Tap 17 — TAPs <<<Documents<<<Home

Continuum Development Through Coalition Building: A Survival Technique for Rural Programs

Patricia Jean Tikkanen, A.C.S.W.
Program Director
Addiction Rehabilitation Center
Marquette General Hospital
President
Addiction Services Consortium of Upper Michigan
Marquette, Michigan

In both urban and rural settings, a rapid rate of change has affected the addiction treatment field in the past few years, primarily due to the new paradigm of managed care with its emphasis on cost containment and outcome measures. However, addiction treatment programs in rural regions face particular obstacles in structuring a new care continuum in this paradigm. These include the following obstacles:

• A reliance on outpatient service models with limited adaptability for rural areas, which have long distances between communities and a scattered population
• An emphasis on the accreditation of programs and certification of staff in programs that have often been underfunded; this underfunding results from the reliance on public sources of funding in areas characterized by high rates of poverty and uninsured families
• Demands from managed care companies and other customers that client care be highly individualized, when small programs have traditionally been organized around structured services with preestablished lengths of stays or predetermined numbers of visits.

Background: Michigan's Upper Peninsula

Programs in Michigan's Upper Peninsula have been struggling with these challenges, along with the additional stress factor of having an unstable political situation in the State bureaucracy for the past 4 years. There have been frequent threats that the regional planning and coordinating agencies which contract the public funds to programs may be eliminated. Various plans have also been proposed to transfer the responsibility for substance abuse treatment services at the State level from the Department of Public Health to the Department of Mental Health. It is widely anticipated that if this plan is ever activated, then the current system of programs would be threatened by the channeling of substance abuse funds through the community mental health boards, with which there is traditionally a lack of cooperation and trust.

However these situations are ultimately resolved, it is clear that the managed care model is now being implemented in the public sector. For the past year, programs seeking State assistance for residential and intensive outpatient care for a client (either from grant funds or Medicaid) have been required to obtain prior authorization from a central diagnostic and referral service. A coalition of mental health boards, which would implement managed care for Medicaid clients in the mental health system, has made a proposal that originally included substance abuse services as well as mental health services. It is felt that this type of system will be utilized if a transfer of responsibility is ever made at the State level. The State is also encouraging the development of health maintenance organizations (HMOs) and clinic plan systems for Medicaid clients. In these systems, the responsibility for arranging any substance abuse care rests with the HMO or clinic plan administrators, who may contract with substance abuse providers.

Agencies Involved in Planning

In response to this environment, the Addiction Services Consortium of Upper Michigan was organized in 1993. Originally there were five licensed programs involved in the planning. These were:

• The regional medical center in Marquette that provides hospital-based care (detoxification, inpatient treatment, and partial hospitalization programs) as well as outpatient care at five clinics in five counties—two in the western region and three in the eastern region
• Two district health departments that each operate multiple outpatient clinic sites and provide a variety of prevention and educational services
• A freestanding residential facility with services for adults (males and females) in two communities and one adolescent facility
• A Native American tribe that provides outpatient services and outreach for its members in three counties

A sixth member was added soon after the group was incorporated. This is a provider of specialized residential treatment for Native Americans (serving three States), which is operated by another tribe in the region. This facility also provides outpatient services to the general population in its home county.

All programs are accredited, which became a requirement for receiving State funding in Michigan as of fiscal year 1994. The Joint Commission on the Accreditation of Health Care Organizations (JCAHO) accredits the hospital and one tribe. The remaining programs are accredited by the Commission for Accreditation of Rehabilitation Facilities (CARF). All programs are well-established providers in the region with origins going back to the 1970s, when services were first being established.

The five original programs are all under contract with the regional planning and coordinating agency that serves the eastern part of the region. The original concept was developed through an informal program directors' group that meets regularly to share ideas and includes the director of the regional coordinating agency. The support of the regional coordinator proved to be essential in obtaining formal authorization from program boards to join the Coalition, since there is overlapping board membership between the coordinating board and the health department boards. The sixth program—the resident Native American Program—is located in the western part of the region. The regional coordinating agency for that district has not been involved in any meaningful way with the Coalition development, but has been kept informed.

While all agencies receive public funding, third-party payments have become an increasingly important proportion of all budgets. Prior to the Consortium's being developed, there had already been fairly extensive redesign of services within several of the agencies.

