2 Medicare is a critical safety net for those who have long-term mental disabilities, yet retain the ability to participate in the community throughout their lives given adequate support. “This arbitrary cap on benefits is discriminatory to the mentally ill,” wrote Sens. John Kerry (D-M.A.) and Olympia Snowe (R-M.E.) in a letter to colleagues announcing their introduction of a bill this spring (S.3028) to fix the problem. The Medicare Mental Health Inpatient Equity Act would repeal the 190-day lifetime limit for patients receiving care in a psychiatric hospital. A total of 48 national organizations of all types have endorsed S.3028, including the AARP, American Hospital Association, American Nurses Association, American Psychiatric Association, Federation of American Hospitals, National Alliance on Mental Illness (NAMI), National Association of Psychiatric Health Systems, National Council on Aging, and Mental Health America, among others. Eliminating the Medicare 190-day lifetime limit, these groups believe, will: Equalize Medicare mental health coverage with private health insurance coverage; Expand beneficiary choice of inpatient psychiatric care providers; Increase access for the most seriously ill; Improve continuity of care; and Create a more cost-effective Medicare program. Implement the Medicaid Emergency Psychiatric Care Demonstration Project Act of 2009 Emergency psychiatric care, delivered in general hospitals and freestanding psychiatric hospitals, is an integral component of community-based care for persons with severe mental illnesses. Yet, a 30 percent decline in inpatient psychiatric beds over the past two decades makes it hard to find beds for these people. As a result, people who have mental health emergencies are often diverted to already overcrowded emergency rooms or forced to travel long distances for care. 3 The Medicaid program is a vital source of support for people with mental disorders, funding more than 50 percent of state and local spending on mental health services. Non-governmental, community-based psychiatric hospitals could help relieve this access problem; however, due to a Medicaid statutory provision called the Institution for Mental Disease (IMD) exclusion, patients receiving care in these hospitals are not covered for their care if they are between the ages of 21-64 and the hospitals cannot get Medicaid federal matching payments for these services. The Medicaid Emergency Psychiatric Care Demonstration Project Act, made law through the Patient Protection and Affordable Care Act (P.L.111-148, Section 2707), takes an important step toward giving Medicaid beneficiaries equal access to emergency inpatient psychiatric care. It will allow states to add inpatient psychiatric beds in their communities to improve access to emergency psychiatric care. Through this three-year, $75 million demonstration project, states can apply to the U.S. Department of Health and Human Services (HHS) Secretary to cover patients in non-governmental, freestanding psychiatric hospitals and receive Federal Medicaid matching payments. They will have to contribute their own matching share of funds. This demonstration project will: Evaluate the role that inpatient psychiatric care plays in the continuum of community-based mental healthcare; Help to determine ways to address timely access to behavioral health services; Focus on the cost-effectiveness of inpatient psychiatric care and the efficiency of the delivery of psychiatric care; and Focus on discharge planning and aftercare to help reduce unnecessary hospitalization. The HHS Secretary will evaluate the demonstration projects and submit annual reports to Congress, ultimately recommending whether the demonstration project should be continued and expanded on a national basis. Some 30 national groups support this demonstration, which is now moving forward. Behavioral disorders are medical disorders and should be treated no differently than other medical disorders. This is the key concept behind parity . It is an underlying principle in healthcare reform, and the mission that our field must continue to champion through efforts such as these. Discrimination, no matter in what form, needs to end.   Mark Covall is president and CEO of the National Association of Psychiatric Health Systems (NAPHS), Washington, D.C. References Henry J. Kaiser Family Foundation. “FACT SHEET: Medicare at a Glance,” #1066-12, January 2010. http://www.kff.org/medicaid/upload/4091_06.pdf . Henry J. Kaiser Family Foundation. “FACT SHEET: Dual Eligibles: Medicaid's Role for Low-Income Medicare Beneficiaries,” #4091-06). February 2009. http://www.kff.org/medicaid/upload/4091_06.pdf . Government Accountability Office (GAO), “Hospital Emergency Departments: Crowding Continues to Occur, and Some Patients Wait Longer than Recommended Time Frames,” (GAO-09-347), April 30, 2009. http://www.gao.gov/new.items/d09347.pdf . Behavioral Healthcare 2010 June;30(6):10-12 Tue, 01 Jun 2010 00:00:00 EST 81CDDE2A61D0490C973C1A4F81063847 http://www.behavioral.net/ME2/dirmod.asp?type=Publishing&mod=Publications%3A%3AArticle&mid=64D490AC6A7D4FE1AEB453627F1A4A32&tier=4&id=E606460D6F0A40ACADBF69B6B8208197 Beds/mattresses Blockhouse Furniture Blockhouse Furniture, an American manufacturer, is pleased to showcase their VISTA Captain's Bed. Designed with the collaboration of behavioral health experts, the bed has no moving parts and may be mounted securely to the floor, which helps to avoid unwanted access or movement. Natural oak wood gives the homelike feel many clients appreciate while providing the strength and durability the staff demands. For more information, please contact Blockhouse Furniture at 1.800.346.1126 or visit the Web site at http://www.blockhouse.com .   Furniture Concepts Furniture Concepts has engineered a durable new collection of Tough Stuff! Anti-Contraband bedroom furniture by replacing traditional drawers with tight-fitting shelves that are doweled, glued, and angle-bored to ensure a strong, secure fit. Staff benefits from enhanced visibility and efficient inspections, while administration benefits from reduced initial costs and minimal upkeep costs. All items are available in a Golden Oak or Wild Cherry pre-catalyzed protective lacquer finish. For information, call 800-969-4100 or visit http://www.furnitureconcepts.com .   This End Up Furniture Co., Inc. This End Up Furniture Co., Inc. offers southern yellow pine wooden beds in a variety of styles. This End Up is known for the durability and safety of their products that comply with the Voluntary Bunk Bed Safety Standards established by the American Society of Testing and Materials. They offer mattress solutions for most applications. Select inner spring or foam cores along with numerous outer options including fluid-proof, bacterial- and fungal-resistance, and flame-resistant. Visit http://www.thisendup.com or call (800) 979-4579.   Clinical decision support ASI-MV Connect ASI-MV Connect is a web-enabled system for behavioral health assessment, treatment planning, and data management. Developed with support from the National Institute on Drug Abuse (NIDA), this unique program includes: client self-administered ASI interviews in English and Spanish; a validated behavioral health assessment tool for adolescents; clinical reports to assist clinicians with treatment planning; and an online data center for analyzing population needs, trends, and outcomes. A free 30-day trial is available at http://www.asi-mvconnect.com .   CarePaths, Inc. The eRecord, CarePaths' Internet-based behavioral EMR, is clinically robust and provides decision support for assessment, outcomes, and treatment planning. Outcomes monitoring is facilitated by decision support algorithms that determine the effectiveness of treatment and flag cases that are at risk for a poor outcome. Treatment planning decision support is provided via problem-based clinical pathways that guide clinicians in clinical decisions about type, intensity, and duration of treatment. Learn more at http://www.carepaths.com .   