Medical Accountability (Early Stages)

Assessment of Agency Readiness for Health Care Reform

The APT Foundation - January 2010

Assumptions Regarding Health Care Reform

Medical Accountability (Early Stages) We have multiple service contract with payors and are credentialed with more than 5 insurance companies. None of our contracts have incentives built in nor are expected outcomes based on process or outcome measures.

Competition (On the Way) We receive referrals from nearly all facets of the community; the courts, mental health agencies, other substance abuse treatment programs, primary care practices, the local hospitals and from prospective customers and their families. Just about 15 – 20% of those referrals come from medical providers. With the exception of our own primary care clinic, we do not have any formal agreements with local health care providers.

Continuum of Care (On the way) Both concurrent and discharge planning is done to assure that clients have access to and are referred to the next level of care. We do not track the success of those transitions except within our own continuum.

Patient/Family Role (On the way) All of the organization’s services are available by walk-in assessment, five days/week. Beginning approximately one year ago, the initial evaluation is a full psychiatric/substance abuse evaluation done by a licensed clinician. Treatment options are explained after the evaluation and initial goals are mutually set. Family members are welcome in our AccessCenter and we provide childcare during the evaluation and early treatment phases. We do not have much more in the way of family involvement, other than education and self-help groups, available to family members.

Performance expectations – Outcomes (patient) Processes (On the way)We implemented the use of the BASIS 24 across all levels of care approximately three years ago. We have a very good data base measuring customer acuity at the point of admission and at mid-point and/or discharge. We use this data on an aggregate basis to assist with program evaluation and planning. We also track other measures such as reduction in use, LOS, housing status and vocational status. Some of these data are collected and analyzed in cooperation with DMHAS. Measures could be much better used at the client level during the course of treatment (especially the BASIS 24).

Role in health care (On the way) We participate in several local committees regarding healthcare planning and have representative in the planning processes of Yale New Haven Psychiatric Hospital and the Yale Department of Medicine, Psychiatry Department. Our primary care clinic is partially staffed with physicians of the Yale New Haven Primary Care group.

Context and Environment

Demonstrate Value/Cost to Purchasers of Service (On the way)We can measure the outcome of an episode of care in several ways. (as described above). We have also have cost data and can demonstrate that cost/episode has declined over the last several year in outpatient services as outcomes have simultaneously improved or stayed constant. Immediate access to treatment is available five days/week.

Integration (Early stages)In early 2009 we implemented the SMART system, an electronic medical records system across multiple outpatient clinic locations. Prior to this, charting was paper-based only. By June 30, 2010, substance abuse treatment records will be paperless and available to all providers in the APT continuum. Our primary care clinic will move onto the SMART system in April 2010, as will residential and vocational programs.

Organization

Infrastructure (On the way) Our IT system collects and manages financial and clinical information. Some human resource information is electronically managed and some is still paper based. We will be adding the “back end” of our new electronic medical record system within the next 3 months. This is billing and financial information system that will be patient specific, or encounter based, and will replace our current clinic/program based billing system.

Facilities (Early Stages) Facilities are all rented space – there are five locations within a 25 mile radius. We have substantially improved the appearance and cleanliness of the facilities in the past two years and have centralized several programs. We are planning to give up a large space lease later this year (October 2010) and further consolidate locations. We also have a board committee that is looking at space in the community so that we could all of our services, except residential treatment, in one location. We are considering both purchase and long-term lease opportunities.

Board (Advanced) The Board is extremely supportive of the initiatives we have taken in the last two years to support improved clinical service and readiness for health reform. Those initiatives include purchasing and installing an electronic record system, opening an AccessCenter, moving stable clients to newly renovated space to enhance recovery opportunities, creating a practice management position and involvement in strategic planning.

Management/Change Skills (On the Way) The majority of the management team at APT is inherited from a time when both clinical thinking and the payment system were much different than they are today and will be in the future. We have strategic initiatives to support healthcare integration, we have set both financial and clinical performance expectations, but there are members of the team who do not prioritize these objectives. Many of the medical staff are contract employees from the Yale Department of Psychiatry, including the medical director, and do not always respond to APT’s priorities without an extraordinary amount of discussion. There are managers throughout the APT organization who have never worked anywhere other than APT and struggle with the need for change and struggle to envision how programs could look any different than they do now. Conversely, there are several excellent clinical managers, now in key roles, who are excited by the changes we have made and the upcoming opportunities.

The Workforce

Licensed clinical/Medical/non-licensed staff (on the way) APT Foundation now has 4 full time physicians who are APT employees, compared to one three years ago. All programs are managed by independently licensed clinical staff. Additionally, there are independently licensed clinical supervisors in each program. All staff have a development plan; the plans could be more specific and better aimed toward organizational goals. Internal staff development and training has improved in the last two years, but there is significant work yet to do in this area. We have recently created a clear “clinical track” that encourages staff to move toward credentialing and/or licensing and have changed our minimum competency requirements for new staff to match the clinical track goals.

Treatment Interventions

Role of Technology – We have excellent access to e-mail, the internet and the clinical record for all staff. We have not implemented any opportunities for clients to interface with the organization electronically.

Evidence-based (On the Way) APT uses medications to treat opioid dependence and co-occurring mental health disorders. We are treating alcohol dependence with medication on a limited basis and are a clinical trials site for the use of medication in cocaine dependency. We have implemented several other evidence based approaches, notably MET and CBT and could do more to extend them throughout programming.

Holistic Care (On the Way)We have a primary care practice as part of the APT Foundation and all clients receive a physical at admission. The practice manages the primary care needs of approximately 40% of our clients on an ongoing basis. APT has integrated vocational services into every level of care; more could be done to identify vocational needs in our substance abuse services treatment plans. We have good relationships with local HIV/AIDS services and HEP C treatment services, but they are not open access nor are they on-site, so clients do not always enter those treatments when needed.

Reimbursement and Revenues(On the Way)APT can bill multiple payers, but the front end of the process is highly manual. We recently (July 2009) hired a practice manager, a new position for APT, and are in the process of making many changes to the front end of our billing system. One of our ongoing challenges in reimbursement is the collection of first party revenues for services – the current processes are retroactive and managed exclusively by office staff, with no involvement by clinical team members. We have made several key changes to these processes in the last three months, and continue to see this as a key opportunity. Other key opportunities in this area include marketing services to commercial payers who currently represent less than 10% of our revenues.

Financial well-being (Early stages) For the last 4 years the organization has ended the operating year with a net profit and has grown from $12M in revenues in 2006 to $19M in 2009. However, the current budget/revenue difficulties in Connecticut have greatly affected revenues and as of December 2009, APT is running a deficit for the current fiscal year of $500K. We have made a number of changes to adjust to the revenue decline, and anticipate that we have cash to cover operations through the year with the changes we have made. We have a line of credit with a lending institution but have not drawn on that line in over three years.