Since the Institute of Medicine’s Crossing the Quality Chasm report regarding the provision of substance abuse and mental health services, Philadelphia’s behavioral health system has been undergoing a transformation. The call for change came from people in recovery and their families, treatment providers, the advocacy community, additional stakeholders, as well as the Philadelphia Department of Behavioral Health and Intellectual disAbility Services (DBHIDS) itself. Leading the change has been Commissioner Arthur C. Evans, Jr., PhD, who has served as the local catalyst in defining the values, culture, and strategic direction of the DBHIDS since his arrival in Philadelphia in 2004.
Collaboration and teamwork were essential to the transformation. “Through our initial discussions with multiple community constituencies, there was a desire to move our system of care toward greater recovery orientation, which was consistent with national policy directions as indicated by the New Freedom Commission Report and recent Institute of Medicine reports,” says Evans. Focusing on a vision of recovery, DBHIDS has moved to align its treatment philosophy, service delivery models, and fiscal administration policies to provide Philadelphians with access to services and supports essential for living meaningful lives of recovery while participating fully in their communities.
Among the many efforts focused on system transformation is a seven year initiative with the NIATx Foundation, which has resulted in long term benefits and mirrors a larger transformational process.
With a long and distinguished role in the history of behavioral health treatment and recovery in America the provider network was fairly settled and uniform when Evans brought NIATx to Philadelphia in June 2007. However, grassroots recovery advocacy movements in mental health and addiction, combined with moderate growth in funding for support programs, called “upon traditional mental health and addiction treatment agencies to transform themselves into ‘recovery-oriented systems of care’ and to use recovery as a conceptual bridge to improve services for persons with co-occurring disorders,” wrote Chestnut Health Systems' Emeritus Senior Research Consultant William L. White of Punta Gorda, Fla.
No longer interested in change demonstrated by the repackaging of the same product in the form of services delivered, DBHIDS wanted to transform the services provided by the entire system. The agency wanted to stress the support of recovery and resilience through assessment, evaluation, and the quality of services provided. DBHIDS’ Practice Guidelines for Resilience and Recovery Oriented Treatment, which is composed of 10 core values, four service domains, and seven system goals, was generated by local stakeholders as a guide the development of principles and strategies.
As DBHIDS sought recovery-oriented ways to grow and improve treatment services and internal efficiencies, as well as enhance and support a higher performing system, the “Communities of Recovery: NIATx Tools for Change” initiative flourished.
The NIATx Foundation began as the Network for the Improvement of Addiction Treatment. It works with treatment providers to make more efficient use of their capacity by sharing strategies to improve access to and continuation in treatment while reducing wait times and “no shows.”
NIATx also works with states, counties, and other governing bodies to provide tools for change that encourage use of a process improvement model. This model, which is quality-driven, customer-centered, and outcome-based, has proven effective in transforming business practices and the quality of care provided using data and existing resources to measure change in order to sustain improvements and spread them across organizations.
In Philadelphia NIATx has worked with both mental health and drug and alcohol treatment providers serving children, adolescents, and adults.
DBHIDS / NIATx Transformation Phases
2008 Improving Access and Retention in Treatment
2009 Expanding to Mental Health Services
2010 Building Infrastructure within the System
2011 Strategic NIATx and the development of system-wide Practice Guidelines
2012 Practice Guideline Implementation and NIATx
2013 DBHIDS Internal Spread and Sustainability
2014 Re-thinking NIATx: Getting the Most “Bang for the Buck”
“Buy in,” readiness, support
Research suggests the way to influence and create “buy in” is through warmth and collaboration and the Practice Guidelines’ core values of community inclusion, partnership, and transparency have facilitated trust and fostered a connection with Philadelphia treatment providers. It was important that DBHIDS acknowledged system problems as perceived by stakeholders, made a commitment to change the problems, and invited all stakeholders to participate in mapping out the process. This was done via the creation of advisory boards, steering committees, workgroups, task forces, and other forums supporting partnership and recovery.
One particularly powerful partnership is the Pennsylvania Recovery Organization – Achieving Community Together (PRO-ACT), which involves working with a regional advocacy organization made up of people in long-term sustained recovery. Other examples include the Mental Health Association of Southeastern Pennsylvania and the Consumer Satisfaction Team. With such a rich tradition of behavioral healthcare, unprecedented levels of participation by persons in recovery, and a demonstrated commitment to our evolving recovery-focused system of care, the stage was set for NIATx.
The goal of the “Communities of Recovery: NIATx Tools for Change” initiative is to give the city’s providers a set of skills to use in adapting to the ever-changing behavioral healthcare environment. In 2007, for instance, the city anticipated an increase in fee-for-service products and pay-for-performance management requirements, with a decrease in budgets and funding. A national recession, increasing budget pressures, and the highly significant implications of impending healthcare reform also loomed large.
Between 2007 and 2013, however, NIATx was successful in supporting and encouraging providers to improve treatment via simple, yet significant and effective organizational changes. By 2014 approximately 80 treatment providers representing hundreds of programs and multiple levels of care in Philadelphia had participated. Dozens of programs have shown successful outcomes and benefits via their participation in the initiative. A few are highlighted here:
Reduce wait times, reduce “no shows,” and increase admissions
Improved all aims and decreased paperwork, total revenue resulting from changes was $170,320 per annum
JEVS Human Services/ACT
Data showed 249 more hours of methadone services equaling $179,000 per year
Sobriety Through Outpatient
Reduce “no shows”
Re-engaged 15% of assessment “no shows” equaling $209,000 in revenue per annum
Increased admissions by 10 per month equaling $266,000 per year
Reduce wait times and “no shows”
Reduced wait times from 9 days to 1 day, and “no shows” from 41% to 24%, resulting in $84,000 per year in regained revenue
MCC Inc. Autism Program
Reduce referral to authorization period
Reduced authorization time from 99 to 42 days, a potential increase of up to $15,022.80 per year
Long term payoffs, benefits
DBHIDS has moved from a traditional service system to a recovery-oriented culture that embraces performance improvement, manages systems change, and promotes resiliency in a systemic, planned, measurable, continual, and collaborative manner. As Roland Lamb, Director of Philadelphia’s Office of Addiction Services (OAS), states, “the greatest challenge for us as a system is to trust one another and the process.” As chameleons change color, from the growth of the caterpillar to the transformation within the chrysalis to its rebirth as a butterfly, each stage of the journey must be understood and appreciated no matter how slow, painful, and unpredictable, “trusting that the end product is the foundation for a community of recovery” and a more efficient way of doing things.
This level of system transformation requires broad stakeholder commitment and newer models of sustained collaboration, as demonstrated by the work DBHIDS has done with NIATx.