Credible Behavioral Health Software Credible Behavioral Health Software provides secure, proven, easy-to-use software for clinic, community, residential, and mobile care providers across the United States. Credible provides fully-integrated clinical, e-prescribing, scheduling, billing, form management, advanced search, mobile, and management reporting functionality. A leading SaaS provider for 10 years, Credible is committed to continuous innovation, an easy-to-use interface and a long-term partnership approach. Learn more at http://www.crediblewireless.com .   E*HealthLine E*HealthLine's Clinical Decision Support (ECDS) enables physicians to improve healthcare decision-making by integrating PHOENIX EMR, E*Prescribe, and E*Lab. The integration of health observations with health knowledge influences health choices by clinicians for better outcomes. ECDS provides clinicians with the necessary tools needed for cost-efficient and quality healthcare measurements for decisive patient disease management. ECDS improves outcomes, streamlines workflow, and enhances the overall quality of care. Learn more at http://www.ehealthline.com .   The next issue's product/service center will focus on staffing/recruitment services and personal health records (PHRs). To participate in these sections, e-mail lbarba@vendomegrp.com . Behavioral Healthcare 2010 June;30(6):39 Tue, 01 Jun 2010 00:00:00 EST E606460D6F0A40ACADBF69B6B8208197 http://www.behavioral.net/ME2/dirmod.asp?type=Publishing&mod=Publications%3A%3AArticle&mid=64D490AC6A7D4FE1AEB453627F1A4A32&tier=4&id=AC89DB53BB4F4E46875A6E711B660223 When Hope Network decided to expand its residential treatment program for autistic youth to include outpatient services for children and adults, its goal was to create a “one-stop shop” for the autistic community of Grand Rapids, Mich. “There has been a groundswell in interest over the last eight years from families for this need to be addressed in our community,” says Pat Howe, LMSW, LMFT, BCD, vice president of Hope Network and executive director of behavioral health services. “In talking with families, we heard time after time that they're often driving across the state to receive services, and it's a difficult experience to have a child with autism who has to go to multiple appointments across town and across the state.” Hope Network's newly-opened Center for Autism ( figure 1 ), financed by a $1.2 million capital campaign, offers clients everything from primary care to dental services, speech therapy, and psychiatric and behavioral therapy. And while the services most in-demand by families and clients were easy to gauge, thanks to a series of family forums, the Center's developers found that incorporating all of them into one space, along with special considerations for safety and effective delivery of services, was more challenging. Figure 1. Hope Network's Center for Autism in Grand Rapids, Mich. Photos courtesy of Hope Network Luckily, Hope Network's experience in serving autistic clients meant that it had the experts needed to make up the specialized taskforce assigned with designing the facility. Along with family forums, this taskforce relied on lessons learned at Hope Network's residential autism facility, scientific research, and an architect experienced in designing for an autistic population. The result is a unique facility that is not only tailored to individuals with autism, but also calming and safe. At the outset of the facility planning process, the Center for Autism was envisioned as a brand-new, 8,000 square foot facility. However, with all of the amenities and services the taskforce hoped to include, the project's architect, Ken Dixon of Dixon Architecture, recognized that the planned 8,000 square foot layout “was really shoehorned.” Another opportunity presented itself in the form of a 12,000 square foot building, previously used for light manufacturing, which was ideally located adjacent to Hope Network's DART (developmental adolescent residential treatment) building. The larger structure “freed up the opportunities to provide all the services and was kind of a breath of fresh air,” Dixon, who was also involved in the building of the DART facility, says. The one-floor layout also appealed to the design team, since stairs are a safety hazard for individuals with autism ( figure 2 ). Figure 2. The floor plan of Hope Network's Center for Autism Once the space was secured, a remodeling plan was developed, based on participation from clinicians that would be working at the Center for Autism. “We sat down and went through all the research together as a team,” says Tamera Kiger, BSW, director of operations. “Then we looked at [Dixon's] preliminary design and said, ‘Where can we incorporate the different things that we are learning from research in this design?’” Design characteristics for autistic consumers The team's foremost concern was creating a space that would ensure low stimulation and low stress, but still radiate warmth and comfort. To achieve this aesthetic, the taskforce paid special attention to every nook and cranny and the facility, from the size of the hallways to the noise level of the heating system: Structure, patterns, and colors. All sharp corners were eliminated, including those in the halls formed by the rectangular floor plan. Instead, smooth, curved walls were built to create the facility's signature curvilinear design ( figure 3 ). “We find that children with autism respond much better if they're allowed to put their hands on the wall while going from place to place,” Howe says. Figure 3. The Center's design deliberately avoids the use of bright colors and distracting art or other wall fixtures in order to establish a calm, low-stress environment for its population Wayfinding patterns were then added to the walls, ensuring simplistic navigation through the facility. “The wayfinding patterns are all butterflies that are color-coded specific to a room,” says Kiger. “So if the children are wayfinding to the model living unit, it's the same color butterfly the whole way-in this case, gold. The colors are all warm pastels, and they're fun and youthful.” Special attention was paid to the use of color throughout the rest of the facility as well, and the design relies on the same palette of warm pastels used in the wayfinding. “Each color was chosen for balance and triggers an emotion,” Kiger says. “Green is harmony, blue is for calming, yellow is an intellect color, and white is the color of peace.” Lighting. Diffused lighting is also used throughout the facility and each room is equipped with dimming capabilities. “Clinicians can use the fluorescent lights for when they're working or dimmer lights for when they're working with the children,” Kiger says. “Our primary goal was to create an environment that was respectful to the children's high sensitivity: the sights, the smells, the sounds,” Dixon adds. “We looked at every element and evaluated how a child could perceive that feature or that color or whatnot.” Noise reduction. Because of this heightened sensitivity, noise reduction was another priority within the facility, which hosts high-activity spaces such as a gymnasium ( figure 4 ), motor sensory room with a wall-to-wall swing ( figure 5 ), diagnostic playroom ( figure 6 ), and model living unit ( figure 7 ). To ensure that these activities would not affect clients partaking in other activities, therapies, or medical services, Dixon installed: Sound-insulated walls between every room; Sound-absorbing carpets, except for high-activity rooms; Acoustical, sound-absorbing ceilings in lieu of standard drywall; and A heating and cooling system that maintains a continuous airflow and eliminates the noise and distraction of on/off cycles.   