Communique — Documents — Home

–Linda R. Wolf Jones, D.S.W., Executive Director, Therapeutic Communities of America

The history of the therapeutic community (TC) movement is one of adaptation to change. Over the past few decades, TCs have developed new treatment approaches and clinical practices in order to meet the needs of different populations, to provide more effective services, and to respond to changes in government mandates and funding streams.

While TCs are responsive to the need for change, however, there are elements of their nature that keep them from making large-scale changes without careful prior consideration of the likely consequences. Most TCs are nonprofit organizations under Section 501(c)(3) of the IRS Code; they have a specific mission and purpose which are related to their tax-exempt status. Any proposed change in program direction or operations must be weighed in terms of its relationship to the mission. Further, the fact that TCs tend to hire clients who have come successfully through the program means that staff have a personal belief and investment in the treatment methods.

Issues for TCs to Consider

As managed care moves to the forefront of health care reform, therapeutic communities will need to pay attention to the changes that will be required to enhance their ability to participate in the new and expanded networks. TCs worked actively in an effort to ensure the best possible benefit coverage for long-term residential treatment in health care reform legislation. They will also have to work at becoming a provider in the relevant networks, getting referrals from them, and meeting the networks' administrative and clinical demands and requirements. Issue areas that may require attention as TCs increase their interactions with managed care providers include:

• Staffing patterns

• Recordkeeping and paperwork

• Utilization reviews and quality assurance procedures

• Justifications of their decisions and actions regarding clients

• The maintenance of control and autonomy with respect to clinical practices, client protections, and program quality and integrity

Financial and cash flow issues may also arise.

Potential Problem Areas for TCs

A number of potential problem areas exist with respect to TCs and managed care, in both the clinical and administrative realms. Clinically, the managed care approach may be too standardized and too medically focused to meet fully the treatment, social, and psychological needs of widely disparate substance-abusing populations. It may also limit access for hard-to-reach populations. If cost and service limits are imposed, they may operate most harshly against the clients with the greatest needs. Additionally, TCs may feel themselves pushed to breach their own standards for client admissions, confidentiality, and program quality.

On the administrative end, TCs may find the paperwork demands of managed care providers to be both onerous and expensive. They may need to revise and/or quantify their standards regarding admission criteria, treatment progress, and outcome measurement. There may be a paucity of referrals, despite the best efforts on the part of TCs to meet the demands of the managed care networks. Finally, it is very likely that TCs across the board will suffer an increase in frustration over the monitoring, second-guessing, and payment practices of the managed care plans to which they belong.

Positive Steps for TCs to Take

There are a number of ways in which TCs can prepare for the upcoming changes. On their own, they can review all of their policy and clinical manuals, recordkeeping forms and procedures, accounting practices, and code compliance–refining and making changes as necessary. They can reassess their staffing levels, staff certifications, and staff training. They can review their mission, paying careful attention to what policies and practices ought to be changed to improve operations, as well as to what could be changed and what cannot be changed in response to managed care demands and requirements.

Some assistance in responding to change will have to come from outside sources. TCs may need technical assistance on how managed care operates, who the providers are, and how to gain access to the networks. They will need the computer equipment and software to bring their systems up to date, together with the staff training necessary for implementing and operating those systems.

Hands-on conferences and meetings between TCs and managed care providers will need to be set up to increase the comfort level and understanding of each other's operations. TCs may need technical assistance on how to meet the demands of managed care without sacrificing their program integrity. Ongoing government safeguards and protections will have to be put in place to take care of disagreements between TCs and managed care providers when they occur, including mediation, an appeals process, and other forms of third-party interventions.

TCs will have to work closely together in national and State associations to stay informed and protect their self-interests. They can advocate for State advisory councils on managed care issues, including TC provider representation on such councils. They can work cooperatively to monitor the implementation of managed care in their geographic area–seeking a grant, if necessary, to set up a monitoring system. Finally, TCs should be prepared to present data and recommendations to government officials based on their monitoring efforts.

Future of TCs Under Managed Care

A few predictions can be made about the future of TC operations in the new health care paradigm, given what we know about managed care at the present time. It is likely that the larger, more sophisticated TC providers will find a way to fit at least some of their operations into a managed care environment. Smaller, less sophisticated programs–as well as the traditional TC operations of larger programs–may have to look, in whole or in part, to other funding streams. These funding sources will likely include the substance abuse block grant, State grants, and criminal justice grants and contracts.

To some extent, all health care providers will have to make changes as a result of the shifting social policy paradigm called managed care–and TCs are no exception. We will hammer out agreements, we will adapt, and we will survive. At the heart of it all, however, will be the maintenance of our mission and our commitment to clients in the face of the changes to come.

Table of Contents

Last Updated