Substance Abuse: Administrative Issues in Outpatient Treatment Robert F. Forman, Ph.D. Consensus Panel Chair Paul D. Nagy, M.S., LCAS, LPC, CCS Consensus Panel Co-Chair A Treatment Improvement Protocol TIP 46 U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment 1 Choke Cherry Road Rockville, MD 20857 Acknowledgments guidelines in this document should not be considered substitutes for individualized Numerous people contributed to the develop- client care and treatment decisions. ment of this Treatment Improvement Protocol (TIP) (see pp. ix–xii as well as appendixes B, C, and D). This publication was produced by Public Domain Notice JBS International, Inc. (JBS), under the All materials appearing in this volume except Knowledge Application Program (KAP) con- those taken directly from copyrighted sources tract numbers 270-99-7072 and 270-04-7049 are in the public domain and may be repro- with the Substance Abuse and Mental Health duced or copied without permission from Services Administration (SAMHSA), U.S. Department of Health and Human Services SAMHSA/CSAT or the authors. Do not repro- (DHHS). Christina Currier served as the duce or distribute this publication for a fee Center for Substance Abuse Treatment without specific, written authorization from (CSAT) Government Project Officer, and SAMHSA’s Office of Communications. Andrea Kopstein, Ph.D., M.P.H., served as Deputy Government Project Officer. Lynne Electronic Access and Copies MacArthur, M.A., A.M.L.S., served as the of Publication JBS KAP Executive Project Co-Director. Barbara Fink, RN, M.P.H., served as the Copies may be obtained free of charge from JBS KAP Managing Project Co-Director. SAMHSA’s National Clearinghouse for Other JBS KAP personnel included Dennis Alcohol and Drug Information (NCADI), (800) Burke, M.S., M.A., and Emily Schifrin, 729-6686 or (301) 468-2600; TDD (for hearing M.S., Deputy Directors for Product impaired), (800) 487-4889; or electronically Development; Patricia A. Kassebaum, M.A., through www.ncadi.samhsa.gov. Senior Writer; Elliott Vanskike, Ph.D., Senior Writer/Publication Manager; Wendy Caron, Editorial Quality Assurance Manager; Recommended Citation Frances Nebesky, M.A., Quality Assurance Center for Substance Abuse Treatment. Editor; Leah Bogdan, Junior Editor; and Substance Abuse: Administrative Issues in Pamela Frazier, Document Production Specialist. In addition, Sandra Clunies, M.S., Outpatient Treatment. Treatment ICADC, served as Content Advisor. Dixie M. Improvement Protocol (TIP) Series 46. Butler, M.S.W., and Paddy Shannon Cook DHHS Publication No. (SMA) 06-4151. were writers. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2006. Disclaimer Originating Office The opinions expressed herein are the views of the consensus panel members and do not Practice Improvement Branch, Division of necessarily reflect the official position of Services Improvement, Center for Substance CSAT, SAMHSA, or DHHS. No official Abuse Treatment, Substance Abuse and support of or endorsement by CSAT, Mental Health Services Administration, SAMHSA, or DHHS for these opinions or 1 Choke Cherry Road, Rockville, MD 20857. for particular instruments, software, or resources described in this document is DHHS Publication No. (SMA) 06-4151 intended or should be inferred. The Published 2006 Contents What Is a TIP?............................................................................................................vii Consensus Panel ..........................................................................................................ix KAP Expert Panel and Federal Government Participants....................................................xi Foreword..................................................................................................................xiii Executive Summary.....................................................................................................xv Chapter 1—Introduction................................................................................................1 Challenges of the Current Treatment Environment.................................................................1 History of Intensive Outpatient Treatment ...........................................................................4 Notes About Terminology.................................................................................................5 Summary of This TIP..................................................................................................... 5 Chapter 2—Management Issues.......................................................................................7 Roles of the Program Executive.........................................................................................7 Strategic Planning and Implementation ...............................................................................8 Board of Directors........................................................................................................10 Program Policy and Procedure Management.......................................................................14 Relationships With Strategic Partners ...............................................................................15 Referring Clients to Services Outside the Program................................................................16 Sharing New Knowledge With Those in the Field..................................................................18 Management and Administrative Issues..............................................................................18 Program Visibility: Outreach and Public Relations...............................................................22 Chapter 3—Managing Human Resources.........................................................................27 Policy Issues and Guidelines............................................................................................28 Guidelines for Staffing...................................................................................................30 Selection of Qualified and Competent Clinical Staff...............................................................36 