# Presentation: 290394

## Thomas A. Kirk, Jr., Ph.D., Commissioner

Department of Mental Health and Addiction Services
A Healthcare Service Agency

June 2006

- Department of Mental Health and Addiction Services
*A Healthcare Service Agency*
*June 2006*

- CONNECTICUT**ACCESS TO RECOVERY**

- Federal Substance Abuse and Mental Health Service Administration**National Advisory Council**

## Getting Started

**Getting Started**

**Notes:**
Hi, My name is TAK.  I’m Commissioner of MH&AS for the State of Connecticut. Today, I’m going to present some of the exciting developments taking place in establishing best practices and innovative programs for people with serious mental illness.  Because I come from an organization that also addresses the needs of people with serious substance use disorders, and because people with serious mental illness often have problems with substance use, and because the risk associated with co-occurring psychiatric and substance use disorders is so great, I’m going to take the liberty of discussing both. 

I’d like to begin by providing several elements of context  First, why should we concern ourselves with  best practices and program innovations?   Is it because new is better?  Its it because old isn’t good enough?  Of course there are a lot of reasons – the ones you choose will depend on your unique perspective.  If you’re a person with SMI or a member of their family, you want to get better, or have your loved one recover.   If you’re a practitioner, you’ve got an ethical and professional  responsibility to provide the best care.  If you’re a Commissioner like me, you have responsibility for promoting recovery for as many people as possible by providing quality services within a system of care– Care that offers the greatest value to the consumer and the taxpayer.  If you’re a legislature you also care about the tax dollar and you want the best possible outcome for each dollar spent – Like me, you’re concerned about value.  

My point here is that for me, implementing best practices isn’t just about doing something new and innovative.  There are always new things – tomorrow there will be a new innovation - it’s really about something more fundamental and important – it’s about using best practices and innovative programs as instruments of change, as a way of transforming a system of care, as a means of  engaging service practitioners and keeping them on their toes, and as a way of involving consumers,  family  members, advocates and legislators in moving toward a value-driven,  recovery-oriented system of care.  For me that’s what it’s about. Using best practices and innovative programs can help to achieve this higher purpose.  Today we’ll look at some examples, some have been developed under the auspices of the federal government, and some are homebrewed by the states. 

The next element of context I’d like to cover involves providing some background about serious mental illness.  I know that you covered some of this yesterday.  I hope this won’t be redundant, but it is important to understand the relationship between the disorders we’re treating and the practices we’re developing.  

## We are a healthcare service agency.

**Promote health**

**Recover and **
**sustain health**

**through prevention and early intervention services.**

**through treatment and recovery support services.**

## Doesn’t anybody ever get better?

**“****a chronic, relapsing disease”**

**“****severe persistent mental illness”**

**Doesn’t anybody ever get better?**

**What message are we conveying?**

## Substance Abuse as too often viewed by the funder and/or service provider

**Severe**

**Remission**

**Notes:**

Now let’s look at what happens in most forms of treatment. 
Typically, the provider of mental health services begins to see the client when symptoms are very pronounced and the client is experiencing intense distress.  In other words, they’re in the Acute Phase.  Treatment is designed to reduce symptoms and distress.  So, the client enters treatment here (point to graphic) and is discharged here.  

## Service Response

- Acute symptoms
- Discontinuous treatment
- Crisis management

**Severe**

**Remission**

**Notes:**
Because the illness is persistent and recurring and the interventions of the treatment system tend to be in play only during the acute phase the so-called negative symptoms aren’t being addressed.  Despite the fact that the illness is persistent with different symptoms at different points in time, treatment lacks continuity, not only temporal continuity, but also continuity of care giver, and is crisis oriented.  
Again, symptoms occurring during the quiescent phase that can be extremely disabling are not addressed. 

## Recovery-oriented response

**Severe**

**Remission**

**Notes:**
How should the system respond to minimize crises & enhance recovery?

## Many Paths to Recovery 

- Many Paths to Recovery

**Notes:**
Connecticut, was one of 14 states plus selected for this competitive federal grant. We’ll $22.8 million over 3 years.  People funded under ATR have a great deal of control over services they receive because it involves the use of vouchers to pay for services.  
ATR covers traditional addiction treatment and rehabilitation, but it also covers non-traditional supports, such as sober houses, transportation, faith-based supports and vocational services that we can’t fund using traditional mechanisms.  

