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M38 Administrative Issues in Outpatient Treatment 2022

Administrative Issues in Outpatient Treatment – Comprehensive Study Notes

  • Source material: CSAT manual excerpts on Substance Abuse: Administrative Issues in Outpatient Treatment (Module 38, ACCSA SA). Two-volume set with companion Clinical Issues in Intensive Outpatient Treatment.
  • Target audience: Primarily outpatient program administrators, directors, executive-type roles. Terminology often overlaps (administrator, executive, director).
  • Core themes: Evolving outpatient landscape, administrative challenges, strategic partnerships, human resources, cultural competence, financing, performance measurement, and governance/visibility. Emphasis on practical guidelines, exemplars, and tools to implement changes in real-world settings.

Section 1: Introduction

  • Purpose of the volume:
    • Addresses administrative issues in outpatient treatment (OT).
    • Companion volume CSAT 47 covers Clinical Issues in Intensive Outpatient Treatment.
    • Builds on Manual 8 (1994) but now targets broader OT audience with two volumes for clinicians and administrators.
  • Consensus panel perspective:
    • Administration and clinical excellence both vital for OT program success.
    • Historically scarce research on OT administration; this manual relies heavily on consensus-based experience and field practice.
  • Changing IOT landscape (Washton, 1997):
    • First expansion in 1980s: cocaine addictions among White, middle-class professionals; opted for treatment without residential stay and work-time disruption.
    • Second expansion via managed care (cost containment) in the 1990s; IOT broadened to homeless, adolescents, co-occurring disorders; became integral to continuum of care.
  • Drivers of diversification and complexity:
    • Public funding shifts: Medicaid referrals to IOT; broader client mix; cost-containment pressures.
    • Managed behavioral health care: IOT as cost-effective option; not only a bridge but a service modality in its own right.
  • Administrative and Staffing Issues (highlights):
    • Turnover challenges among administrators (National Treatment Centre Study): ~31% annual administrative turnover; counsellor turnover often higher than national averages in other fields.
    • Need for new administrators to possess business/management skills, budgeting, fundraising, reporting to funders, etc.
    • High turnover in counsellors (reports: >50% in some studies within 4 years; many under 4 years on the job).
    • Emphasis on staff development, mentoring, and strategies to improve job satisfaction and retention.
  • IOT’s connections to strategic partners:
    • Emphasis on partnerships with hospitals, mental health services, criminal justice, mutual-help groups, EAPs, and funders.
    • Community outreach as marketing/education tool; feedback loops with the community to guide program design.
    • Strategic partnerships expand referral networks and funding opportunities; drive convergence of systems for mutual goal alignment.
  • Program visibility and marketing:
    • Regular reporting to media and funders; client graduations and events used for public relations.
    • Performance improvement/outcomes data as promotional tools and funding leverage.
  • Funding environment and managed care context:
    • Managed care dominates funding; negotiations with MCOs are common; outpatient services compete for contracts; a program’s financial viability depends on diversified funding streams and cost-effective operations.
  • Historical arc overview:
    • Early outpatient clinics in the 1900s; Yale model in mid-20th century; growth of day treatment and ambulatory detox in the 70s–80s; cocaine-driven expansion in the 1980s; Medicaid-driven expansion in the 1990s.
  • Terminology note:
    • The manual prefers the term "intensive outpatient treatment" rather than IO P; consistently uses OT for outpatient treatment and IOT/IOT for context where relevant.

