Assessing Arapahoe House Readiness for Health Care Reform

  1. Assumptions Regarding Health Care Reform
  1. Medical Accountability

We are “On the Way”. More than 50% of our contracts include specific performance and/or accountability measures. Our challenges include reliable internal and external reporting of performance. We have initiated changes to internal accountability measurement systems; changes are not fully mature.

  1. Competition

“Early Stages” in our treatment services; we have significant difficulty conceptualizing ourselves at an Optimal level. “On the Way Plus” in our social detoxification services due to our relationships and active referral and transportation systems with hospital emergency departments

  1. Continuum of Care

We are “Early Stages”/“On the Way” with a series of change projects implemented focused upon “continuation” and “hand-offs” both within our own system of care and external systems of care. We are “Early Stages” in our adoption of a disease management perspective that includes recovery-oriented care. We have some grant specific pilot projects that come close to “Advanced”, but practices are unique to grant specific activities and traditionally have not been maintained post grant funding.

  1. Patient/Family Role

We are “Early Stages”, with some characteristics of “On the Way” in our treatment of patients and family members and their engagement as active consumers. Patients have limited roles in setting goals and treatment plans. Part of the challenge is referral source mandates regarding treatment goals and requirements.

  1. Performance Expectations – Outcomes (patient) & Processes

We have a mix from “Early Stages” to “Advanced”. At our best, we have some specific pilot projects, including clinical trials and demonstration projects, which are “Advanced”. These advanced practices are unique to grant specific, evaluation research activities and traditionally have not been maintained post grant funding. We are in the process of changing our performance and outcomes measurement to make it an integral part of our regular practices and quality improvement efforts. Our performance metrics have been largely financial, as well as demographic items required by the State. Some of the State’s reporting requirements and reporting systems significantly warp the quality, validity, and reliability of data reporting. Since our reporting systems have been designed around these, our internal data have had the same challenges. We are in the process of redesigning all of these.

  1. Role in Health Care

We range from “Early Stages” to “Light Advanced”, with continued movement in a positive direction. We are more active is some social service planning. In 2009 initiated significant planning with local public health systems around seasonal and H1N1 flu response and the function of our detox clinics in accepting intoxicated patients with flu symptoms from emergency departments.We are currently involved in initiating collaborative services in a primary care clinic. Participate in a number of substance-use/behavioral health planning processes. Just beginning involvement in a state-wide planning/implementation commission to enhance services for the deaf and hard of hearing.

  1. Context and Environment
  1. Demonstrate Value/Cost to Purchasers of Service

We are largely “Early Stages” but have“Advanced” ability to measure costs and outcomes of an episode of care with regard to with specific services. Areas where we are more advanced tend to be as a result of “necessity” – external requirements, research projects, demonstration pilots, etc. – those situations where there are “generous” resources supplied for conducting measurement and performance outcomes. We have an independent evaluation research department (Colorado Social Research Associates) that produces quality performance and outcome information and is a direct report to the Deputy Director/COO.

  1. Integration

We are in the process of implementing an EMR system with an integrated scheduling and claims billing system organization-wide. When complete we will be “On the Way” to “Advanced”. We should have some ability to share clinical information with other behavioral health and primary care partners. Sharing with behavioral health partners within our own MSO (Signal Behavioral Health) will be easier than with partners outside Signal.

  1. The Organization
  1. Infrastructure

The IT department is sophisticated, forward thinking, and participates in multidisciplinary problem solving and planning. The utilization by the organization of available IT resources varies highly in effectiveness and sophistication, and is not integrated. We have a DOS-based system for collecting encounter information for reporting and billing. It is not “user friendly”. Data entry is not intuitive (which is an understatement); reliability and validity of reports produced by the system are of dubious value for management purposes; and reports require significant work to ensure accuracy. Data base administrators and Colorado Social Research Associates (CSRA) staff are able with effort to mine and clean data to produce performance and outcome information. This process is not pretty, but quality improvement data are available.We are in the process of replacing this system with an integrated, scheduling, billing, and EMR system. Completion target June 2010.

We have an intranet with ability coordinate shared tasks and documents, quality improvement data, but none of our systems are integrated.

Our finance operations are largely manual. There is an electronicaccounting system for general ledger, payables and receivables, which is liberally “enhanced” by layers of Excel spreadsheets. Much of our billing, accounting, and financial reporting involves significant manual labor operations. We are not connected to an electronic claims clearinghouse, nor do we currently have that capacity. Our new EMR system has that capacity. We do not use online payment or account management systems. We do not export to Medicaid, but enter individual encounters into a web-based Medicaid system. Payroll is ACH, but timesheets are paper.