Figure 4. The gymnasium hosts structured play and gross motor activities for both outpatient clients and residential clients from the DART program Figure 5. The motor sensory room provides a wall-to-wall swing for clients. Says Kiger: “The swing increases the child's vestibular stimulation; that form of stimulation is very calming for them.” Figure 6. The diagnostic playroom shares a two-way mirror with an observation room, so that staff can observe the parent and child during playtime and make suggestions on more effective interactions Figure 7. The model living unit features a bedroom (shown here), kitchen, and bathroom to teach clients necessary skills for daily living Durability. Durability was another key issue-one that the staff at the DART building had experienced firsthand. While clinicians played a crucial role in designing effective therapy, activity, and administrative spaces throughout the facility, suggestions from maintenance staff were essential to creating an easy-to-maintain facility. “They've repaired and they've seen what the kids can do,” Dixon says. “The idea is for the Center for Autism to be world-class in its appearance and function-and part of that is maintaining a nice, crisp, clean environment. If kids can put holes in the walls, those might become elements that are distracting to a child and won't allow them to focus.” After consulting with the maintenance staff, the design team chose high-impact drywall and tempered glass for use throughout the facility. “Everything that we did was to keep [the environment] calm, orderly, and simple, because that's what the children function best in,” Kiger says. “We wanted to make sure they would feel comfortable, but not set them apart from the rest of the people. This is just the way the building is and this is how we exist in this building-it doesn't marginalize them.” Since the Center's official opening in April 2010, Kiger says that “our phone has rung off the hook with people wanting to bring their children here.” Perhaps this is proof enough that the Center has succeeded in its mission to provide more accessible and higher-quality care for individuals with autism. Behavioral Healthcare 2010 June;30(6):28-31 Tue, 01 Jun 2010 00:00:00 EST AC89DB53BB4F4E46875A6E711B660223 http://www.behavioral.net/ME2/dirmod.asp?type=Publishing&mod=Publications%3A%3AArticle&mid=64D490AC6A7D4FE1AEB453627F1A4A32&tier=4&id=CC9A23B58FB4466FA463EC8EB2D799B9 Drug and alcohol testing, commonly used in the workplace as a hiring and firing tool, is used in substance abuse treatment settings for a very different reason: helping patients recover. In substance abuse treatment programs, testing is used for two purposes: to establish a baseline level for any recent substance use by the patient and to monitor patients who are involved in ongoing substance abuse treatment. In neither case is the purpose to “catch” someone abusing drugs or alcohol, because the patient has already asked for help. There are strict federal regulations for the use of drug testing in the workplace, but no rules-with the narrow exception of methadone and buprenorphine treatment-for the use of substance abuse treatment programs, says Robert Lubran, director of the division of pharmacologic therapies at the federal Center for Substance Abuse Treatment (CSAT), part of the Substance Abuse and Mental Health Services Administration (SAMHSA). “Programs are pretty much on their own” when it comes to deciding what kinds of tests to use, and what to test for, he tells Behavioral Healthcare . But urine is definitely the kind of specimen that is preferred-in part because of the scientific rigor labs have developed as a result of the federal workplace testing program-considering it passed the muster of the U.S. Supreme Court. Urine testing update The “classic five” drugs that are tested for in the workplace via urine testing are heroin, cocaine, PCP, methamphetamine, and cannabinoids (marijuana and hashish), says Robert L. Stephenson II, director of the division of workplace programs at the Center for Substance Abuse Prevention, also part of SAMHSA. “When we created the workplace program 22 years ago, we made a deliberate decision not to test for prescription medications so that we did not get between a patient and a physician,” says Stephenson. Today, the situation is somewhat different. Given the increasing abuse of prescription medications, drug testing programs cannot be limited to “illegal” drugs. Legal opiates-fentanyl, oxycodone, methadone, codeine, and morphine, for example-are increasingly popular as drugs of abuse, instead of or in addition to illegal opiates like heroin. Stephenson points out that if a substance abuse program utilizes lab services, the program must clearly explain that the setting for its testing is a treatment center, not a workplace. There are two basic kinds of urine tests: the screen (done either on site or in a lab), which can give a negative or a “presumptive positive,” and a second more expensive and definitive confirmation test (always done in a lab) on that initial test. Instead of an expensive confirmation test, in the treatment setting, the confirmation will usually be the admission of the patient, says Stephenson. “They will say that they relapsed or used,” he says. If, however, the patient doesn't admit to drug use, the treatment provider should send the urine off to an accredited lab for the confirmation testing. “Point of care” tests, in which the treatment program tests the urine immediately instead of sending it out to a laboratory, can have error rates of as high as 30-40 percent, says Stephenson. “In the real world, some programs might discharge patients for positive tests,” he says, and strongly recommends against taking any action at all based on a positive point-of-care test that the patient denies. Workplace tests tend to have high cutoff levels for a positive, and Stephenson strongly urges that treatment programs use low cutoff levels to detect even the slightest level of drug use. New saliva test options The “next agenda” beyond urine testing is oral fluid testing, says CSAT's Lubran, adding that methadone treatment programs are already using saliva testing. Intercept, the first oral fluid drug test, was cleared by the FDA for use in 2000 (see figure). Since then, oral testing has seen significant advances, explained Ron Ticho, senior vice president for corporate communication for OraSure Technologies, the Bethlehem, Pennsylvania-based manufacturer of the Intercept drug test. Currently, this test may be used to detect 10 different drugs, and, over the course of the next few months, several more drugs will be added. One saliva specimen is taken, with various “microplates” used for the testing. OraSure Technologies' oral fluid drug test, Intercept The collection is done on site and the sample is stored in a container provided by OraSure and then sent to the lab. Various labs are set up for doing the testing, with results in 72 hours, says Ticho. CDT marks heavy drinkers Researchers are exploring the use of “biomarkers” to test for very heavy drinking, based not on the presence of alcohol in the body, but on its effects on the body. Carbohydrate-deficient transferring (CDT) is one such test, explains Raymond Anton, MD, director of the Clinical Neurobiology Laboratory at Medical University of South Carolina in Charleston. Anton became interested in CDT testing because in the course of his alcohol research, “it became clear that people don't accurately report what they drink.” He says that anyone who tests positive on the CDT test is likely to have been drinking “at least five to six drinks a day for a few weeks.” Treatment providers can contract directly with Anton's lab for CDT testing, which is performed using blood. If the provider doesn't have the ability to collect blood, Anton can do the testing through a commercial lab, which has collection sites where patients can have blood drawn. Be mindful of testing's limits At Caron Treatment Centers, based in Wernersville, Pennsylvania, all patients are given a comprehensive drug screen and alcohol breath test upon admission. The alcohol test is used to help clinicians determine whether the patient will have withdrawal symptoms, says medical director Kenneth Thompson, MD, noting that even in a treatment program, patients may not want to admit the extent of their drinking. “If their blood alcohol is positive, we know the drinking was recent,” says Thompson. Breath tests correlate with blood tests for alcohol; the results are immediate. There are limitations to drug tests, says Dr. Thompson. “A drug test does not tell you whether a person is addicted or not,” he says. “It doesn't tell you whether somebody is impaired. And the level of drugs found in the urine does not necessarily correlate with cognitive functioning.” But tests can be used therapeutically “to confront someone's denial,” he says. And that, for treatment programs and patients alike, can be the key to a successful outcome. “In a good treatment program where there is a therapeutic alliance, the patient should see that the test is therapeutic for them, as a useful tool to prove that they're sober.”   