All current program directors have several years of experience in the leadership role in their programs, with one having over 20 years, two serving over 10 years, and the other three averaging 3 to 4 years. All had either extensive clinical or administrative experience prior to taking their current positions.

Description of the Region

The Upper Peninsula stretches across the northern part of Michigan, separated from the rest of the State by Lakes Michigan and Huron and connected only by the Mackinac Bridge that spans the Straits of Mackinac. The region is approximately 350miles in length from east to west and 100 miles north to south. There are 15 counties in the peninsula, varying in population from approximately 2,000 residents in Keweenaw, a bony finger of land jutting into Lake Superior in the far northwest area, to Marquette in the north central area with 74,000. Total population of the region is under 325,000. The city of Marquette—at 24,000—is the largest population center. The geographic location of the area is illustrated by the fact that Marquette is 400miles from the State capitol in Lansing—an expensive commute by air or a lengthy 8hours by car.

The region was originally settled following the discovery of rich deposits of both copper and iron ore, and iron mining remains one of the leading economic sectors in the central Upper Peninsula. Other large industries are primarily based on forest products, including a number of paper mills throughout the southern and western sections. In the past 10 years, the region has also become the site of extensive State-operated corrections facilities, with more than 2,000 employees working in a variety of minimum- and maximum-security facilities.

The Native American tribes are the only minority population of any size. There are five federally recognized tribes in the region. The largest ethnic groups are from Finnish and Italian backgrounds, with substantial representation from French, English, Slavic, and Swedish groups.

There is a commonly held belief that heavy drinking and rates of dependency and abuse are high in the region. However, there is little research evidence to support this, because little research has been done. The only formal survey ever conducted regionwide was done in 1982 by the Michigan Department of Public Health. This survey was part of the Michigan Opinion: Behavioral Risk Factors, a statewide survey of an adult sample that broke out data for four State regions, including the Upper Peninsula. This study did show that rates of heavy drinking (defined as consuming 14 or more drinks a week) were higher in the Upper Peninsula (14.7percent) as compared to the Lower Peninsula (6 percent). This was even more dramatic in the 18- to 24-year-old age group, where the rate was 30.5 percent in the Upper Peninsula as compared with 3.2 percent in the Lower Peninsula and 11.7percent in the Detroit metropolitan region (Michigan Department of Public Health 1983).

While alcoholism is the most common diagnosis in all treatment programs in the region, there is also a significant use of other drugs in the dependent population. These patterns would generally be the same as in other rural regions of the country, including:

• A high abuse of prescription drugs especially in the older, the disabled, or the dual-diagnosed client
• Marijuana use and abuse in many of the younger and middle-aged groups
• Polydrug abuse in younger and adolescent clients

In the late 1980s, treatment professionals became concerned with the number of children and adolescents who had started presenting with histories of significant inhalant abuse. In 1993, a drug survey done in the Marquette schools noted a rate of inhalant abuse significantly higher than in the State as a whole. In the middle to late 1980s, residential programs experienced a sharp increase in clients who had cocaine addiction. For a few years, cocaine addiction accounted for about 10 percent of the client population. This percentage has now declined, but another, and more unique, phenomenon has replaced cocaine as the stimulant of choice. In the early 1990s, the Upper Peninsula became the first site for widespread manufacturing of methcathinone—an amphetamine-type drug made in home laboratories. Still, clients abusing or addicted to this substance remain a small proportion of the client population. Fortunately, most Upper Peninsula drug addicts prefer to snort these substances rather than injecting them, which has kept the problems associated with intravenous drug abusers to a minimum in the region.

Organization Process

Developing the Mission

The first discussion of what was to become ASCUM was at a program directors' meeting with a representative of the Superior Health Alliance, a clinic plan for Medicaid recipients that was then being organized in the eastern part of the region. The initial idea was to create some sort of network that could contract as a group with this, and other, managed care organizations. The planning group was limited to the five agencies accredited in the eastern Upper Peninsula planning district and under contract to serve publicly funded clients. The reasons for these initial exclusions were that accreditation was already required for programs being reimbursed with Medicaid funds, and because this particular clinic plan was not envisioned as covering families outside of the district for some time. It was also decided to exclude from initial discussions the other two accredited programs in the eastern region that are not a part of the publicly funded system. Originally, it was thought that once a mission statement and organizational details were completed, these programs would be invited to join the Consortium. As it turned out, this has not been the case, as will be discussed later.