Our Human Resource systems utilize IT systems more effectively. Human resource information is managed largely electronically. Employee evaluations use web-based systems, training employs e-Learning, benefit administration is electronic. There is interface with electronic payroll records.

We are “On the Way “, and should be “Advanced” within the current year, but our current systems and utilization infrastructure are not efficient, nor elegant, nor integrated.

  1. Facilities

Our facilities for the most part are contemporary and well maintained. Most outpatient clinics are as nice as many primary care offices. We have some challenges specific to our three detox centers. There are development plans for improvements. Site development for detox centers is difficult in Metro-Denver. We just committed to purchase of a bare land site to build a combined service center to replace our most deficient facility, but zoning challenges remain. We have been searching for a site for 3 years, initiated purchase previously in other locations, and were unsuccessful.

Overall we are “On the Way Plus” to “Advanced Minus” with some facilities that are outliers.

  1. Board

The Boards (Arapahoe House and Arapahoe House Foundation) are knowledgeable, involved, and assist as appropriate in accomplishing strategic goals. We could use some additional engagement around specific issues, but are “Advanced Minus” overall.

  1. Management

Overall management is “Advanced” and actively engaged in planning integration of behavioral health and primary care in more than one health setting. As a general rule, management at various levels is flexible, performance oriented, and capable of implementing new organizational approaches. There are current infrastructure impediments in terms of performance and financial measurement systems that are in the process of being corrected.

  1. Change Management Skills

Change management is embraced by management at all levels of the organization. Within management there are different degrees of comfort with, and styles of, change. We are “Advanced” in our change management skills.

  1. The Workforce
  1. Licensed Clinical Staff “Early Stages”

We have 47% of clinical staff with a clinical masters and addiction counselor certification, but just under 20% of clinical staff with a professional mental health license in addition to addictions counselor certification.We have proactive processes to improve this.

  1. Medical Staff “Early Stages”

We have less than 5% medical staff. We are actively recruiting additional staff including a psychiatrist.

  1. Non-licensed Staff “Early Stages”

Our staff with only addiction counselor certification exceeds staff with a professional license.

  1. Annual Turnover “On the Way”

Turnover has gone from 27.2% (FY 07-08), to 24.9% (FY 08-09), to 9.94% for the first half of this fiscal year (09-10). We have professional development plans for all employees, a continuing education budget, and active internal initiatives for clinical supervision for professional licensure and addiction counselor certification.

  1. Treatment Interventions
  1. Role of Technology

We have a SAMHSA demonstration grant for “e-Treat”. This was originally targeted to provide interim services for persons waiting for treatment. We have expanded this to aftercare. These e-services currently exist “in a silo”, part of which is related to grant logistics. We are currently implementing a project that integrates e-services broadly into our clinical activities. Currently “Early Stages”.

  1. Evidence-based

We explicitly employ evidence-based practices (EBP) in our treatment services. We range from “On the Way” to “Advanced”. We have a consistent internal campaign to implement a number of EBPs including Medication Assisted Treatment (MAT). This has included continuing education, structural changes, and specific change teams focused upon implementation and adoption. Our major challenge to MAT being “fully available” at this point is the expense of certain medications (e.g., Vivitrol) and the indigence of our patients. We had a “work around” that included manufacturer donations of doses couple with some funding, which has fallen apart in the last 30 days due to changes by the manufacturer. There exist small pockets of clinicians uncomfortable with some aspects of MAT and/or other EBPs, and we are aggressively addressing this. We are implementing changes to enhance our fidelity infrastructure and measures.

  1. Holistic Care

We are holistic in philosophy, approach, and practice. “Advanced minus” is roughly where we are across treatment services. We do need to improve fidelity measurement in this area.

  1. Reimbursement and Revenues
  1. Sources of Revenue

We are “Advanced” in our ability to bill fee-for-service, different payers, private insurance as well as Medicaid. We are increasing our formal credentialing of our clinicians with health plans and managed care organizations. Our technical billing infrastructure is on the cutting edge of 1992. We largely bill via paper.

Form of Revenue

Traditionally our corporate culture is grant oriented. Discussions of increasing income production and partnering with other organizations tend to focus upon grants. We are slowly moving toward a focus upon producing services that have value in the general healthcare market.

  1. Role of Technology

We are “Early Stages” in the utilization of technology in our financial management and billing. We have the capacity to report encounters to our own MSO and thus the State.

  1. Financial Viability

We are “Advanced” with > 120 days cash on hand and positive assets for reserve.