Section 2: Management Issues

  • Roles of the Program Executive:
    • Transition from clinician to executive is common; requires planning, leadership, budgeting, strategic thinking, organizational growth, fundraising, and reporting.
    • New executives may maintain a few clinical tasks but prioritize program systems and operations.
  • Strategic Planning and Implementation:
    • Strategic planning should be a regular activity, not a one-off project.
    • Benefits:
    • Provides direction when starting a program; clarifies mission and directions.
    • Sets clear goals; identifies cost savings and new resources.
    • Energizes board and staff; improves morale and performance.
    • Process considerations (The Change Book – ATTC Network):
    • Community audit/needs assessment to identify unmet treatment needs and niches.
    • Identify comparative strengths and competitive advantages (e.g., rapid intake, breadth of services).
    • Clarify mission, values, goals; develop multiple strategies and evaluate merits.
    • Guidelines for collaborative planning: maintain a safe environment, stay task-focused, accept consensus where unanimity is not possible.
    • Implementation: develop an annual operating plan with assigned responsibilities; involve entire staff; track outcome measures aligned with goals.
  • Board of Directors:
    • Purpose: governance, oversight of operations, budgets, and fiscal controls; fundraising; community representation.
    • Common responsibilities (exhibit patterns): monitor operations; approve mission and long-range plans; oversee executive performance.
    • Board member selection and development:
    • Orientation for new members; ongoing responsibilities (committees, task forces).
    • Regular communication: fact sheets, meeting minutes, agendas.
    • Evaluation: consider outside consultant evaluation at intervals; self-evaluation forms for ongoing improvement.
    • Board committees (examples – see Exhibit 2-2): standing (Executive, Nominating, Finance & Budget, Resource Development); optional (Personnel, Bylaws, Program).
  • Program Policy and Procedure Management; Accreditation:
    • Establish and manage policies around HR, governance, and program operations; align with accreditation standards.
  • Relationships With Strategic Partners:
    • Strategies for collaboration: intake at partner sites; services at partner sites; cross-referrals; mutual-benefit arrangements.
    • Marketing and outreach to attract referral sources: managed care companies, employers, mental health providers, EAPs, schools, hospitals, criminal justice agencies, religious groups.
    • Marketing strategy rooted in community audit; follow-up with referral sources; treat referral sources as key partners.
    • Example: Exhibit 2-4 – Emergency Room Strategic Alliance – OT staff conduct on-site assessments, generating referrals and opening cost-efficient partnerships.
  • Referring Clients to Outside Services; Sharing Knowledge:
    • Outside services: maintain updated resource files; formal service agreements; linkages to ensure appropriate levels of care.
    • The executive leads dissemination of field updates: legislative changes (HIPAA), clinical/research advances, regulatory/funding changes (CSAT resources, NIDA/SAMHSA sites).
  • Management and Administrative Issues; Program Visibility: Outreach and Public Relations
    • Emphasis on visibility in the community to secure support and funding.
    • Community outreach functions to reduce stigma and improve program perception.
    • Public relations tools: brochures, promotional materials, gifts, media releases, public service announcements, Yellow Pages listings, and community events.
    • Program reporting to media, funders, and community leaders as a marketing and fundraising tactic.
  • Key performance and accountability context:
    • Outcomes monitoring and performance improvement are central to funding and accreditation expectations.
    • States and payers increasingly require outcomes data; federal initiatives (CSAT) and national networks (Washington Circle) guide measures.

