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Providing Needed Treatment Options in the Face of Managed Care

Jim Lohmeyer, M. Div.
Program Director/Chaplain
Family Recovery Center
Clara Barton Hospital
Hoisington, Kansas

The purpose of this paper is to describe the approach taken by one treatment center to gain needed flexibility within the current treatment market: a market that faces providers with limited resources and with outside funding sources that dictate at what level our patients will be treated. We developed this staffing pattern prior to the advent of managed care. But we found this approach helped us to make the transition to managed care rather easily, while others around us struggled with putting an outpatient program in place.

Background of the Approach: Changing To Survive

If necessity is the mother of invention, then survival is its midwife. In 1986, the Family Recovery Center at Clara Barton Hospital in Hoisington, Kansas faced a crisis of survival. We had just watched our nationwide chemical dependency management corporation leave us for greener pastures. We were faced with the stiff competition of a couple of aggressive hospitals in the area that were vying with us for patients in our largely rural counties of western and central Kansas.

We looked at our situation and asked what services we could provide that would be both unique to the area and yet effective. An outpatient day treatment program to complement the inpatient program seemed to be a natural. Such a program provides several advantages:

• Outpatient day treatment is more affordable than inpatient treatment.
• It provides the structure that many patients need and still allows them to maintain commitments to work and family.
• It also requires the patients to begin practicing the principles of recovery from the first day of treatment, because they continue to function in the world where they will need to stay sober after treatment.

There was, however, no money for extra staff. The solution was to use existing staff.

The Program Plan

Family Recovery Center made the decision to develop two outpatient day treatment programs with the inpatient program at the heart of both programs. We started this approach by looking at the inpatient program's day schedule; we noted that there were two basic treatment activity times. One lay at the heart of the day, from 9:00 a.m. to 3:30 p.m. Monday through Friday. The second was early evening.

The Family Recovery Center had a program director, a day counselor whose work began at 8:00 a.m., and an evening counselor who began the work day at 1:00 p.m. With some slight modification of the inpatient program, we could develop an outpatient day program for unemployed patients and night workers on the daytime schedule and could develop a second program for day workers from 6:00 p.m. to 10:00 p.m. Monday through Friday evenings.

Our subsequent experience is that some schedule modifications have to be made from time to time to meet an individual's employment and commuting needs. For example, patients who go to work before 3:00 p.m. may need an 8:00 a.m. to noon schedule. But generally, these are workable schedules for most patients.

Implementing the Program

We began with some very flexible criteria for admission to each program. Persons considered to be a good risk for outpatient day treatment were those who were either a first-time patient or had had a period of quality sobriety, especially recently. If the person was a daily drug user with poor structure in his or her life, we might begin treatment in the inpatient program for 10 days to 2 weeks before transferring the person to outpatient day treatment.

This approach—a shortened inpatient period followed by outpatient day treatment—was a novel approach that became very useful in dealing with managed care programs. Obviously, this new approach also brought more specific and defined criteria for admission and continued care in each level.

The New Era of Managed Care

Shortly after we instituted the new approach, managed care came into the rural medical treatment market with the health maintenance organization (HMO); managed care has now been instituted in the practice of most third-party payers. The goal of managed care is to reduce the expense of medical care by funding the least extensive (and expensive) therapy necessary for the patient.

Impact of Managed Care on Treatment Providers

For chemical dependency treatment providers, this meant that the tried-and-tested practice of inpatient treatment (usually providing 3 to 6 weeks of inpatient treatment) was being challenged. The challenge came because of a study which stated that patients in outpatient treatment had results comparable to those receiving inpatient treatment. In order to meet these demands for outpatient treatment, some rural programs added an outpatient program while continuing to maintain their inpatient program. For instance, one 16-bed treatment program in our area added two more counselors to run their outpatient program side-by-side with their inpatient program. Within months, both modalities were closed. The cost of added staff brought an end to many treatment programs in our area.

In the "good old days" before managed care, western Kansas (west of Highway 81 and excluding Wichita) had at least 11 inpatient treatment programs, most of them hospital-based. Some had histories going back almost 20 years; some were filling unused beds in rural hospitals. In the same area today, there are only four inpatient treatment programs, including Larned State Hospital. Those that remain have drastically reduced their level of service or have received State funding.

Advantages of an Outpatient Day Program

In the beginning, Family Recovery Center regularly sent 50 to 75 applicants away annually because they were not able to pay for treatment. In 1988, our Center was helped when we sought to expand our income and service base by offering services to the State of Kansas Alcohol and Drug Abuse Services (ADAS). ADAS agreed to partially fund Family Recovery Center, primarily because of the outpatient day treatment program, which could also provide a component of up to 10 days of intermediate treatment. Intermediate treatment is nonmedical residential care.