SAMHSA, together with the FDA and the Health Resources and Services Administration, is developing a physician's guide for the selection of drug and alcohol testing, says Lubran. He says that the guide will be available later in 2010 and can be expected to help doctors with screening, brief intervention, and referral to treatment (SBIRT) for substance use disorders, a key component of the national drug strategy issued last month by the White House. Alison Knopf is a freelance writer based in New York. Behavioral Healthcare 2010 June;30(6):19-20 Tue, 01 Jun 2010 00:00:00 EST CC9A23B58FB4466FA463EC8EB2D799B9 http://www.behavioral.net/ME2/dirmod.asp?type=Publishing&mod=Publications%3A%3AArticle&mid=64D490AC6A7D4FE1AEB453627F1A4A32&tier=4&id=0D4B45FC0C4D42F596A6D470190CA3C5 Substance use disorders (SUD) are treated with a variety of pharmacological agents. For example, it is standard practice to see medications including clonidine, barbiturates, and benzodiazepines prescribed for acute withdrawal syndromes from alcohol, sedative-hypnotic medications, opioids, and nicotine. For later, maintenance phases of SUD treatment, there are at present a limited number of labeled medications. For maintenance-phase, alcohol-abuse treatment, we see disulfiram (Antabuse), naltrexone (Depade, Nalorex, Opizone, Vivatrol, and others), plus acamprosate (Campral). For maintenance-phase opiate use disorder treatment, we see buprenorphine (Buprenex, Subutex, Transtec), methadone (Dolophine, Methadose, Metharose, and others) and the buprenorphine/naloxone (Suboxone) combination. Patients in the maintenance phase of SUD treatment may also be prescribed antidepressant, antianxiety, and/or antipsychotic medications that target coexisting mania, psychosis, anxiety, depression, or other psychological conditions. More recently, anticonvulsant medications have assumed a greater role in the pharmacologic management of SUD maintenance-phase treatment. At one time, these agents were routinely prescribed for withdrawal states associated with a high risk of seizures, but more recently have been used to impact cognitive, behavioral, and symptomatic dimensions of SUDs. Dr. Robert Post, Professor of Psychiatry at George Washington University School of Medicine, was a pioneer in the development of a role for anticonvulsants in treatment of bipolar disorder. He maintains that “some of the mechanisms that are pertinent to blocking seizure discharges in epilepsy may also be applicable to the broad uses of the anticonvulsants [in the treatment of] neuropsychiatric disorders, including SUDs.” Indeed, clinicians have employed anticonvulsants off-label to treat conditions ranging from anxiety disorders, substance abuse disorders, and migraines to eating disorders and obesity. While the FDA has not approved any anticonvulsant for use in SUD treatment, many experts believe that they can play a role SUD treatment. Dr. Jayesh Kamath, Assistant Professor of Psychiatry at the University of Connecticut Health Center, is one. “In my clinical experience and based on limited evidence, anticonvulsants, especially divalproex sodium (Depakote), have a significant role in [treating] patients with substance use [disorders].” He asserts that the impact of anticonvulsant medication therapy is “probably much more significant in bipolar patients with substance use comorbidities,” based on his belief that there are shared “pathophysiological mechanisms involving the GABA-ergic system.” A recent scholarly review by a group of Italian psychiatrists led by Icro Maremmani noted that there are few studies of the role of anticonvulsants in SUD treatment. 1 Of these, most are short-term in duration and therefore offer little insight into long-term effectiveness (e.g., relapses into agitation, impulsivity, and dissatisfaction). The authors believe that anticonvulsants are preferable to antipsychotics or antidepressants in dually diagnosed, substance-abusing patients with bipolar disorder. They argue that long-term use of antidepressants among such patients may contribute to “switches” into mania along with increased impulsivity and subsequent relapse into substance use. In addition, they argue that the long-term risks of antipsychotic medications outweigh those of anticonvulsants. For providers considering the value of anticonvulsant medication therapy for “pure” SUDs (e.g., SUDs not associated with other clear psychiatric diagnoses), a handful of studies suggest effectiveness. According to Kamath, “Anticonvulsants have a larger application for [treatment of] alcohol and benzodiazepine use disorders than other substance use disorders.” Some investigators, including Post, theorize that anticonvulsants may help in the treatment of some SUDs because they reduce cravings. “Most anticonvulsant medications have indirect effects on dopamine or glutamate. These are critical inputs to the nucleus accumbens [an area of the limbic system] that affects the brain's reward system.” Studies in alcohol, benzodiazepine, and cocaine dependent patients have borne out this thinking. But if this is true, what is the mechanism of action through which anticonvulsant medications assert their effects? Post says: “I wonder about [their] mechanistic properties such as blockade of sodium channels and decreased release of glutamate, decreased calcium influx through the NMDA receptor, increases in potassium efflux, as well as a variety of aminergic effects and effects on gene expression.” Spiegel and Radac recently described cases in which adding the anticonvulsants (valproic acid, levetiracetam or gabapentin) to benzodiazepines in patients experiencing alcohol withdrawal syndrome yielded better outcomes than seen with benzodiazepines alone. 2 The authors also suggest that the long-term use of these anticonvulsant agents helped curtail craving in these patients. There is at least some evidence to support the use of the anticonvulsants in substance-addicted/dependent patients (see table ). 1 Another review, originating in Greece, suggests that pregabalin (Lyrica) may be efficacious in SUD treatments for alcohol and benzodiazepine dependence. 3 Table. Possible indications (X) for use of anticonvulsant medications in treatment of addicted/dependent patients 1   Opiates Alcohol Cocaine Gabapentin X X X Oxacarbezine X     Topiramate   X   Valproic acid   X X Carbamazepine     X Gabapentin     X Lamotrigine     X Tiagabine     X Clinicians frequently struggle with two significant concerns when considering the possible use of anticonvulsant medication therapies for SUD treatment. First is the impact on liver function. Klamath says that “many of these patients have a history of Hepatitis C due to IV drug use or risky behaviors, or their livers are compromised from heavy alcohol use.” As a result, he says that “close monitoring of liver functions is critical in this population.” A second concern is suicidality. A recent survey of prescription claims in a Danish population found an increased risk of suicide for patients who had recently initiated valproate or lamotrigine therapy. 