Section 3: Managing Human Resources

  • Policy Issues and Guidelines; Guidelines for Staffing:
    • OT programs require a core full-time staff to maintain continuity of care; reliance on part-time staff should be limited.
    • Four staff categories:
      1) Core clinical staff: direct treatment services; detoxification medicine may require medical staff.
      2) Clinical management: supervisors, case managers.
      3) Specialized services: psychologists, psychiatrists, social workers, vocational counselors, family therapists; medical staff for assessments and medication management.
      4) Administrative, clerical, support staff; outreach workers; security guards.
  • Multidisciplinary Teams:
    • Build teams with overlapping competencies to address medical, counseling, case management, family services, social services, psychology, psychiatry, and criminal justice liaisons.
    • Staffing levels depend on funding; collaboration with external partners essential when full internal coverage is not feasible.
  • Specialized Services:
    • Core staff can deliver many specialized services (vocational rehab, recreation therapy, nutrition, HIV/AIDS counseling, spiritual counseling, literacy, etc.).
  • Interns and Trainees; Staff in Recovery:
    • Interns/trainees can enhance staffing; policies needed for oversight, licensing, and client care responsibility.
    • A substantial share of counsellors in recovery exists (e.g., National Treatment Centre Study: ~60% in recovery).
    • Policies regarding hiring staff in recovery: many laws protect individuals in recovery; ADA and Rehabilitation Act protections vary by status (in recovery vs. actively abusing substances).
    • Exhibit 3-2 outlines key federal laws protecting certain individuals with substance use disorders (discrimination protections; nuances across recovery status and substance type).
  • Personnel Policies: Substance Misuse and Drug-Free Workplace:
    • Develop and enforce drug-free workplace policies; consider pre-employment drug testing and testing for cause; abstinence may be a job requirement for certain positions.
    • Policies should address relapse and return-to-work timelines; supervision levels after relapse.
  • Staffing to Meet Diverse Needs:
    • Culturally diverse staff across all levels improves service delivery to diverse populations.
    • Affinity-group staffing considerations (women, adolescents, co-occurring disorders).
  • Staff Structure; Size and Ratios:
    • Proposed staff-to-client ratios vary; typical ranges cited: 1:8 to 1:15.
    • Factors influencing ratios: state regulations, care type, auxiliary services, caseload management.
    • Organizational relationships: clear org chart; job descriptions; formal evaluation processes; performance metrics.
  • Staff Communications System; Meetings and Supervision:
    • Regular staff meetings, case reviews, and supervision (group and individual) to ensure clinical integrity and adherence to mission.
    • Administrative feedback loops to keep clinicians informed about program performance and changing funding/policies.
    • Teambuilding through retreats; structured agendas; avoid overloading retreats with too many issues.
  • Selection of Qualified and Competent Clinical Staff:
    • Therapeutic alliance is crucial; experience may trump formal education in some contexts; emphasis on empathic, nonjudgmental clinicians who can mobilize change.
    • Criteria for effective counsellors include empathy, warmth, motivation, boundary setting, optimism, and capacity for self-reflection.
    • Certification and credentialing: staff should be licensed/certified in their discipline and have addiction-treatment credentials (e.g., NAADAC, ASAM) with ongoing professional development plans.
    • Clinical competencies required: evaluation, treatment planning, referral, services coordination, counselling, education, and documentation; confidentiality compliance.
    • Addiction knowledge base: pharmacology, biology of addiction, evidence-based practices.
    • Client with co-occurring disorders: ensure staff competencies to address multiple conditions.
    • Appendix references (Exhibit 3-3 Counsellor Interview Form) and (Exhibit 3-2 Laws) provide practical hiring and legal guidance.
  • Supervision:
    • Clinical supervision is central to quality care and staff well-being.
    • Supervisors should be trained, have time for supervision, and may delegate caseloads to senior staff.
    • Supervision modalities include case studies, chart reviews, external experts, and audio/video reviews.
  • Continuing Education and Training:
    • All staff should have individualized professional development plans; ongoing training fosters motivation and reduces burnout.
    • Resources: ATTCs, summer institutes, conferences, online education; recommended topics include confidentiality, cultural competence, supervision, program administration, and data/reporting skills.
    • Exhibit 3-4 provides a staff education planning form; Exhibit 3-5 lists training resources.
  • Onsite Training for Nonclinical Staff:
    • Security guards, reception/clerical staff, and outreach workers require role-specific training including confidentiality, customer service, boundaries, and crisis handling.
  • Training for Clinical Staff:
    • Focus areas include motivational interviewing; co-occurring disorders; relapse prevention; CBT; cultural competence.
  • Motivating and Retaining Staff:
    • Key issues: pay competitiveness, recognition, work-life balance, and opportunities for professional growth.
    • Strategies: flexible schedules, job rotations, performance incentives, ongoing feedback, and employee assistance programs (EAPs).
    • Consider organizational culture changes to reduce burnout and retain talent.
  • Resource and Recruitment Strategies:
    • Advertising widely; utilizing ATTC networks, NAADAC, SSA bulletins, universities, and diversity-focused outreach.
    • Interview processes often involve a staff panel and role-plays to assess fit; credential verification and background checks are critical.
    • Special emphasis on recruiting diverse staff; universities and internships as pipelines; culturally competent interviewing questions.
  • Staff in Recovery – Legal considerations:
    • Laws protect certain individuals with substance use histories ( Rehabilitation Act, ADA) with nuanced protections depending on recovery vs active use and job type.
    • Policies should consider abstinence requirements for counselling roles and how to handle relapse appropriately.