Staff Supervision..........................................................................................................41 Continuing Education and Training...................................................................................44 Motivating and Retaining Staff.........................................................................................49 iii Chapter 4—Preparing a Program To Treat Diverse Clients.................................................53 Understanding Cultural Competence.................................................................................53 Learning About Cultural Competence in Organizations..........................................................55 Preparing for Cultural Competence Assessment ...................................................................57 Understanding the Stages of Cultural Competence................................................................58 Performing Cultural Competence Assessment ......................................................................58 Implementing Changes Based on Cultural Competence Assessment ...........................................60 Developing a Long-Term, Ongoing Cultural Competence Process..............................................61 Undertaking Program Planning .......................................................................................63 Appendix 4-A. Cultural Competence Resources....................................................................68 Appendix 4-B. Community Diversity Form .........................................................................71 Chapter 5—Outpatient Treatment Financing Options and Strategies.....................................73 Planning and Developing a Program..................................................................................73 Funding Streams and Other Resources in the Substance Abuse Treatment Environment................74 Working in Today’s Managed Care Environment..................................................................84 Contracts Are Primary Tools in Managed Care ....................................................................85 Elements of Financial Risk in Managed Care Contracts..........................................................87 Networks, Accreditation, and Credentialing........................................................................88 Organizational Performance Management...........................................................................90 Utilization and Case Management.....................................................................................93 Strengthening the Financial Base and Market Position of a Program.........................................93 Preparing for the Future................................................................................................94 Chapter 6—Performance Improvement and Outcomes Monitoring.......................................95 Increasing Importance of Outcomes Measures in Today’s Funding Environment ..........................96 Improving Performance and Monitoring Outcomes ...............................................................97 Measuring Performance and Outcomes ..............................................................................98 Outcomes Measuring Instruments....................................................................................104 Program Monitoring for Special Purposes.........................................................................106 Working With Staff on Performance and Outcomes Improvement...........................................106 Costs and Funding of Outcomes Improvement....................................................................110 Using Performance Data To Promote the Program..............................................................112 Appendix 6-A. Satisfaction Form for Clients......................................................................113 Appendix 6-B. Satisfaction Form for Referral Sources.........................................................114 Appendix A—Bibliography .........................................................................................115 Appendix B—Resource Panel .....................................................................................125 Appendix C—Cultural Competency and Diversity Network Participants .............................127 Appendix D—Field Reviewers ....................................................................................129 Index .....................................................................................................................131 iv Contents CSAT TIPs and Publications Based on TIPs ..................................................................137 Exhibits 2-1 Sample Statement of Board Member Responsibilities ......................................................11 2-2 Examples of Board Committee Structure ......................................................................12 2-3 Board Member Self-Evaluation Form ..........................................................................13 2-4 Example of an OT Program and Emergency Room Strategic Alliance ..................................15 2-5 Example of Reducing Costs for an Emergency Hotline .....................................................23 3-1 Issues Regarding Professional Standards .....................................................................29 3-2 Laws Regarding Hiring and Employing Staff in Recovery .................................................33 3-3 Counselor Interview Form ........................................................................................42 3-4 Sample Plan for Staff Education and Training ..............................................................45 3-5 Resources for Staff Education and Training ..................................................................46 3-6 Selected Training Documents ....................................................................................48 4-1 Glossary of Cultural Competence Terms ......................................................................56 4-2 