AEA Conference November 2010 Creating Sustainable Structural Changes

AEA Conference – November 2010 Creating Sustainable Structural Changes in State Mental Health and Substance Abuse Systems: Findings From the National Evaluation of SAMHSA’s Co-occurring State Incentive Grant Program John Hornik, Ph. D. , Project Director, AHP on behalf of the evaluation team Advocates for Human Potential, Inc. Albany, NY and Sudbury, MA This research was supported by Contract (No. GS-10 F-0148 P ) from the Substance Abuse and Mental Health Services Administration (USDHHS) to AHP, John Hornik, Ph. D. , Director of Research, jhornik@ahpnet. com

COSIG Background • What is COSIG? – Co-occurring State Incentive Grant. – Response to the SAMHSA Report to Congress on Co-occurring Disorders. – Each grant 5 years with $2 to 4 million per grantee over 5 years. – 15 grantees in three cohorts; 4 new grantees in FY 2006. • Assumptions of COSIG grant – Allows States to be flexible in identifying critical pathways to address co-occurring disorders. – COSIG provides resources to help remove system barriers, without which real change cannot occur. – All States are eligible for COSIG, whether they have extensive prior work in COD or are new to addressing the issue. • Related initiatives: State Policy Academy, Co-occurring Center of Excellence (COCE).

Why COSIG was initiated? q Persons with both MH and SA disorders rarely receive integrated/coordinated treatment for both q MH and SA in organizational silos both in state government and at the provider level q Poor Identification: Infrequent screening and assessment for complementary disorder by providers q Workforce unprepared to work with persons with cooccurring disorders q Systems not coordinated although individuals have multiple needs for services and supports q Financing obstacles to reimbursement for care q Poor information sharing among state agencies

Goals of the National COSIG Evaluation 1. Assess the accomplishments of the States in meeting the national goals and objectives of the COSIG program in these areas: • screening & assessment • licensure & credentialing • service coordination & network building • financial planning, • information sharing, and • sustainability of changes. 2. Evaluate the activities of the COCE and other resources that provide technical assistance and training. 3. Evaluate SAMHSA’s role, including the design of the incentive grant structure.

Evidence of Sustainability of Changes beyond the Grant • Changes in statute, including changes in appropriation • Changes in regulation, administrative rules • Changes in standard contract language • Changes in payment rates • Changes in policy reflected in formal MOU, agreements, etc. • Changes in organization Additional considerations: o Changes in infrastructure that are intended to affect access, quality and outcomes o Changes that affect the entire state, not just one part

Primary Evaluation Method: Site Visits • Site Visits to all 15 States in Cohorts 1 -3 – Preparation: detailed review of State documents • Original Proposals, Quarterly Reports, Continuation Applications, Evaluation Reports (if available), and any other information available – 2 -2. 5 days on site in first and third contract years • Meet with individuals involved with planning and implementation • Visit pilot programs – Follow-up telephone site visits (8 hours) in other years

FINDINGS

Organization for Change • Wide variation in how States organized for change: – In a handful, COSIG is organizationally situated to drive major systems change; the majority report to Division Directors and are positioned to advocate for COD within their agencies but not at higher systems level. – The majority operate within a combined behavioral health agency, although program separation at this level is more apparent than integration.

Organization for Change - 2 – Few Governors’ offices are actively involved although formally the grantee. – For the majority, multi-stakeholder leadership structures are in place. – However, decision-making is generally done by internal leadership groups rather than by stakeholder consensus. – Few have broad involvement of consumers & families; the majority have only small numbers of consumers participating in stakeholder committees.

Access to Universal Screening for MH and SA Problems • Seven states achieved full implementation; four moving toward universal screening; • Five states incorporated results into client MIS; • Ten states build language requiring screening into regulatory/contract language; • States varied in the extent to which specific screening instruments were required.

State Strategy for Screening Instrument Selection

Access to MH and SA Assessments following a Positive Screen • Only two states achieved full implementation of assessment; three moving in that direction; • No specific assessment tools are mandated; • Barriers included: – Provider resistance – Lack of trained and credentialed staff – Lack of treatment options following assessment

State Progress in Assuring Access to MH & SA Assessment

Credentialing of Therapists as Providers of both MH & SA Services • Program developed by PA • Adopted by International Certification and Reciprocity Consortium (IC&RP) • Two levels of certification: – Certified co-occurring disorders professional diplomate • Adopted by five other states, as well as 10 non-COSIG states and Canada

Strategies for Improvement of Workforce Capacity by States • All states developed training activities, most often based upon internal planning workgroups; • Eleven states included training (4 -16 hours) in “core COD competencies”; • Training was directed both to pilot sites and to other programs; • Wide range of delivery strategies (mentoring, onsite training, conferences, web-based) • Sustainability: With the end of COSIG, future of COD training was uncertain in most states.