Section 4: Preparing a Program to Treat Diverse Clients

  • Cultural competence: an ongoing process rather than a goal to be achieved; staff must engage with diversity learning continuously.
  • Why it matters:
    • Demographic shifts: clients from diverse backgrounds represent substantial portions of those seeking treatment; mismatches between staff and client populations can affect engagement and retention.
    • Funding and accreditation considerations increasingly include cultural competence requirements (e.g., JCAHO/CLAS considerations).
    • Culturally competent practice can improve client retention and access to care.
  • Understanding diversity and terminology:
    • Exhibit 4-1 provides a glossary: cultural diversity, culture, discrimination, ethnicity, ethnocentrism, multiculturalism, prejudice, race, etc.
  • Learning about Cultural Competence in Organizations:
    • Administration must model and fund cultural competence; flexible organizational structure supports diverse service delivery.
    • Diversity expands staff worldview and helps create an environment where staff and clients feel respected.
  • Stages of Cultural Competence (Exhibit 4-2):
    • Six-stage continuum: Cultural Destructiveness → Destructiveness → Blindness → Pre-Competence → Competence → Proficiency.
    • Most programs start at cultural incapacity or blindness; progress toward cultural proficiency with deliberate processes.
  • Performing Cultural Competence Assessment:
    • Three-pronged assessment: community, clients, and program.
    • Community assessment uses demographics (Appendix 4-B: Community Diversity Form), comparing catchment area demographics with program staff and board composition.
    • Client assessment gauges satisfaction and accessibility; discharge surveys recommended; stratified analyses by gender, race, ethnicity, religion, ability.
    • Program self-assessment covers administration, facility, staff diversity, training, screening/assessment tools, program design.
  • Implementing changes based on assessment:
    • Quick changes: update mission statement to include cultural competence; modify program policy; diversify board; adjust facility appearance to reflect diversity.
    • Staffing changes: hire diverse staff; modify recruitment practices; improve screening/assessment tools to reduce cultural bias.
    • Long-term process: acquire new screening/assessment instruments; open staff dialogues; address staff development needs; revise budgets to support diversity initiatives; identify funding opportunities; remove barriers to treatment for diverse groups.
  • Staff selection and training for diverse populations:
    • Hire staff with backgrounds similar to clients; ensure depth of cross-cultural competence beyond token representation.
    • Interview questions should probe understanding of diversity beyond race; consider group sessions during interviews.
    • Training topics include self-assessment of biases, cross-cultural communication, and clinical strategies for diverse clients.
  • Administrative support for counsellors:
    • For general programs, counselors may need longer individual sessions to address cultural needs; alumni/mutual-help support groups may be insufficient for some groups; programs may sponsor targeted alumni groups.
  • Specialized treatment programs:
    • When necessary, develop ethnocentric programs for specific groups; ensure adherence to state licensing and accreditation.
    • Components of specialized programs: staff mirrors client backgrounds; trained supervisors; unbiased assessment tools; culturally relevant content; focus groups with community members.
  • Clients with disabilities – Deaf and other disabilities:
    • Deaf clients face communication barriers; ADA requires accommodations (e.g., ASL interpreters); avoid relying on family members as interpreters.
    • Prepare resources and networks for treatment of Deaf and hard-of-hearing clients; reference resources such as the Minnesota Deaf program.
    • For other disabilities, ensure ADA compliance, transportation accommodations, and accessible facilities; reference Manual 29 for detailed guidance.
  • Community outreach and ongoing engagement:
    • Partnerships with cultural organizations; targeted outreach to reduce barriers like transportation, childcare, and scheduling.
    • Outreach activities include sponsored talks, addiction education courses, workplace trainings, and school/community presentations (e.g., parent-teacher groups).
  • Administrative development of cultural competence resources (Appendix 4-A):
    • A compendium of training tools, posters, and population-specific resources; contact points for trainers and networks.
  • Population-specific information (Appendix 4-A/4-B reference):
    • Appendix 4-A contains population-specific resources; Appendix 4-B provides a Community Diversity Form with categorical fields (age, sex, ethnicity, income, etc.).