4 Of course, more work is indicated before causality can be inferred. The role of anticonvulsant medications in the treatment of SUDs has resulted from a combination of psychopharmacologic tourism and therapeutic application of scientific constructs and principles. For this reason, prescriptions for off-label uses of anticonvulsants for SUD treatment should be managed only by skilled psychiatrists or addictionologists, and only then with careful monitoring of risks and benefits over time. There is, of course, a tremendous need for new and proven advances in the treatment of patients with SUDs. Here's hoping that some of our current anticonvulsant medications can help. William M. Glazer, MD, is president of Glazer Medical Solutions ( http://www.glazmedsol.com ) of Key West, Fla., and Menemsha, Mass. He is a clinician, researcher, lecturer, and consultant, and has been a member of faculty of the departments of psychiatry at the Yale and Harvard Schools of Medicine. References Maremmani I, Pacini M, Lamanna F. et al: Mood stabilizers in the treatment of substance use disorders. CNS Spectr 2010; 15:2, pp 95-109. Speigel DR and Radac D:Alcohol withdrawal: When to choose an adjunctive anticonvulsant. Current Psychiatry 2010; 9:4, pp 27-39. Oulis P, Konstantakopoulos G. Pregabalin in the treatment of alcohol and benzodiazepines dependence. CNS Neurosci Ther. 2010 Spring; 16 (1): 45-50. Olesen JB, Hansen PR, Erdal J, et al. Antiepileptic drugs and risk of suicide: a nationwide study. Pharmacoepidemiol Drug Saf. 2010, Mar 16. [Epub ahead of print]. Behavioral Healthcare 2010 June;30(6):32-33 Tue, 01 Jun 2010 00:00:00 EST 0D4B45FC0C4D42F596A6D470190CA3C5 http://www.behavioral.net/ME2/dirmod.asp?type=Publishing&mod=Publications%3A%3AArticle&mid=64D490AC6A7D4FE1AEB453627F1A4A32&tier=4&id=8625C7F304F54BB2857A8FC591D97FB0 We've been hearing a lot of rumors about what's happening in New York lately-lots of interesting news about changing times. We have a friend there who always knows what's really happening, so we asked him to give us the scoop. Our “go-to” guy is none other than Harvey Rosenthal, executive director of the New York Association of Psychiatric Rehabilitation Services (NYAPRS). Harvey, a major player in the New York behavioral healthcare system since 1993, has put his heart into promoting services and policies that advance the recovery, rehabilitation, and rights of people with psychiatric disabilities. Harvey Rosenthal has over 35 years of experience working to provide or promote public mental health services and social policies that promote the recovery, rehabilitation, and rights of people with psychiatric disabilities.   We tried to think of some provocative questions for Harvey that would inspire him to give us some fearsome wake-up calls and scare us a little. Harvey not only came through with thought-provoking answers, but he also took us to a new level of understanding how the future could unfold in ways that promote recovery-based services. Tell us Harvey, what's really going on in New York these days? What's the big picture?   Harvey: New York's political environment is at an all-time low, with a $9.2 billion budget deficit, another late budget and legislative deadlock, and a lame duck Governor. This could be discouraging, but as you know, problems like these often create opportunities for transformation. Glad you can maintain a positive attitude about all this. Are there positive forces at play to help you with the transformation?   Harvey: Sure, there are. One of our strongest assets is a leader with a strong vision for recovery-Mike Hogan [Commissioner, NYS Office of Mental Health]. Leadership is critical when it comes to turning a crisis into a transformation, allowing us to build on promising trends contained in national healthcare reform (with its emphasis on prevention and integrated care) and mental health and substance abuse parity legislation. The recovery, community integration, and consumer and peer services movements give us a strong set of principles on which we are building. Tight budgets and challenging times often give rise to creative solutions. So in spite of all the problems, we have some assets we can harness and draw strength from. We think we can use our strengths to overcome our problems, just like we teach people in recovery to do. How's that working for you? Harvey: This is an opportunity to make changes that would otherwise be politically very difficult. Right now, however, there's a lot of pressure to make changes that will produce better outcomes and be less expensive to provide. Sounds like a great idea. Can you give us some specifics about what you're planning? Harvey: Sure. I think what we are doing falls into four broad categories. I'll describe them for you: Service reform . We're renaming and changing the focus of our traditional outpatient services. The new name symbolizes the changes we plan to make. The Office of Mental Health (OMH) calls it PROS (Personalized Recovery Oriented Services). PROS's priorities are helping people to build skills and supports for community living, encouraging the development of increased wellness self-management, health and financial literacy, employment readiness, and community-based housing opportunities. Another very promising OMH initiative in development are new Recovery Centers, which are peer-run resource centers intended to foster employment and educational goals, benefits advisement, asset development, wellness self-management, and crisis diversion. We're also restructuring our outpatient clinic system to include a new peer community outreach and engagement component. These initiatives will continue to transform our service focus from maintenance to recovery, resilience, and a full life in one's community. Community integration . New York has set up a 19-member Most Integrated Setting Coordinating Council aimed at supporting state agencies to set Olmstead-related goals we hope will help move people and public dollars from segregated to integrated community settings. There's a strong focus on housing and employment, and OMH is heading up a $14 million Medicaid Infrastructure Grant that is working with consumers, providers, government, and employers to raise awareness and success in increasing our employment rates. Integrated care . Our Health Department tells us that 20 percent of our Medicaid beneficiaries use 75 percent of the resources. For the most part, this 20 percent is composed of folks with multiple problems including psychiatric issues, substance use, and major medical conditions. We are developing a plan to serve them in ways that will better meet their needs and also be less costly for the overall system. ( Readers, next month we plan on dedicating our column to this conundrum, so stand by for some good ideas on how to save money while providing better services to this group of folks .) Peer services . We are seeing peer services mature and take substantial roles in meeting our most pressing challenges. For example, NYAPRS is building upon our 15-year-old, nationally replicated Peer Bridger model that has helped thousands to successfully transition from state hospitals to the community. In partnership with OptumHealth, we are moving to offer Peer Bridging services to Medicaid managed care beneficiaries and Peer Wellness Coaches to what the state is calling ‘high needs, high cost’ individuals. PEOPLe Inc. has developed a peer crisis respite program that is being replicated across the state and nation. As healthcare systems seek to improve their outreach and engagement to people they're currently failing to serve adequately, peer services' appeal, effectiveness, mobility, and relative affordability will make it a critical component going forward. You know, Harvey, it's sounding like you think New York could actually emerge from this crisis in better shape. Is that what you're thinking? Harvey: Yes! If the budget crisis doesn't cause us to lose critical mental health funding, services, and staff, we should be able to come out of this more focused on recovery and offering better, more relevant, and more modern services. What will you be happy to see disappear? Harvey: I'd love to see an end to the perennial conflict and distraction [caused] by efforts to wrongly play up a violent image of people with psychiatric disabilities to expand the use of forced outpatient treatment initiatives like our Kendra's Law. What do you worry about most? Harvey: Our new vision depends heavily on the availability of affordable housing and employment opportunities. I worry that these will be challenging to develop and to make continuously available to people who use our services. I am also concerned about our critical need to expand