Vol. #14, No. 10
Welcome to all the new subscribers this month. Happy New Year to everyone for the January edition of Tips and Topics. 恭喜发财 Kung Hei Fat Choi for the Year of the Yin Rooster starting January 28!
Can you believe we are almost into February?
David Mee-Lee M.D.
Not only is 2017 the start of a new year, but also here in the USA the start of a new era in government with President Trump at the helm. Whether you are thrilled or threatened by this change, whether you greet this with excited anticipation or excruciating anxiety, I am focusing on what endures during the uncertainty in so many areas. The one area most relevant to Tips & Topics’ readers is health care in general and addiction and mental health treatment in particular.
Regardless of what happens to the Affordable Care Act (ACA) in its improvement or replacement, some enduring principles will remain important for all of us in the field to stay focused on.
Design, describe & deliver services for addiction and mental health as a flexible, seamless continuum of care that always promotes cost-consciousness, quality and effectiveness.
Whether a country provides socialized medicine and healthcare for all or strives to provide access to affordable healthcare insurance for all, the challenges are the same:
- How do we slowdown rising healthcare inflation?
- How do we ensure timely access to care?
- How do we assure Value = health outcomes per dollar spent? In other words, how do you focus on achieving effective services while being good stewards of resources and being cost-conscious? Value is the embodiment of being “cost-effective.”
For more on this, read “What is Value in Health Care?” Value in Health Care?
If you still describe your treatment program as a 28 day residential program, or a 6 week or 6 month Intensive Outpatient service, or “extended residential”, or use predominantly one or two levels of care, then you likely have waiting lists, decreased access to care, and trouble stretching funding to provide long-term chronic disease management.
Approach the conversation and planning around improving services for all with compassion, acceptance and empathy. As well, keep active the thought & view that we are all people of good will trying to do our best.
A number of years ago, I was on a workgroup addressing integrated services for people with co-occurring addiction and mental disorders. All of us were clinicians working in the behavioral health field, wanting to improve services. The group was composed of an African-American woman, a Caucasian man and woman; and me, an Australian-born Chinese man.
By the end of our allotted time to come up with recommendations, I was exhausted and dismayed. We struggled coming to any consensus. There was so much animosity expressed about issues of black versus white culture; male versus female power; physician versus non-physician personnel; and pathology versus person-centered views that we couldn’t make much headway towards solutions.
I am all for robust debate and looking at all the angles. I am all for consciousness-raising and education on what might be our blind spots. We often don’t know what we don’t know. However it is hard to listen when people are “yelling” at you.
Keep the person (the patient, client, consumer, customer) at the center of all systems and clinical change.
This has to be much more than a politically correct espousal of “person-centered” services. It should impact in these ways:
- How easy or hard it is for people to access services? Is there a complicated phone answering system with a confusing menu of branching responses where a distressed client or family might not be able to navigate? Is there a long waiting list?
- How focused are you on identifying and prioritizing what the client wants versus what you think they need? How attached to you get to prescribing treatment with which they must comply? Is your first question and concern: “What is the most important thing you want which made you decide to call or come today?” Or is it “What insurance do you have?” Is the treatment plan a written expression of the therapeutic alliance (agreement on goals and methods and strategies within the context of a collaborative relationship)? Does the client even know their treatment plan? Does it makes sense to them? (After all, they are the ones who should have helped write it.)
- Is there really shared decision-making about how treatment is progressing or not, when and how to move through the continuum of care? Is the focus on patient compliance and completing the program? Are you focusing on progress and outcomes as assessed by the client in collaboration with the clinician? Is the client focused on “doing time” and saying the right things, or on an individualized plan guided by the clinician within a mutually trusting and safe, empathic therapeutic relationship?
In SKILLS of the May 2013 edition of Tips & Topics, when the new 2013 edition of The ASAM Criteria was soon to be released, I detailed how the new edition helps address needed improvements in addiction treatment. You can see more at:
In that edition there are many skills and systems issues allowing you to implement the true content and spirit of The ASAM Criteria. Here are just a couple for a refresh.