The advantage of such an outpatient day schedule is that when managed care emptied our beds, we were prepared with an alternate program. Like most inpatient units, our inpatient admissions have gone down drastically since the advent of managed care. Inpatient treatment dropped from 813 to 333 days during the same period in which the number of outpatient day sessions provided climbed from 749 to 1,623. Figure 1 shows the evolving pattern in utilization of outpatient, inpatient, and intermediate care days between 1987 and 1993, with ADAS support beginning in 1988.

Figure 1. Evolving pattern in utilization of outpatient, inpatient, and intermediate care days
[Not currently available]

We have reduced inpatient length of stay from about 15 days in 1987 to just over 4 in 1993 (see figure 2). Our experience has shown that, when correctly referred, patients who complete outpatient day treatment have about the same level of recovery as inpatient treatment patients, but there are definitely times when treatment in a residential program is important. The added structure is often necessary, whether it is because of relapse in the outpatient programs, for health reasons, emotional stabilization, or the need to separate from a "less than supportive" support system.

Figure 2. Length of stay
[Not currently available]

Moving Patients Among Treatment Modalities

Because Family Recovery Center is able to maintain the inpatient/intermediate treatment modalities, we do not have to refer those patients who are not able to remain chemical-free in the outpatient program. History has shown us that when we refer patients out of the facility—unless there is a big legal hammer hanging over their heads or they are otherwise highly motivated—we lose a larger percentage than if we are able to move these patients to inpatient care for stabilization and then return them to outpatient treatment. All our staff members work with all our patients, and many patients from the various modalities work in groups, sharing lectures and the family program with one another. This shared experience of staff and patients improves the development of trust levels for transferred patients.

In addition to outpatient day and inpatient/intermediate treatment programs, Family Recovery Center offers a continuing care program and a Family Focus Week. Continuing care consists of weekly support groups for alumni led by a counselor or counselor trainee. The monthly Family Focus Week consists of 20 hours of support for the patient and family members.

Handling Staff Levels and Costs

Family Recovery Center has been able to maintain the two outpatient day treatment programs and inpatient/intermediate treatment, plus a continuing care program and a Family Focus Week using 7.2 full-time equivalents (FTE) of direct care staff. (Full-time equivalents are the equivalent staff needed to staff the program in a given week.) This staff includes a program director, a day counselor, and an evening counselor, plus a registered nurse and nurse's aides. Since we are housed in a hospital, we usually share 1.4 FTEs with nighttime nursing staff on the medical wing, which has a physical view of the facility from the nurse's station.

We have been able to endure many changes in patient load and in the treatment climate without being overwhelmed by staff costs or staff cuts. We are able to continue to provide inpatient treatment, a needed service for some, without having the expense of maintaining the inpatient treatment center cost us out of business.

We share indirect salary costs with the hospital, such as meals and laundry, administration, and housekeeping; this affords further staff cost savings. The number of admissions to all programs averages 94 patients per year or 9.8 per month, although in the real world nothing is average. Monthly admissions have been as few as 2 and as many as 20. We can find ourselves sitting around wondering when the next referral source is going to call, or we can find ourselves checking in four patients in a day with assessments, treatment plans, and discharge summaries to do.

Flexibility of Staff

One of the reasons Family Recovery Center is able to maintain these programs along with two sessions of Continuing Care and a monthly Family Focus Week is because of the willingness of the staff members to wear more than one hat and to be flexible in scheduling. For instance, the program director and the evening counselor have both worked with families and, depending on needs, can easily cover the Family Focus Week program. Both counselors can take care of afternoon groups, depending on patient load. The program director is in a position to cover administrative needs, as well as to cover clinical needs when the staff and patient load require it.

Patients find this flexibility helpful as well, because even though we may have only one patient in our inpatient/intermediate program, he or she is not stuck in a group of one. Patients work together with other patients. Outpatients can be supportive of the inpatients. Inpatients can lend insight to outpatients, who are sometimes caught up in the dailiness of their lives.

Findings and Recommendations

While outpatient treatment has become the modality of choice in the days of managed care, there remains a need for inpatient treatment. In order to maintain an inpatient program while serving our patients with an outpatient day treatment modality, Family Recovery Center has been able to combine all modalities and use one team to staff these modalities. Such an approach requires a talented, multifaceted team with a willingness to be flexible to program needs and supportive of one another. While this may seem counterproductive to staff stability, the same team members worked together from the development of this concept until the untimely death of the program director last year. Today, one of the team members has moved into the program director's position and another has come to fill his place.

Our treatment team would wholeheartedly recommend our approach to those with existing programs who wish to expand their continuum of services or to initiate program services in a rural area. It has been a supportive approach for the patients, who can maintain trust while moving from modality to modality in the continuum of care and can work together in groups of workable sizes. Our approach has also been supportive for staff, providing the flexibility of a shared team approach.

Last Updated 11-7-02