prison diversion, treatment, and re-entry initiatives, and to see cultural competence become heavily intertwined with recovery movements. Communities of color get prison and forced treatment in tragically disproportionate amounts. These present huge challenges that require a lot of collaboration and cooperation between state agencies. What will the New York system look like in the future if you have your way? Harvey: In the wake of national healthcare reform and mounting frustrations with our poorly coordinated, ‘siloed’ mental health, substance abuse, and healthcare systems, there are growing predictions about the end of public mental health systems as we know them. We should be working to help create skills and strengths-based systems that will integrate our best tools (wellness self-management, advance directives, peer services, employment readiness, and housing support) within the broader healthcare system. Along the way, I'd love to see New York and other states adopt the new (1915.i) Medicaid home and community-based services option and extend waiver-like self-directed care with individualized budgets to people with psychiatric disabilities. That'd take us so far beyond the more passive, site-based, ‘chronic’ systems we still have today. Well, there you have it: a state in turmoil with political and financial problems. But with a vision of recovery and committed mental health leadership at all levels, the transformation continues. Political and financial crises are the times when vision and leadership are most important, and Harvey has given us a picture of a state that will go forward in spite of very real difficulties. We thank Harvey for his hopeful perspective. Lori Ashcraft, PhD, directs the Recovery Opportunity Center at Recovery Innovations, Inc. in Phoenix. She is also a member of Behavioral Healthcare's Editorial Board. William A. Anthony, PhD, is Director of the Center for Psychiatric Rehabilitation at Boston University. Behavioral Healthcare 2010 June;30(6):8-9 Tue, 01 Jun 2010 00:00:00 EST 8625C7F304F54BB2857A8FC591D97FB0 http://www.behavioral.net/ME2/dirmod.asp?type=Publishing&mod=Publications%3A%3AArticle&mid=64D490AC6A7D4FE1AEB453627F1A4A32&tier=4&id=EC023D7104D04D15A88DCB586E4FF3E7 As spring waxes into summer, our personal enthusiasm for national health reform needs to evolve as quickly into a practical commitment to successful implementation. Our field work must begin quickly, so that behavioral healthcare is fully positioned to participate in each wave of reform as it mushrooms across the health landscape. We will need some important tools to accomplish this work, and we will want to make some new partners as we undertake this once-in-a-lifetime journey. A tactical plan. First, we need a clear, tactical plan for implementing reform. This should be very practical, with operational steps and timelines. Reform has many working parts, including insurance, coverage, quality, payment, and IT-each of which we must address in order for reform to be successful. It is very similar to an orchestra that only produces a symphony when the instruments are played in unison from the same music. We call on the U.S. Department of Health and Human Services to provide leadership and resources to undertake the development of this tactical plan. For us, HHS needs to coordinate the effort of SAMHSA, HRSA, CMS, AHRQ, and ONC, as well as the offices of the Assistant Secretary for Health and the Assistant Secretary for Planning and Evaluation. Resources will be available to undertake this work, since Secretary Sebelius was provided $1 billion in the legislation to implement reform. To develop this plan, HHS should work with our national behavioral healthcare leadership organizations, such as ACMHA: The College for Behavioral Health Leadership and the Carter Center Mental Health Program; our national membership organizations, such as MHA, NAMI, FAVOR, NASMHPD, NASADAD, NACBHDD, and the National Council; and our national coalitions, such as the Whole Health Campaign and the National Coalition of Consumer-Survivor Organizations, to undertake this urgent planning effort. Transparency is critical, and timing is urgent. Our plan should be available by the end of the summer, at the latest. Informational bulletins. Key groups in the field, such as consumers, family members, providers, and employers, have already expressed an urgent interest in the availability of informational bulletins that can interpret in simple language what reform actually means for them: Will their insurance change? Will their care change? Will their financial obligations change? The current information deficit is massive, and the need for accurate information is very urgent, particularly around reforms that will become effective in 2010. We call on HHS and the Secretary to undertake this work as soon as possible. These informational bulletins can be produced by HHS staff directly, as well as through contract mechanisms that are already in place. Hopefully, the first bulletins will be available by the beginning of the summer. Priority should be given to bulletins for those persons who need and use services. New partners. Perhaps most important for each of us, but also the most difficult to accomplish, will be the development of close working partnerships with organizations and groups with whom we have never worked in the past. These can range from a local federally qualified health center to a new accountable care organization that is being configured as we speak. (An accountable care organization is one that has a highly qualified staff, employs EBPs, monitors costs carefully, and assesses its success with each consumer; it is accountable for both outcomes and costs.) Our long-term, historical approach of “going it alone” will no longer be an effective adaptation in this new world. Our entire context and structure will be changed. A beginning point can be a proactive assessment of available partners within our own spheres. For some, that will be other local entities and organizations; for others, national associations and organizations. Further, consideration should not be limited only to provider entities. For example, we must also include insurance carriers and IT vendors in our thinking. Being proactive will be exceptionally important. In this very short commentary, I only have been able to provide the most rudimentary introduction to some key steps in implementing national health reform. I urge each of you to take these notions and provide the essential leadership to elaborate them further. We need a groundswell of interest in the steps to successful implementation of reform. I think that we will be judged harshly by history if we don't succeed. Ron Manderscheid, PhD, worked for more than 30 years in the federal government on behavioral health research and policy. He is the Executive Director of the National Association of County Behavioral Health and Developmental Disability Directors as well as a member of Behavioral Healthcare 's Editorial Board. Behavioral Healthcare 2010 June;30(6):40 Tue, 01 Jun 2010 00:00:00 EST EC023D7104D04D15A88DCB586E4FF3E7 http://www.behavioral.net/ME2/dirmod.asp?type=Publishing&mod=Publications%3A%3AArticle&mid=64D490AC6A7D4FE1AEB453627F1A4A32&tier=4&id=F5A59C394B8F4F28806701152F4751FE “Instead of being on the outside, we're part of the system in a way we've never been before…” With the passage of the Patient Protection and Affordable Care Act, the U.S. Congress swept aside a nearly 80-year-old legislative logjam, fundamentally altered the insurance industry, and left providers across the healthcare spectrum scrambling to understand and respond. “This will totally transform the way the industry functions over the course of the next several years,” says Dick Dougherty, CEO of DMA Health Strategies, a Lexington, Mass.