Stages of Cultural Competence for Organizations ...........................................................59 5-1 Financial Arrangements With Providers ......................................................................86 5-2 Resources on Costs of Services ..................................................................................89 6-1 Evaluation Resources ............................................................................................104 6-2 An IOT Program Outcomes Study: Findings and Actions ................................................111 Contents v What Is a TIP? Treatment Improvement Protocols (TIPs), developed by the Center for Substance Abuse Treatment (CSAT), part of the Substance Abuse and Mental Health Services Administration (SAMHSA), within the U.S. Department of Health and Human Services (DHHS), are best-practice guidelines for the treatment of substance use disorders. CSAT draws on the experience and knowledge of clinical, research, and administra- tive experts to produce the TIPs, which are distributed to facilities and individuals across the country. The audience for the TIPs is expanding beyond public and private treatment facilities to include practitioners in mental health, criminal justice, primary care, and other health care and social service settings. CSAT’s Knowledge Application Program (KAP) expert panel, a distinguished group of experts on substance use disorders and professionals in such related fields as primary care, mental health, and social services, works with the State Alcohol and Drug Abuse Directors to generate topics for the TIPs. Topics are based on the field’s current needs for information and guidance. After selecting a topic, CSAT invites staff from pertinent Federal agen- cies and national organizations to be members of a resource panel that recommends specific areas of focus as well as resources that should be considered in developing the content for the TIP. These recommenda- tions are communicated to a consensus panel composed of non-Federal experts on the topic who have been nominated by their peers. Consensus panel members participate in a series of discussions. The information and recommendations on which they reach consensus form the foundation of the TIP. The members of each consensus panel represent substance abuse treatment programs, hospitals, community health centers, counseling programs, criminal jus- tice and child welfare agencies, and private practitioners. A panel chair (or co-chairs) ensures that the content of the TIP mirrors the results of the group’s collaboration. A large and diverse group of experts closely reviews the draft docu- ment. Once the changes recommended by these field reviewers have vii been incorporated, the TIP is prepared environment in which outpatient treatment for publication, in print and on line. TIPs programs operate. The TIP provides basic can be accessed via the Internet at information about running an outpatient www.kap.samhsa.gov. The online TIPs are treatment program, including strategic plan- consistently updated and provide the field ning, working with a board of directors, with state-of-the-art information. relationships with strategic partners, hiring and retaining employees, staff supervision, Although each TIP strives to include an evi- continuing education and training, perfor- dence base for the practices it recommends, mance improvement, outcomes monitoring, CSAT recognizes that the field of substance and promotion of the program to potential abuse treatment is evolving, and research fre- clients, funding agencies, and government quently lags behind the innovations officials. More specialized sections address pioneered in the field. A major goal of each challenges that have emerged and gathered TIP is to convey “front-line” information importance in the last decade: preparing a quickly but responsibly. For this reason, program to provide culturally competent recommendations proffered in the TIP are treatment to an increasingly diverse client attributed to either panelists’ clinical experi- population, succeeding in a managed care- ence or the literature. If research supports a dominated world by diversifying the funding particular approach, citations are provided. sources a program draws on, and under- standing privacy and confidentiality This TIP, Substance Abuse: Administrative requirements imposed by Federal legislation. Issues in Outpatient Treatment, was written to help administrators work in the changing viii What Is a TIP? Consensus Panel This TIP is a consensus-based document, developed by the experts listed below. Although all panelists made significant contributions in the development of the TIP as a whole, some pan- elists took on the additional responsibility as writers for upfront development of particular chapters. Those chapters are listed after their names. Chair Margaret K. Brooks, J.D. Consultant Robert F. Forman, Ph.D. 27 Warfield Street Clinical Scientist Montclair, New Jersey Medical Affairs Alkermes, Inc. Frederick T. Chappelle, M.S.S.W., LCADC, Cambridge, Massachusetts CCS Formerly Vice President and Financial Officer Senior Investigator Chappelle Consulting and Training Treatment Research Institute and Services, Inc. Assistant Professor of Psychology Middletown, Connecticut in Psychiatry Writer, chapters 3 and 4 School of Medicine University of Pennsylvania Gerard J. Connors, Ph.D. Philadelphia, Pennsylvania Director Writer, chapters 1, 2, 3, 5, and 6 Research Institute on Addictions Co-Chair University of Buffalo Buffalo, New York Paul D. Nagy, M.S., LCAS, LPC, CCS Anita L. Crawford Program Director Chief Executive Officer Duke Addictions Program Roxbury Comprehensive Community Clinical Associate Health Center Department of Psychiatry and Roxbury, Massachusetts Behavioral Sciences Duke University Medical Center Chris B. Farentinos, M.D., CADC II, Durham, North Carolina NCDC II Writer, chapters 1 and 2 Clinical Director Consensus Panelists Change Point, Inc. Portland, Oregon Fred Andes, D.S.W., M.P.A., LCSW Writer, chapter 4 Assistant Professor of Sociology New Jersey City University Jersey City, New Jersey ix