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Masters of improvement

April 17, 2012
by Gary A. Enos, Editor
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Two of the largest providers are pioneering redefinitions of effective clinical treatment
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Two high-profile but very different addiction treatment organizations are sharing a similar clinical mission these days—one that could serve as instructive and perhaps even essential for other treatment facilities like them. Both Phoenix House, the large nonprofit that has grown substantially from its 1960s-vintage therapeutic community (TC) roots, and CRC Health Group, the for-profit leader that grew rapidly through acquisitions nationwide, have been re-examining everything they do in client care under the oversight of a chief clinical officer.

Each organization’s effort is designed to make high-quality care better and to weed out anything resembling marginal performance. Neither organization appears to mind the notion that its efforts could serve as a prototype for clinical quality improvement in a rapidly changing marketplace.

“Phoenix House is just transforming in front of my eyes,” says Deni Carise, PhD, who was hired more than two years ago to institutionalize an evidence-based approach to treatment at the nonprofit. “We do hope we can be a model.”

“This kind of work is probably happening a little more now in isolated single facilities,” says Phil Herschman, PhD, who has been with CRC for about 10 years and became chief clinical officer last summer. “You have to have a commitment to high-quality patient care, and you have to have the resources to reinvest.”

A number of factors have contributed to the timing of these clinical improvement initiatives, from the promise of significant change under health reform to the growing need to distinguish an organization’s clinical services from the crowd. A member of CRC’s 10-person Clinical Advisory Board believes that if the addiction treatment field is going to avoid the upheaval that followed managed care’s arrival more than a generation ago, treatment centers must avoid believing that “good enough” is really sufficient when it comes to clinical quality.

“I think there’s a lot of lousy treatment out there,” says Gerald Shulman, a nationally known behavioral health trainer and consultant who recently reached 50 years of service in the field.

Evidence-based strategy

Phoenix House has around 125 total programs in regional operations in New England, New York, the Mid-Atlantic states, Florida, California and Texas. With more than 1,600 employees and around 16,000 adult and adolescent clients served annually, the process of defining clinical operations on an organization-wide basis must be done systematically. Phoenix House issues a detailed clinical three-year plan that gets refreshed with an update every year.

Probably the most prominent question addressed in the plan and at the facilities in implementation is, “How are we going to deliver as many evidence-based services as we can?” Carise says. In its initial inventory of each Phoenix House facility’s conventional practices, the organization found that 16 of its 20 most frequently implemented practices nationwide were already classified as evidence-based.

Phoenix House proceeded to create toolkits for each of the commonly used practices. It seeks to have each staff member in residential or outpatient programs demonstrate a proficient understanding of at least three evidence-based practices, and it sets important real-world practice goals to ensure that this knowledge is being applied. For example, 80% of evidence-based groups delivered in the past month were conducted by staff who have had the appropriate training and who passed the content knowledge quiz for that evidence-based practice.

In order to accomplish this, clinical staff members will receive training over a period of two to three months in a number of evidence-based practices, Carise says, with post-training refreshers scheduled in order to ensure retention of the information. “In many cases, the practices that sites deliver are more than what their state requires,” she says.

Where evidence-based practices are not being applied to a particular clinical challenge, the organization’s goal is to upgrade to an evidence-based strategy where available. As the organization’s three-year plan states, “We must continually strive to raise the quality and scope of our services. This implies the consistent use of evidence-based practices delivered by educated, knowledgeable staff as well as the expansion of our service delivery to include a broader array of outpatient services, mobile services in schools and local medical settings.”

Phoenix House’s review of ongoing practices did uncover one non-evidence based approach that still has proven extremely useful to the organization and that therefore has been retained. A process of “emotional cartography” (mapping) that helps individuals who have struggled to identify triggers for certain feelings has proven useful from both client and clinician perspectives, so it is still part of Phoenix House’s approach.

The process of clinical improvement is not seen as having an endpoint at Phoenix House. Just as the three-year plan keeps getting a new look, the clinical toolkits will continue to be updated as new research-based information reaches the field, Carise says.

She attributes some of the momentum for this effort at Phoenix House to the changes occurring in healthcare nationally. “Healthcare reform gave us the shove to look at this,” she says. She adds that the combination of business and clinical leadership is necessary to sustain the effort.

And with Phoenix House having evolved over the years from a purely residential model most closely identified with serving the offender population into an organization with a full continuum of prevention and treatment services, Carise sees the organization’s efforts as potentially helping numerous other types of providers.

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Wow, a whole article with all the buzz words and NO OUTCOME DATA. If you have improved outcome, prove it.

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