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2014 Model Practices
Application Name: 2014 Model Practices : Boulder County Public Health : Alcohol Emergency Commitment:Gateway to Immediate Treatment Access for High Service Utilizers
Applicant Name: Mr. Widd Medford
Alcohol Emergency Commitment:Gateway to Immediate Treatment Access for High Service Utilizers
Boulder County Public Health
3180 Airport Road
Submitting LHD/Agency/Organization/Practice website:
Boulder County Public Health Department
Practice Contact Job Title:
Intensive Services Program Manager
Head of LHD/Agency/Organization:
Provide a brief summary of the practice in this section. Your summary must address all the questions below.
Size of LHD jurisdiction (select one):
In the boxes provided below, please answer the following:
1)Where is LHD located? 2)Describe public health issue 3)Goals and objectives of proposed practice 4)How was practice implemented / activities 5)Results/ Outcomes (list process milestones and intended/actual outcomes and impacts. 6)Were all of the objectives met? 7)What specific factors led to the success of this practice? 8) What is the Public Health impact of the practice?
1. Boulder County Public Health is located on the front range of the Rocky Mountains, serving a population base of 300,000 people within the borders of Boulder County.
2. An increase in the number of homeless in the area has stretched the emergency services network, creating a disproportionate impact on vital services to the entire community. The increase is due to the slowing economy, more people accessing services for the underserved, and the difficult job market, compounded by a stressed affordable housing market. Due to the historic flood in Boulder County this September, the affordable housing stock has decreased to the point that we have less than 5% available subsidized housing options as of 10.13.2013. We already had a limited number of spaces, and with people displaced due to the flood, primarily mobile home residents, and an assisted living center that was severely damaged, it is understandable that the stock would be reduced so much.
3. The goal is to reduce the number of substance abusing and dependent homeless clients from inappropriately accessing emergency rooms, jails, homeless shelters and the county detox center, stressing an already strained network of safety net services. The measureable objectives were to 1. Identify the highest utilizers; 2. Count the number of admits, ER visits, and police contacts in the previous year; 3. Measure the total number of days that the client was in substance abuse treatment after the EC ended, to see how long the average length of stay was.
4. Using the Alcohol Emergency Commitment (EC’s) statute in the State, we were able to immediately admit chronically homeless and substance abusing and dependent clients into Transitional Residential Treatment (TRT), addressing treatment and temporarily reducing the impact on a strained housing market.
5. We opened 123 TRT episodes on clients placed on emergency commitments during the fiscal year of 2012-2013. These are not unique episodes, as many are placed on several EC’s. We intentionally target the highest utilizers in both Longmont and Boulder, the largest cities in Boulder County. The focus of this program was on people on the high utilizer list. We had 24 clients that were both on the high utilizer list, and that were placed on EC’s. The number 1 and 3 highest utilizers in Longmont and the number 1 utilizer in Boulder were placed in TRT treatment, reducing the impact of their previous behaviors on the safety network in the county.
6. The objectives were met in that we were able to show that immediate access to treatment while on the civil hold increased the likelihood that the clients would engage in treatment.
7. The factors that contributed to the success of the project were the involvement on Detox staff. Most of them are not credentialed mental health clinicians, but they are certified drug and alcohol counselors. Their ability to establish relationships with these difficult clients was a key role in the process. It indicated that entry-level counselors, with support from experienced detox supervisors, can have a major impact on a significant public health issue. This increased the capacity in the county of substance abuse providers that are able to intervene in the lives of chronic system utilizers.
8. The public health impact is twofold. We are assuring that we have a capable and competent workforce that is able to directly impact a community problem. We are also preventing a major public health issue, in that the chronically homeless and substance abusing population die on average 25 years earlier than the general population, and disproportionately impact the community safety net continuum. Eleven of our full time public health employees are certified as Prevention Specialists, a recent certification in the State of Colorado. This certification, along with being Certified Addiction Counselors, shows an increase in the community capacity to treat this difficult population. We made sure that all 24 clients in the program were enrolled in a Federally Qualified Health Center (FQHC), ensuring ongoing preventative health care services. Many of these clients will be eligible for Medicaid services as the Affordable Care Act unfolds. By getting primary care services in place, we are able to use preventative services to extend and increase the quality of life for our clients.