For example, we know from research, and from the experiences of professionals and people in recovery, that having a job can be pivotal to recovery.  A job can help to consolidate and sustain a person’s recovery by providing a focal-point in their life.  So, if a person has a clearly established interest in a career path, we can help them to get there.  We’ve sent people to be trained as certified nursing assistants, dieticians, and even cosmetologists.  We’ve also learned that for some people, faith-based supports are helpful to recovery.  Recognition of the role spirituality in recovery and of a “Higher Power” is ingrained within the AA tradition.  Faith-based supports can also be useful for people with serious mental illness.  Because of the flexibility of ATR program, we are able to reach populations that have been difficult to engage in treatment.  The role of faith-based supports can be particularly helpful in reaching out to diverse racial/cultural communities.   

## DMHAS APPROACH

## How Does ATR Fit Into CT’s Larger Picture?

- ATR is not just another program, it represents a significant investment in the promotion and enhancement of the Department’s overarching goal of a recovery-oriented system of care
- ATR builds upon a combination of previously undertaken steps and programs

## Connecticut’s ATR Model

- High degree of collaboration with other targeted state agencies
- Five regional networks -  a total of 36 clinical and 130 recovery providers (including peer and faith-based) to ensure client choice
- One lead agency in each network assisting with implementation, certification of providers, auditing, etc.

## Collaborative Agencies & Programs

- Department of Correction
- Judicial Branch
- Department of Children and Families
- Department of Social Services
- Primary Healthcare Sites (Hospital ED & FQHC Sites)
- DMHAS-funded Outreach &
- Engagement Urban Initiatives

## Clinical Services

- Evaluation
- Brief Treatment
- Ambulatory Detoxification
- Intensive Outpatient (IOP)
- Methadone Maintenance
- Recently implemented: an evidenced based model of IOP for individuals using cocaine and/or methamphetamines

## Recovery Support Services

- Short-term Housing
- Case Management
- Childcare
- Transportation
- Vocational/Educational Services
- Basic Needs (food, clothing, personal care)
- Faith-based Services
- Peer-based Services
**Two thirds**** of CT’s ATR service budget is invested in Recovery Support Services, not clinical services.**

## What are Recovery Support Services?

- Complement the focus of treatment, outreach, engagement, and other strategies and interventions to assist people in establishing an environment supportive of recovery and in gaining the skills and resources needed to initiate and maintain recovery.

- Substance use,
- Symptoms,
- Relapse Triggers

- Recovery Capital

-   Treatment		           Recovery Supports

- +

## Recovery Capital is . . .

**	****“**the quantity and quality of both internal and external resources that a person can bring to bear on the initiation and maintenance of recovery” (W. White, 2006)
- 	In contrast to people who achieve “natural” recovery (without care), most people with addictive disorders entering treatment have never had much recovery capital or have dramatically depleted such capital by the time they seek help.

## Recovery Support Services aim to:

- remove personal and environmental obstacles to recovery (e.g., through the provision of child care or transportation)
- enhance identification of and participation in the recovery community (e.g., through connecting people to treatment and to 12-step and other mutual support/recovery-oriented groups)
- enhance the person’s “recovery capital” (e.g., by assisting people in addressing their basic needs, gaining employment, going back to school, forming sober social relationships, etc.)

## Year To DateAugust 3, 2004 – June 11, 2006

- 10,158 Unduplicated Individuals Served
- Year 1 Total Unduplicated Individuals: 106
- Year 2 Total Unduplicated Individuals: 10,032
- Received over 75,000 service level authorizations (clinical and/or recovery support services)
- $10,228,529 total paid claims

## More people working and in housing, less inpatient costs

*Based on a Corporation for Supportive Housing study, these supportive housing units are projected to generate over $140 million in direct and indirect economic benefits for the state. *
*                                              *

**% Working or in training**

**Inpatient costs**

**Notes:**
Here are some results from an evaluation of the impact of stable housing on other aspect of consumer recovery.  Look at this.  People in the supportive housing units who had a decent place to live and assistance finding work and getting other services they needed, like behavioral health and medical care, were much more likely to find jobs or to become enrolled in job training, and showed an equally dramatic decline in inpatient usage.  

## Putting People to Work

** ****Enhancing Employment and Self-Sufficiency through **
**Vocational Rehabilitation**
*The likelihood that a person served by DMHAS will become gainfully employed is more than  doubled when he/she receives vocational rehabilitation.*

**It pays!! **

**Notes:**
Here is an example of some evidence from our work in Connecticut that supports using Supported Employment.  In these data we can see that the likelihood that a consumer will become gainfully employed more than doubles if the person is receiving vocational services.  Work is at the heart of recovery and contributes to the persons self esteem and sense of control over their environment.  It also opens the possibility of enhanced social relationships and helps provide the person with spending money to support social activities.  The data presented here are from an administrative database, not from a study using random assignment of subjects in experimental and control groups.  But does anyone doubt that vocational services contributed to the results??