The mission of the group began to expand almost immediately, partly helped by the concepts in a pamphlet, Community Care Networks, which was published and distributed by the American Hospital Association (AHA 1993). Their concept of a "seamless continuum of care" became particularly relevant for the planning group.

The community care network would provide: (1) a full continuum of health and related social services, (2) care coordination among provider organizations, (3) interorganizational planning, and (4) integrated systems (information, financial, clinical, administrative) that track patients and assist caregivers to manage care.
—American Hospital Association 1993

While this was a vision for a network of many types of providers, it also seemed relevant for this specialized network. It addressed a number of problems that individual programs were currently dealing with on their own. For example, during the previous year, the hospital program had discovered that even transfers to its own clinic sites were resulting in large amounts of duplicated paperwork; the program staff had subsequently spent 6 months developing one recordkeeping system to be utilized in all service sites. Several outpatient programs reported a high degree of staff frustration with the inability to get clients admitted to any type of inpatient or short-term residential care. Staffs were also frustrated with the short lengths of stay that were being provided even when an admission could be arranged. All programs were trying to implement client followup systems to replace a system discontinued because of lost funding. This previous system had been developed by the State and implemented through the regional planning and coordinating agency.

And so, in attempts to develop a mission statement, it became clear that simply contracting as a group was not the answer. The mission statement that was eventually adopted reads as follows:

The mission of the Addiction Services Consortium of Upper Michigan is to organize and maintain a quality, cost-effective, seamless continuum of substance abuse care that is available to all families in the Upper Peninsula and which promotes:

• Intervention in the disease as early as possible
• Long-term abstinence from nonprescribed mood-altering substances
• Decreases in coexisting physical, emotional, spiritual, social, and family problems

This led to development of the following seven goal statements, of which only one addresses issues of reimbursement:

1. Ensure and strive for continuous improvements in the quality of client care through an interagency quality improvement program.
2. Promote certification and accreditation efforts of agencies and professionals in the network.
3. Develop an efficient service delivery system that minimizes duplication of services.
4. Provide for ongoing casefinding and education programs to serve health and human service providers, court and law enforcement agencies, and employers in the region.
5. Ensure a diversity of services designed to meet the special needs of specific population groups in the region.
6. Strive for reimbursement of services that will increase the financial stability of the programs involved in the network.
7. Collect outcome data to demonstrate the effectiveness of substance abuse services in the health care system.

Organizational Structure

The vision behind the mission and goals of the Consortium was used to shape its bylaws, and these in turn provided the structure of the organization. It was decided by the group that all programs should adhere to a single Code of Ethics, and that this code would need to be developed. The bylaws would need to reflect the programs' adherence to the code. This code focuses more on administrative behavior than on clinical conduct. However, one of its tenets is that a program will require professionals to adhere to an acceptable code, such as that of the National Association of Alcoholism and Drug Abuse Counselors. Other standards address financial policies, promotional materials, maintenance of national accreditation, the treatment of other programs and professionals, abstinence as the treatment goal for the dependent client, and maintaining the client's interest and welfare as the primary concern in clinical decisions. A copy of the Code of Ethics is shown in table 1.

The actual structure of the organization is simple, with each member organization having one seat on the board of directors regardless of the number of service sites or State licenses held. It was felt that this needed to be done to ensure that smaller programs had a full voice in the Consortium and that charges of dominance by one or two programs could not be made.

Decisions about the recruitment of additional members were also made in light of the mission and bylaws, and targeted only those counties and communities not currently covered by a Consortium member. This was contrary to earlier discussions in which the intent was eventually to ask all qualified (accredited) programs in the region to join. The reason for this change in sentiment came as the group realized that, if the Consortium was to achieve its goals, these programs needed to have a high degree of commitment to the mission of the organization. It was felt that inviting competing organizations to join would weaken the organization unless the competition was managed in constructive ways.

Competition exists only to a limited degree among current members, with one community in the region being served by outpatient clinics from two member organizations. However, in this case the programs had already done significant joint planning to avoid any conflict. Such planning was not necessarily true of other communities where competing clinics operate.

Using certain criteria, the Consortium added its sixth provider—the Native American residential program and community outpatient services in a county not covered by another member. The criteria for adding new members are:

• The services offered by another agency must be needed to complete a part of the continuum within the particular area
• The program must be accredited
• The program must be willing to be committed to the goals of the Consortium, including making an investment of staff time

At this point there remains only one area of the region not covered, and the sole provider in that area is being recruited. If this provider chooses not to join, then members will be encouraged to develop services in that county to complete the initial continuum. Figure 1 shows service sites.