-based consulting firm. “Instead of being on the outside, we're part of the system in a way we've never been before,” adds Ron Manderscheid, executive director of the National Association of County Behavioral Health and Developmental Disabilities Directors (NACBHDD). “We have to adjust ourselves to that new role.” Adjustment is a central theme for the behavioral healthcare industry, which has barely had time to adjust to the changes wrought by the long-awaited passage of the Mental Health Parity and Addiction Equity Act (MHPAEA), whose provisions were written in as baseline requirements for the newer healthcare reform legislation. Passage of healthcare reform means that MHPAEA's parity definitions will soon apply to virtually all Americans, even as Medicaid is expanded, new health insurance exchanges are established, and new coverage mandates and penalties are created for employers and individuals. As broader reforms make behavioral healthcare “part of the system,” providers will be expected to work more closely than ever with hospitals, primary care physicians, and other medical specialists to function in the collaborative, evidence-based, prevention-focused world envisioned by reformers. And, while building their identity as a recognized (but relatively pint-sized) subspecialty in the larger medical world, behavioral health professionals will have to adapt to new, insurance-driven funding sources as the majority of states continue to slash budgets in response to major tax shortfalls resulting from the recent, deep recession. “Behavioral health is just a little piece of the healthcare puzzle,” says Kris Ericson, executive director of the College for Behavioral Health Leadership (ACHMA). “A lot of our services will likely get wrapped into primary care and other types of organizations, and that makes people incredibly nervous. They fear there won't be enough resources for behavioral health. We have to figure out how to create partnerships and collaboration so we're making the best use of the money we have.” Reform will mark a massive shift away from state funding and block grants, and toward private insurance and Medicaid. “There is a sense that hope is on the horizon, but we have to be able to bail water out of the sinking system so we can make it until then,” says Chuck Ingoglia, vice president of public policy at the National Council. The first glimmer of reform's new day is already in sight. This year, family insurance coverage has been extended to dependent adults up to age 26 while insurance exclusions for pre-existing conditions are being eliminated for children. Small businesses have access to new tax credits to help provide insurance to employees, and several states are already creating high-risk insurance pools. The District of Columbia has asked permission to expand its Medicaid program (allowed under the bill) in a move that will shift some 35,000 individuals away from a current, city-run program. Connecticut has submitted a similar plan, and a handful of other states are considering doing the same. Challenge 1: Understand reform's impact Many of the new law's effects on the behavioral healthcare industry are still vague-dozens of government agencies have yet to draft regulations, and many of the requirements of the bill don't kick in until 2014 or later. Industry associations are organizing educational efforts for consumers, and providers and are lining up to help influence the new regulations so that mental health and substance abuse treatment are given due consideration as reform is implemented. “The first challenge we confront is getting accurate information out to people in the field so they can appropriately understand what national health reform is and what it is not,” says Manderscheid. “There's a high level of anxiety because we don't have information and we don't have a tactical plan. In each of these areas, we need to know what we're doing, know the pros and cons, and determine our capacities. Today, I don't think any of this has been worked on in the context of health reform.” “A lot of our services will likely get wrapped into primary care and other types of organizations, and that makes people incredibly nervous. They fear there won't be enough resources for behavioral health…” Challenge 2: Manage capacity and workforce expansion When the new health insurance exchanges (HIEs) are established by states in 2014, the insurance plans offered through those exchanges will have to offer as-yet-undefined “essential health benefits,” with parity coverage of substance abuse and mental health treatment. Although there will likely be a heated debate about what exactly to include in those benefit packages (designated Platinum, Gold, Silver, and Bronze in reform legislation), more patients with behavioral healthcare needs will be utilizing private insurance, rather than grant-funded programs, for coverage of their conditions and needs. “The vision is that assertive community treatment would be a service covered by insurance companies under health reform,” Dougherty says. “Right now, the vast majority of community treatment is at least partly funded through state grants and other sources. That's an uphill battle that's going to be fought around benefit plan design.” By some estimates, the combination of expanded Medicaid coverage and new HIE insurance options will provide coverage for an additional six million to 10 million people that will require mental health or substance abuse services. “Do we have the capacity to service all of these people? Do we have programs in place that are child-oriented? That's the analysis that has to be done,” Manderscheid says. At present, many behavioral health facilities are understaffed and face problems in recruiting and training new employees, due to both funding limitations and a limited pool of people. Yet, the field may have to develop entirely new types of positions to meet the requirements laid out in the reform statutes. “There are not enough boots on the ground to do this,” Ericson says. Both the Substance Abuse & Mental Health Services Administration (SAMHSA) and Health Resources and Services Administration (HRSA) will play key roles in developing new recruitment and training efforts for the field nationwide. The reform law establishes a national Health Care Workforce Commission, as well as several workforce development grants and healthcare workforce loan repayment programs. But only time will tell if these make a difference. Challenge 3: Help puzzled consumers Expanded access to insurance, while vital, will not produce better outcomes for more consumers unless they know how to get and use their insurance benefits. For the population of consumers served by mental health and addiction treatment providers, this is a significant challenge. Many of them will be unable to enroll themselves in new insurance and Medicaid programs without assistance. And, once enrolled, they'll likely need more help to properly utilize their benefits. “That's one of the continuing issues in Massachusetts,” Ingoglia says, referring to results of a statewide insurance reform effort launched in 2006. “The folks that remain uninsured are disproportionately homeless, have severe mental illness, or have chronic addiction disorders. These people have not been able to navigate the enrollment process.” “What the exchanges will offer will not be adequate to address the problems these new consumers have,” Manderscheid says. “Simply because they're at 133 percent of the poverty level doesn't mean that they have a job and permanent housing and other resources that would make the healthcare system work well for them.” Consumers and their families will need help understanding exactly what reform can mean for them, how their benefits may change, and what new coverage options are available. Even as HHS is developing new consumer-information programs, John O'Brien, senior advisor on health financing at SAMHSA, believes there “is a significant role for peer specialists or recovery staff to help people navigate to those portals and get that information. They are going to be overwhelmed and intimidated by it.” The burden of helping these individuals to secure their benefits will likely fall where it always has: on providers. This will further strain an already overtaxed workforce. “How do we include the voices of consumers in the development of this new system?” Ericson says. “That's a huge challenge, and we haven't even successfully done it in our own