## Client Vignettes

**“****Mary”** prior to discharge from York Correctional Institute for Women, met with an ATR case manager to review discharge plans. “Mary”, through informed choice, selected an intensive outpatient program from a list of providers and a faith-based housing provider from a list of housing providers. Additionally, the ATR case manager assisted “Mary” with transportation from the correctional facility to her housing provider. Once in the community, the housing provider submitted a request on behalf of “Mary” for food, clothing, personal care items and bus passes to attend her IOP program and look for employment.

## “Jim” was referred from the Judicial Branch-Probation Division, with a history of crack, cocaine, and alcohol abuse. As an important milestone in his recovery, he was returning to work as an electrical contractor. ATR paid for textbooks required for the Electrical Code Review Contractor Course and for the course itself. ATR also assisted “Jim” in purchasing the electrical contractor tools required for employment.

- Client Vignettes

## “Karen” has been receiving substance abuse treatment funded by non-ATR sources since May 2005. She is becoming self-sufficient and is now in classes at the Stone Academy, with ATR covering textbook costs. 
“Frank” requested and is receiving ATR financial assistance to cover the cost of a Faith-based Men's Retreat where people support each other in their recovery. 
“Patti” is attending Hairdressing school, requested and received ATR assistance in purchasing hairdressing supplies needed for her courses. Her treatment is being funded by the General Assistance funds. 

**“****Frank”** requested and is receiving **ATR** financial assistance to cover the cost of a Faith-based Men's Retreat where people support each other in their recovery.
**“****Patti”** is attending Hairdressing school, requested and received **ATR** assistance in purchasing hairdressing supplies needed for her courses. Her treatment is being funded by the General Assistance funds.

- Client Vignettes

## Challenges

- Developing administrative infrastructure
- A voucher program requires an agency to have infrastructure to support the necessary administrative processes, including appropriate documentation of delivering the service
- Many grassroots organizations, including faith- based organizations, struggle with the paperwork that is required of a voucher (fee for service) program

##       Lessons Learned

- ATR represents a major service system change that takes time and commitment from all entities
- Need to support Recovery Support Service (RSS) providers in building infrastructure to collect and maintain client, program, and administrative level data and documentation
- Some RSS providers over-extended themselves on their ATR business and ignored other potential revenue streams

## ATR’s Impact on the CT System

- Expands clinical continuum of care to include Cocaine/Meth. IOP and Brief Treatment Services
- Expands recovery services continuum to include an array of peer- and faith-based services
- Adds new “non-traditional” provider base (peer- and faith-based)
- Offers extension of ATR processes and services within CT’s General Assistance BHP (I.e, housing provider credentialing application, expansion of basic needs, etc.)
- Helps to improve continuity of care and maximize existing capacity of system.

## Helping People Move into Recovery Zone 

- Helping People Move into Recovery Zone

- Improved client outcomes

**Severe**

**Remission**

## NEXT STEPS:SUSTAINING ATR IN CONNECTICUT 

- Enhance credentialing process for on-going monitoring of quality of care, performance, and resource efficiency;
- Consider formal regional networks for integrated prevention, intervention, treatment, and recovery support services;
- Determine comparative effectiveness of recovery support services, including a cost effectiveness analysis; and
- Explore the feasibility of expanding recovery support services within its existing General Assistance Behavioral Health and Basic Needs Programs

## In addition to those outcomes already expected by ATR, recovery support services may lead to positive outcomes in the following domains:

- Sense of personal hope for recovery
- Work searches and applications submitted
- Work activities, including volunteer positions
- Educational searches and applications submitted
- Educational activities (academic and alternative educational and skill building pursuits)
- Friendships and social connections
- Time spent in self-selected valued social roles, including giving back to others
- Time spent in self-selected prosocial community-based activities
- Acquisition of symptom/illness self-management skills

## FOR FURTHER INFORMATION

- Thomas A. Kirk, Jr., Ph.D.
- 860-418-6700
- _[Thomas.Kirk@po.state.ct.us](mailto:Thomas.Kirk@po.state.ct.us)_
- www.dmhas.state.ct.us