County pushes toward elusive goal of treatment on demand

People with substance use problems don’t usually return home to sit by the phone when they’ve been denied immediate treatment. In fact, they often return to what brought them to seek help in the first place. The federal government estimates that overall, around 90% of the people who need rehabilitation for substance use never receive it.

King County, Wash., has embarked on an ambitious effort to reverse the trend. The county Health and Recorder Division oversees a network of 30 providers furnishing addiction and mental health services for the county. County officials have partnered with the Ballmer Group and Third Sector Capital Partners, along with MTM Inc., to find a way to offer patients same-day access to these providers. The program, dubbed “Pay for Success,” directs $1.4 million per year to behavioral health providers that offer treatment on demand to the 22,000 low-income King County residents who will be eligible for the program.

Jim Vollendroff, director of the county Behavioral Health and Recovery Division, tells Addiction Professional that it's critical for the county to be able to offer timely access to addiction and mental health services. Patients who don't get access to the treatment they need when they need it most end up having poor outcomes and are more likely to die prematurely as a result of lack of access and care coordination, Vollendroff says.

A 2006 report published in the Journal of Drug Issues highlighted this problem through narratives. The study followed 52 individuals with substance use problems, reporting on their experiences in seeking treatment. More than 45% went to rehabilitation intake centers of their own accord, 21% were court-ordered to do so, nearly 12% were referred by another provider, around 10% were sent by family members or friends, and about 12% were referred by homeless shelters or children's services. Only about one-third of the patients who reported to the intake unit received an appointment within 24 hours, according to the report, with 11.5% having to wait more than a week to get help. The average wait time to enter a treatment program after initial contact with a provider was 42.5 days.

These, Vollendroff says, are the types of delays King County is working to avoid with the new program, which has been modeled after the National Council for Behavioral Health's same-day access initiative. “One of the things that we found as we looked into this is, the earlier you access care, the better the outcome,” he says.

Program mechanics

The county is rolling out the program with a small group of providers, and will increase the number of participants and the financial incentives offered over time. Debra Srebnik, a quality improvement specialist with the county, says providers who participate are offered a front-end incentive payment simply for implementing a rapid access program, in order to recognize them for the resources they have spent in developing these systems.

“We really wanted to recognize those first six months,” says Srebnik. With the submission of a plan and the results of patient satisfaction monitoring, the providers are getting six months of incentives without having to undergo a performance review. “After six months, incentives will be based on their ability to meet the metrics,” says Srebnik.

There are three metrics the program will use to measure performance and to award incentives, Srebnik says:

• The amount of time it takes from a patient's request for service to when intake is offered. The target is zero to one days, and the goal is to have 85% of patients covered in that range, she says, adding that half of the incentive payment will be based on this metric alone.

• The second metric is the time elapsed from when a service was requested until actual intake occurs. Srebnik says that ideally, an appointment would take place no more than four days from the initial request or offer, and 80% of patients would fall under this.

• Finally, providers will be incentivized based on the time it takes for patients to move from their first appointment to a routine or follow-up visit. The target is within seven days, based on a national benchmark, Srebnik says.

Biggest challenge

This move toward better outcomes is ambitious, Vollendroff says, because many challenges complicate the effort to offer same-day services in addiction and mental health.

“We're rolling out a number of projects in which we are moving to a value-based system and paying providers a number of incentives to reach certain outcomes,” he says. “It's a challenge for providers from a staffing standpoint,” which he sees as the most pressing issue for participating organizations.

Vollendroff says King County is working on a legislative strategy for improving reimbursement for addiction and mental health care as a way to attract more providers to the field, alleviating workforce shortages.

Initially, six agencies signed on to the King County program, says Srebnik. Now, 23 of 29 outpatient providers are participating. Although the effort is still in its pilot phase, Srebnik says metric-based incentive payments will start later in 2018. Program leaders report early successes, based on anecdotal reports.

“I hear a lot of feedback and I hear a lot of phone calls from family members,” Vollendroff says. “Just having the conversation with our providers has heightened their awareness and commitment.”

Beratta Gomillion, executive director of the Center for Human Services, says the provider agency has worked with the county and MTM to implement same-day access and that it has been a “win-win-win” for patients, the organization, and clinicians.

“The consumer benefits because it eliminates long wait times for an assessment. It allows us to strike while the iron is hot and provide services when the consumer wants it,” Gomillion says. “Clinicians love it because it eliminates no-shows, freeing up their time to do other tasks. Our management loves it because it improves clinicians’ productivity. My only wish is that we had implemented this years ago.”