Services and Systems • Service Coordination and Network Building: “Conventional boundaries between single-focus agencies impede the clinical progress of persons with co-occurring disorders. Network building will help States develop more effective linkages across systems of care” (GFA, p 5). • Services Integration: State-supported development of dual diagnosis capability, including appropriately coordinated treatment at the local level. • System Collaboration: Development of processes or structures that assure coordination and collaboration among agencies (e. g. , MH, SA, Medicaid, housing) at either the State or local level or at both levels.

Strategies to Assure Access to Integrated MH & SA Services • 13 states took actions resulting in sustainable changes in services integration; • These included statutory changes (1), appropriations (3); regulations (4), contract language (9), payment rates (4), policy (6), and other (6); • Different models employed: CCISC, Tip 42, IDDT, ASAM DDC; • Some measurement (12): DDCAT, IDDT fidelity, COMPASS.

Strategies to Assure Access to Integrated MH & SA Services • Relevant training is offered to providers in most States. • Implementation is limited to selected pilot sites in most States. • Service settings vary by State: outpatient, emergency, case management, jail, prison. • Structure: - Integrated treatment within a program; - Parallel treatment with a program; or - Parallel treatment with collaborating programs. • Not a formal goal in two States.

Reorganizing to Assure Systems Collaboration • Limited collaboration between MH and SA at the State level. • SA and MH collaboration at the local level is generally limited to pilot agencies. • Limited number of States adopted systems integration (beyond MH & SA) as COSIG goal. • Involvement of other State agencies is generally limited to committee participation, except Medicaid (see Financing below) and Criminal Justice. • Very limited involvement of other human service agencies at the local level, primarily in pilot programs.

Financing Changes to Assure Access to Integrated MH & SA Services • Very few changes occurred; • Nine states attempting changes in Medicaid program, service additions and rate changes; – Obstacles: complexity of rules for reimbursement and making program changes; • Four states attempting changes to statecontrolled funds, including Block Grant; • Two states attempting administrative efficiences (e. g. , single contract).

State Progress in Implementing Financing Changes

Types of Financing Changes • Medicaid changes to allow billing for COD services • State contract changes to allow billing for COD services • New state appropriation specific to COD • State funds to continue support of a part of COSIG initiative: LA, MO, PA, TX • Payment incentives: AK, CT, DC, PA

Sharing MH & SA Client Data Across State Agencies • • 11 states defined this initially as a goal; Minimal progress toward significant changes; Major projects in Texas and Alaska; Most states have legacy client information systems that are not integrated (exception: Oklahoma); • Wide range of barriers encountered: definitional, technical, multiple systems, prior investment, lack of new resources.

State Progress in Implementing Information Sharing Changes

Types of Information Sharing Changes • New IT systems with a range of new data incorporated, including screening, assessment and outcomes: AK, TX • Grantees worked to bring together information stored in separate silos: AR, DC, LA, MO, PA

Unanticipated Outcomes Emerging from Technical Assistance Process The Learning Community • Co-occurring Practice Improvement Collaborative • Adoption/adaptation of PA COD credentialing model • Sharing of information and ideas through COCEsponsored list serve and meetings • Strong support for continued TA resources and meetings

Summary of Findings Across by Domains • Rates of implementation by domain-number of states with either full implementation or moving toward full implementation • Screening(11) • Workforce training (9) • Financing: Medicaid (7); State (3) • Services integration (7) • Workforce credentialling (6) • Assessment (6) • Information sharing (5)

Summary of Findings Across Grantees • Rates of implementation by grantees-number of domains with either full implementation or moving toward full implementation • Eight domains (4) • Seven domains (3) • Six domains (2) • Five domains (1) • Four domains (3) • Three domains (1) • One domain (1)

Is Five Years Enough? • State Start-up – Most States take time to get organized, causing a slow start-up in Year 1. – Implicit expectation that unspent funds will be available for carryover to support activities in later years. • Five Years In – Even with eleven States completing their fifth year, it is too soon the judge the success of grantees in meeting their goals. – Grant period may be too short to accomplish some structural changes.

COSIG Funds: Percent of Grant Funds Spent in Year 1 for 14 States • Many States expended less than 20% of their COSIG funds in the first year. • Slow start-up and delays in releasing the funds at the State level contributed to low rates of expending funds.

How long does it take to produce sustainable systems change? Who—in government—has the patience to wait five years? A week is a long time in politics. A year is a short time in the bureaucracy. --- Yes, Minister

Thanks to our colleagues AHP • Joli Brown • Susan Hills • Darby Penney • Amy Salomon • Kristin Stainbrook SAMHSA • James Herrell • Charlene Le. Fauve • Angela Galloway • Lawrence Rickards HSRI • Virginia Mulkern • Teresita Camacho-Gonsalves • Deborah Potter UMass Medical Center • Douglas Ziedonis • Kenneth Fletcher • Carl Fulweiler • Kristen Roy-Bujnowski UMDNJ • Anna Kline