systems.” Challenge 4: Work with insurers By Manderscheid's rough estimates, the expansion of Medicaid and the establishment of HIEs could bring as much as 70 billion new dollars into the behavioral health field. Much of this money will, however, have to be processed through in the form of insurance claims that track and bill services provided, encounter by encounter. “Just in terms of being able to handle the volume of personal health insurance claims and payments, I don't think most facilities have the capacity to deal with it,” says Manderscheid, noting, “Public providers have dealt with large grants and they spend the money until it's gone. They aren't doing the person-by-person assessment of these resources or linking expenditures to outcomes.” The shift from grant-based funding to private insurance will pose a significant IT challenge to providers that are not set up to interface with, negotiate with, and bill multiple insurance companies. “Many of our providers are very good at delivering services, but have not had any experience interfacing with third-party insurers,” O'Brien says. “It requires an infrastructure to convert service delivery units into billable services.” Providers will have to evaluate new insurance packages and map their services onto those plans, and will face new requirements to provide performance data such as average length of stay, referral compliance, and drop-out rates. This type of data is clearly needed, but not necessarily well developed yet. “We have to talk about outcomes compared to cost,” Dougherty says. “Are we saving money? We have to have that kind of argument, but [the field] is not prepared for it yet. [Effectiveness data] will be mandatory in order to work with commercial insurers and health plans in the context of providing more chronic care services.” IT will also play a role in helping providers and payers provide better care. “We need to be able to share data so we can identify people in need who have co-morbidities or untreated mental health issues,” says Ed Jones, senior vice president at Value Options, a Los Angeles-based MBHO. “There needs to be integration [of data between stakeholders] so we can do a better job of finding the people who need the help.” Community mental health centers and other providers may face choices about joining one network or another, choices that may decide which consumers they work with and where those consumers may be referred, based on their coverage. In Massachusetts, the state and behavioral health providers quickly realized that they needed new systems to understand the implications that various health networks would have on referral decisions and services available to consumers. “The normal referral pattern was leading people to providers that were not in the network they were covered by, and that provider then tried to bill the state,” Dougherty says. “The state had to issue a new policy that said they were the payer of last resort, and they began enforcing that policy in a way they hadn't been able to before. Providers are going to find they cannot take everybody the way they may have in the past. They will have to refer people to other providers who participate in that commercial carrier's network.” Challenge 5: Become collaborative providers Among reform's notable innovations are the establishment of new health/medical homes and accountable care organizations (ACOs). These aim to coordinate care and-theoretically-reduce the cost of treating patients with chronic conditions, including severe mental illness. “If you want to rein in the costs of people with chronic medical conditions, we have a huge contribution to make,” Jones says. “People are not getting anywhere in terms of management and stabilization of chronic medical conditions until they get their mental health and substance abuse issues under control.” Under new Medicaid rules effective in 2011, patients with chronic conditions can designate a provider as a “health home” to provide comprehensive care and services, with a 90 percent subsidy in federal matching dollars for two years. Behavioral healthcare organizations can qualify as medical home providers, but they will compete with general practitioners and others for status as the “hub” in this collaborative model. ACOs are built around a bundled risk model (under Medicare) in which a group of providers create a network that seeks to manage care, improve quality, and reduce spending for certain patients. These would typically involve hospitals or multi-specialty physician practices that forge relationships with other outpatient providers. Increased grant funding included in reform legislation and managed by SAMHSA will support the co-location of mental health and primary care providers. Additional seed money is earmarked for new wellness and prevention programs, although the role of behavioral health in those programs has yet to be defined. The goal is to move from a reactive to more proactive treatment model, while hopefully holding down costs. “Behavioral healthcare is really a small percentage of the healthcare dollar,” Jones says. “We need to focus on measures that help ensure costs are not going to escalate, and that includes an intense focus on co-morbidities and health and wellness programs.” “We'll have to compete with other kinds of healthcare providers, some of which are very large,” Ingoglia says. “We're being asked to step up our game as specialists and to extend what we do to have more reach into primary care. The good news is that people now recognize that mental illness and substance abuse disorders are common and treatable, and that any attempts to bend the cost curve must address these disorders.” To collaborate successfully with other specialists and hospitals, behavioral health providers will have to meet new operational and IT challenges, while depending on government to resolve thorny issues about the handling of, for example, substance use treatment information. “How do you set up memorandums of understanding between primary care providers and behavioral health providers, so that you're sharing information but not breaching confidentiality rules?” Ericson says. (See “Confidentiality law: Time for change'” in Behavioral Healthcare , April 2010, or at http://www.behavioral.net/popovits1004 .) For a host of reasons, the consolidation of behavioral health organizations is sure to accelerate as organizations grapple with the opportunities, demands, and competitive realities of a transforming healthcare system, an influx of new consumers, and demanding internal performance requirements. Awaiting the next phase At present, the behavioral healthcare industry joins with businesses and stakeholders throughout the country in awaiting the many detailed regulations needed to fill out the nation's plan for a reformed healthcare system. As those regulations are being written, the White House, HHS, and other government agencies are striving to plan and launch a new series of healthcare reform communications. Industry and advocacy groups have joined the fray as well: NACBHDD has called on HHS to provide information bulletins to concerned stakeholders (consumers, employers, providers, etc.) to explain exactly what reform will mean for each group, while the National Council, ACHMA, SAMHSA, and other groups are putting together conferences, webinars, and other resources to build awareness of key issues as a broader plan coalesces. For the time being, Dougherty recommends that providers reevaluate their capabilities, notably, for managing new payment streams through financial, IT, and billing systems; for tracking referral compliance; for collecting cost and outcomes data; and for improving the quality and reliability of their processes. “I don't think we're clear enough yet as a field for people to invest a lot of resources, but that time will come quickly when you have to make decisions about what those investments will be,” Dougherty says. “The winning providers are the ones that are ahead of the curve.” Brian Albright is a freelance writer. Behavioral Healthcare 2010 June;30(6):14-18 Tue, 01 Jun 2010 00:00:00 EST F5A59C394B8F4F28806701152F4751FE