You may provide no more than two supplement materials to support your application. These may include but are not limited to graphs, images, photos, newspaper articles etc. (Please use one of the following: pdf; txt; doc; docx; xls; xlsx; html; htm)
Model Practice(s) must be responsive to a particular local public health problem or concern. An innovative practice must be 1. new to the field of public health (and not just new to your health department) OR 2. a creative use of an existing tool or practice, including but not limited to use of an Advanced Practice Centers (APC) development tool, The Guide to Community Preventive Services, Healthy People 2020 (HP 2020), Mobilizing for Action through Planning and Partnerships (MAPP), Protocol for Assessing Community Excellence in Environmental Health (PACE EH). Examples of an inventive use of an existing tool or practice are: tailoring to meet the needs of a specific population, adapting from a different discipline, or improving the content.
In the boxes provided below, please answer the following:
1)Brief description of LHD – location, jurisdiction size, type of population served 2)Statement of the problem/public health issue 3)What target population is affected by problem (please include relevant demographics) 3a)What is target population size? 3b)What percentage did you reach? 4)What has been done in the past to address the problem?5)Why is current/proposed practice better? 6)Is current practice innovative? How so/explain? 6a)New to the field of public health OR 6b)Creative use of existing tool or practice 6b.1)What tool or practice did you use in an original way to create your practice? (e.g., APC development tool, The Guide to Community Preventive Services, HP 2020, MAPP, PACE EH, a tool from NACCHO’s Toolbox etc.) 7)Is current practice evidence-based? If yes, provide references (Examples of evidence-based guidelines include the Guide to Community Preventive Services, MMWR Recommendations and Reports, National Guideline Clearinghouses, and the USPSTF Recommendations.)
1. Boulder County is located on the front range of the Rocky Mountains. It is home to the Flagship University of Colorado. The public health department covers Boulder County, including the major cites of Boulder and Longmont. With a 2012 estimated census of 305,000, it has shown steady growth over the past decade. With a growing Latino and/or Hispanic population of 13%, and less than 1% African American, we see a predominantly White demographic. However, the east part of the county has a significantly more impoverished population and a Hispanic population of closer to 35%.
We serve as a part of the continuum of services to insure that the underserved and underrepresented populations receive quality services, regardless of their ability to pay. The Addiction Recovery Centers Detox facility is an iconic program, starting out in a trailer in 1975, moving to a place of such prominence in the community that 6 years ago, the voters raised their taxes to provide a state of the art facility for the residents of Boulder County.
2. The public health issue is the impact of chronically addicted and homeless individuals on the emergency service continuum in the county. The public health issue is reflected in Healthy People 2020 objectives:
AHS 53: Increase the proportion of adults aged 18 – 64 who have a specific source of ongoing care. 81.3 percent of persons aged 18 to 64 years had a specific source of ongoing care in 2008. 70% of the chronically homeless are without a specific source of ongoing care, so they disproportionately impact emergency services, according to the National Coalition for the Homeless.
SA 8.2: Increase the proportions of persons who need alcohol and/or illicit drug treatment and received specialty treatment for abuse or dependence in the past year. 9.9 percent of persons aged 12 years and older who needed alcohol treatment and/or illicit drug treatment reported that they received specialty treatment for abuse or dependence in the past year in 2008
SA 15: Reduce the proportion of adults who drank excessively in the past 30 days. 28.2 percent of adults aged 18 years and older reported that they drank excessively in the previous 30 days in 2008.
3. The number of chronic homeless individuals with co-occurring disorders has increased dramatically in recent years. According to the latest Point in Time Survey for the Denver Metro area, 42% more homeless people on Jan 23, the night of the survey, reported spending the night in Boulder (866), than reported Boulder as their last place of housed residence (608). The only other county reporting more homeless on Jan 23 than their last place of residence was Denver (34%). All other counties reported the same or fewer homeless on Jan 23 than those reporting that county as their last place of housed residence. For the first time since opening the Boulder Shelter for the Homeless, they have had to turn away women due to capacity issues. Detox admissions have steadily increased over the years. In 2010, we had 2200 admissions, growing to over 3000 in 2012. We targeted the chronic substance abusing homeless clients placed on emergency commitments that were identified by community collaborations in the cities of Boulder and Longmont.