To join the Consortium, there are initial membership dues of $500. These fees are used to develop some working funds for the group, as well as to ensure that there is some financial commitment from each member.

Continuum Development

In many ways, the first year of development of the Consortium was easy, compared to the current focus of attention on continuum development. From the beginning, the directors realized that, while they could create the organization, it would be necessary to sell this concept not only to the boards and administrative structures of their organizations but also to the clinical staffs. For this reason, current activity is focused on establishing the committees needed to move toward the "seamless" ideal that has guided the organization thus far. The first step being taken is a planned retreat for clinical leaders and directors from all member organizations with the following objectives:

1. Understand the forces of change in the addiction field today
2. Appreciate the needs of our new managed care consumers
3. Develop a shared vision of recovery and the recovery process
4. Generate a service model based on this vision of recovery rather than on specific modalities of service
5. Define the terms of the relationship that ASCUM members will need to work together in this model
6. Identify changes that need to happen to realize this relationship

Several managed care providers, including the hospital Employee Assistance Program (EAP), the Superior Health Alliance, and the regional coordinator who has supported ASCUM, will also participate. As a result of this retreat, the plan is to establish two committees that will include both directors and clinical staff. The first will be the joint quality improvement group, which will focus on the issue of transfers as its first task. The second group will work on developing two pieces of the recordkeeping system that the board would like to standardize between programs—the initial screening and intake form and the treatment planning form.

Marketing

In a sense, marketing began before the organization was ever created. In fact, one of the first contracts was with the Superior Health Alliance group; the director of this organization was consulted several times during the organizational phase. Marketing has also been helped by the hospital's EAP, which developed a managed care product that covers one major employer in the southern part of the region. The ASCUM group thus became the addiction service provider for this plan. Another fortunate event that is helping the ASCUM group was a decision on the part of the State of Michigan to contract out managed care for behavioral health to new providers this year. This has allowed ASCUM to apply to be the provider group for both companies that were awarded contracts; these applications are still pending.

Reaction to the ASCUM concept has been positive on the part of all the managed care companies approached so far. The idea of one continuum is very attractive, particularly because it does cover almost all communities in a region where it has not always been easy for such companies to find suitable providers.

Results and Conclusions

While the ASCUM endeavor is still relatively new in its development, it has had a number of positive results to date. First, there has been a strengthening of relationships among the member organizations, as evidenced by a greater willingness to share information and clients. The work has been energizing for the directors involved, who view this as a proactive and protective measure for their programs. It has also had educational benefits as the group has worked together to market their services. One director from a smaller program commented that she has received more than the initial $500 in education about managed care.

It is also apparent that managed care companies like such networks. One of the companies to gain a State contract has never before worked in Michigan and certainly not in the Upper Peninsula. When the ASCUM group was able, at the meeting with this company's representatives, to show them a map of the region that designated all their covered employers and how the ASCUM network would serve them, there was both surprise and gratitude expressed. There was no way that this could have happened if each program had approached the company separately. Clearly, making the clinical process work as well will also be a challenge, but there is optimism that this will also work and that the results will be better care than has ever been provided.

In summary, creating a consortium between programs in a rural area that focuses not just on the marketing of services but on the development of a treatment continuum can create a number of positive advantages. It can:

• Strengthen relationships between programs
• Provide a new focus for marketing
• Give direction for the improvement of clinical care

Recommendations

We make the following recommendations for programs in rural areas interested in developing a consortium.

1. Develop a mission that focuses on continuum development, which will ensure that the effort remains client- and customer-driven and will also assist in marketing efforts.
2. Keep competition to a minimum through the selection of providers or by negotiating clear "niches" when possible.
3. Involve only those programs that support the mission and are willing to make time investments in the organization.
4. Recognize that clinical staff will ultimately need to be involved in the planning.
5. Involve "customers" in the planning when appropriate.

References

American Hospital Association. Community Care Networks. Chicago: the Association, 1993.

Holmes, R.E.; Harding, S.H.; Lafkas, G.A.; Eyster, J.T., and DeGuire, P.J. Michigan Opinion: Behavioral Risk Factors—Results of a 1982 Statewide Survey. Lansing, MI: Michigan Department of Public Health, 1983.

Last Updated 11-7-02