Section 5: Outpatient Treatment Financing Options and Strategies

  • Planning and developing an OT program:
    • Upfront capital demands (office space, equipment, staffing, IT, etc.); align with strategic plan and funding strategy.
    • Partnerships with strategic partners provide space, funding, or referrals; focus groups with potential funders and referral sources help shape the program.
  • Funding streams and resources:
    • SAPT Block Grant (federal funding) via SSAs; block grants comprise a substantial portion of public funding; States set eligibility criteria.
    • Medicaid: optional benefits vary by state; coverage for OT may exist but is not universal; EPSDT can provide access for children; IMD exclusion limits some services; MBHO/MCO arrangements common for managed care coverage.
    • Private payers: MCOs, MBHOs, EAPs; direct patient payments; indemnity plans; out-of-network coverage.
    • Grants and foundations: discretionary grants, program-specific grants; often require matching funds or alignment with program goals.
    • Self-pay and sliding-scale fees; sometimes used to attract clients with limited coverage; risk of revenue gaps.
  • Major funding concepts and tools:
    • Cost estimation methods for service costing (DATCAP, SATCAAT, TSR, etc.) to inform rate-setting and feasibility analyses.
    • Cost data used to negotiate with payers and demonstrate cost-effectiveness.
    • Exhibit 5-2 provides key cost/price resources and methods for projecting program costs and funding needs.
  • Managed Care and Networks (Section 5.3–5.4):
    • Four contract models with providers:
      1) Fee-for-service (FFS): bundled services; risk-minimized; provider must cost-out services to ensure coverage.
      2) Capitation: per-member-per-month payments; risk of under- or over-utilization; requires robust utilization data.
      3) Case rate: fixed rate per client for specified services and timeframe; risk-adjusted to address higher-need individuals.
    • Key risks and cautions:
    • Ensure rates cover actual service costs; track utilization, outcomes, and costs in real-time.
    • Build relationships with MCOs; obtain understanding of medical necessity criteria; align with MCO protocols.
    • The contract is not a guarantee of referrals; relationship-building with MCO staff improves approval rates and service access.
  • Cost of services and cost analysis:
    • Importance of understanding unit costs for different services to support negotiation with payers.
    • DATCAP and SATCAAT are standard tools used to estimate unit costs; other methods include Cost-Procedure-Process-Outcome Analysis (Yates), etc.
  • Networks, Accreditation and Credentialing:
    • MCOs require credentialed staff and facility accreditation; some MCOs contract more readily with licensed facilities than with standalone OT programs.
    • Accreditation bodies: CARF, NCQA, JCAHO; alignment with these bodies is beneficial for network participation and funding acceptance.
  • Organizational Performance Management:
    • Payers require performance indicators; national measures (e.g., NCQA, Washington Circle) and state systems drive performance-based payments.
    • Internal performance measures should cover processes and outcomes with adjustments for case mix.
  • Utilization and Case Management:
    • MCOs manage utilization via case management; discipline in obtaining approvals; establish good working relationships with MCOs’ case managers.
  • Strengthening financial base and market position:
    • Strategies: demonstrate program quality, address special populations (e.g., adolescents, co-occurring disorders, Deaf clients) as competitive advantages.
    • Economies of scale: expand sites to spread fixed costs; beware of administrative overhead.
    • Build community support and coalitions; avoid antitrust issues; seek legal guidance when forming coalitions.
  • Preparing for the future:
    • Maintain diversified revenue streams; nurture partnerships; stay informed about managed care, policy changes, and funding opportunities.

Section 6: Performance Improvement and Outcomes Monitoring

  • Rationale and approach:
    • Performance improvement and outcomes monitoring are increasingly central to funding, accreditation, and quality assurance.
    • The goal is to improve client outcomes using objective data, not to punish staff; foster a learning culture.
  • What to measure:
    • Engagement rate: proportion of new clients who attend a third session (clinic-wide and per-clinician).
    • Attendance rate: ratio of sessions attended to sessions scheduled.
    • Retention rate: weeks in treatment across clients; average weeks in treatment per admitted client.
    • Abstinence rate: proportion of negative drug tests (or other objective abstinence measures) among tests administered.
    • Quality-of-life indicators: behavioral changes in employment, housing, education, criminal activity, and health outcomes.
    • Client satisfaction: standardized satisfaction forms (Appendix 6-A) and referral-source satisfaction (Appendix 6-B).
    • Success of client transfer: rate of transferring to lower-intensity follow-up care and retention post-discharge.
    • Client dropout analyses: investigate reasons for leaving treatment; implement targeted interventions to re-engage.
  • Data and instrumentation:
    • Instrument sets: ASI (Addiction Severity Index), TSR (Treatment Services Review), PPC-2R references; use validated tools for reliability.
    • Data sources include client records, staff reports, and administrative datasets; MIS should support two-way data transfer with payers.
    • HIPAA and confidentiality are critical; data sharing must comply with federal regulations.
  • Implementation considerations:
    • Phase-in approach to performance measures; start with engagement, then add more indicators.
    • Case-mix adjustments when comparing performance across staff or clinics; avoid punitive comparisons; focus on improvement trajectories.
    • Use data to guide staff development, resource allocation, and process improvements.
    • Independent research involvement can enhance credibility of findings and help bridge practitioner-academic gaps.
  • Using performance data to promote the program:
    • Solid, transparent reporting to funders can attract ongoing support; cost-effectiveness data support “social investment” arguments.
    • Performance results can be used for marketing, fundraising, and public relations purposes.
  • Dissemination and governance of performance findings:
    • Form performance improvement teams or quality councils including clinicians, administrators, board members, funders, and possibly alumni.
    • Share clinic-wide data publicly where appropriate; keep individual clinicians' data confidential.
  • Exemplars and exercises (referenced exhibits):
    • Exhibit 6-2: I