Focus on what is of value to your patient, client or customer.
While we develop and design improved systems of care, remember there are always several stakeholders, all of whom may have different priorities:
- The identified patient or client may want symptom relief from depression or anxiety; “to get people off my back or get my children back”; to escape the impacts of addiction like a loss of job or relationship, or medical complications, or legal issues; or ideally to embrace recovery and well being.
- The family and significant others may want their loved one to be safe, or behave, or get a job or better grades, or leave, or stay, or be happy.
- The judge, law enforcement and criminal justice teams may want public safety, decreased legal recidivism and crime and safety for children and families.
- The employer may want increased productivity, decreased workers comp. cases, absenteeism or presenteeism (Presenteeism)
- The school may want better attendance, grades or behavior, less arguing with the teacher, and no vandalism.
- The legislator may want better use of public funds, health care initiatives to get them re-elected, services to improve their district and constituency.
- The managed care company, payer or funder may want services at the lowest cost which will be accepted by their membership or insurance customers.
- The labor union may want services costing the lowest co-pay; or even no insurance co-pay; or easy to access services, or comprehensive services like there has been in past years.
This is not the end of the stakeholder list. You could extend the list to advocates for women’s needs, cultural priorities of ethnicity, sexual identity, migrant status, spirituality and age.
Gather team members to re-visit the Mission, Vision and Values of the health care system involved in a change process.
When any system changes, it asks of team members to be receptive to having their attitudes, perspectives and comfort zone of work competence challenged and examined. Where is a good place to start with this? Everyone needs to meet together, to understand the context for, and to collaborate in fashioning, the new Mission. Here everyone has the opportunity to take responsibility for re-committing to their job; or for deciding that they are not interested in, or committed to the new Mission.
- Some long-time addiction counselors view residential treatment as the gold standard. They believe all patients should start with at least a month, then go to aftercare. That perspective is diametrically opposed to a flexible continuum of care in a chronic disease management model.
- Some mental health clinicians believe most addiction clients use substances because of underlying mental health conflicts, and that these need to be resolved first for the person to stop using.
- Some counselors focus on consequences like suspension or discharge for substance use while in treatment. They would never do that for a patient with an acute flare-up of suicidal or cutting behavior.
A discussion of Values has the following benefits for designing and delivering new or improved systems of care:
- It allows the team to create their principles and discuss the implications of those values before hard decisions are made about – for example: What levels of care should we add? What staff qualifications do we need and who should be hired? Perhaps our program needs more mental health professionals in the addiction program or vice versa in a mental health setting?
- It engages all team members in fruitful examination of personal attitudes and team attitudes about: What is addiction treatment? How should services be designed? What do we think about medication in addiction treatment? How do we handle the patient who uses substances while in treatment?
- For example, suppose one Value was the following: Relapse in addiction and mental health are both addressed as crises in a person’s treatment requiring evaluation of the crisis and revision of the service plan. Suspension or discharge from treatment and zero tolerance of relapse will not apply to either a person’s substance use or mental health crisis. This value, if embraced by all team members, would impact policies, procedures and how the continuum of care is used.
(“Tips and Topics: Opening the Toolbox for Transforming Services and Systems” pp. 18-20)
On Saturday, January 21, the day after President Trump’s inauguration, there were many marches in large cities in the USA and internationally. My son, Taylor, witnessed two of those marches in Oakland and San Francisco, California, which drew 60,000 and 100,000 people respectively. He photographed signs, handcrafted and painted, expressing people’s feelings, thoughts, admonitions and inspirational messages.
I am sharing just five of those signs that express sentiments meaningful to me and hopefully for you too.
Civilized exchange of ideas
A mind is like a parachute. It doesn’t work if it isn’t open
To be Great you must Do Good
They thought they could bury us. They didn’t know we were SEEDS
Mr. Rogers: When I was a boy and I would see scary things in the news, my mother would say to me, “Look for the Helpers. You will always find people who are Helping.”
May we come together, open-minded to exchange ideas and grow together to do good and help all the people we serve.
Until next time
I’m glad you could join us this month. See you in late February.