Overflow Responsiveness - 1
4. The cost to the emergency services in the community has increased as we take on the care of more acute clients, with serious and persistent mental health and substance abuse disorders. The Boulder Complex Client Group and Longmont Housing Opportunities Team Emergency Services Committee were assembled to address the increase in services delivered to chronic homeless clients that impacted emergency rooms, the county jail, ambulance, law enforcement, and the county detox facility in disproportionate numbers. The goal was to identify the high utilizers of emergency services, and work toward decreasing their use of the safety net services in the county. The clients were identified, and specific activities were initiated to decrease their dependence on emergency services in the county. In the City of Boulder, we identified 60 clients that impacted three or more agencies in the past year, and in Longmont, we identified 17 clients that were targeted for intervention.
5. As the only social model, non-medical detox in the county, we are the facility that accepts alcohol emergency commitments (EC). An emergency commitment in the State of Colorado is a 5 day hold, where individuals with significant substance abuse issues are held in our facility for 5 days. This hold is different from mental health holds, which are in place for people that are a danger to self or others. Anyone in the community, including hospitals, law enforcement, family members, and other service providers can apply for the EC. We need to have two solid criterion out of our list in order to accept the EC, and essentially take away the rights of an individual for 5 days. We take seriously the idea of taking away the rights of a person in order to help them protect themselves. We make sure that we have 2 solid criteria in place in order to take this action. Here is the approved list of criteria:
• 3 admissions in 3 weeks or 2 admissions in 2 weeks
• Recorded BAL of over .300
• Makes suicidal statements while intoxicated
• Threatens to harm other while intoxicated
• Has a history of driving/riding car/bike while intoxicated
• Does not take prescribed medications due to intoxication
Overflow Responsiveness - 2
It is a legal hold, and if a client leaves the facility, law enforcement is informed, and the client is returned to our facility to insure that they are safe. We take seriously the legal removal of rights in the attempt to protect people from the impact of serious alcohol and drug abuse and dependence. The 5 day hold is used to make sure people are safe and sober for 5 days, with the hope of breaking the addictive cycle, and to engage them in treatment. It is better because at the time of accepting the EC, we are intentional in engaging the client in looking at TRT as an option. Our single goal is to get them to agree to enter treatment, and by using Motivational Interviewing techniques, we try to get them to move toward longer periods of sobriety.
6. The practice is innovative in that we are actively trying to get these chronically difficult clients to agree to long-term treatment, even though they know the civil hold ends in 5 days. We are not a locked facility, and they can leave at any time. Law enforcement does what they can to help us, but when a chronically homeless client walks away from our facility, it is not considered a serious public safety concern. They will bring the client back if they encounter them on the street, but it is not a top priority. The immediate admission is key to keeping these clients in the building. 6b. In fiscal year 2012-2013, we had 123 emergency commitments. All of these persons on EC’s were not the chronically homeless, and some were people that have the means to pay for their treatment, and are not negatively impacting the emergency services network. Many of the 24 clients had multiple EC’s. In our program, we highlighted people on the list of high utilizers, and we looked at the 24 EC’s that were initiated on these clients. When a person on an EC is brought to our facility, we open a TRT episode of care, and develop a residential level of care treatment plan that included individual therapy, and group therapy, with the goal of increasing the length of time in treatment. The goal was to move all EC clients toward 90 days of treatment, which national studies show to be the benchmark for increased periods of sobriety, and decreased periods of use. The clients that are on EC’s are the clients that were on the list of clients identified as chronic users of emergency and safety net services in our county. The Guide to Community Preventative Services says “excessive alcohol consumption is the third leading cause of preventable death in the United States and is a risk factor for many health and societal problems. In 2006, the estimated economic cost of excessive drinking in the U. S. was $223.5 billion (Bouchery et al., 2011)”.
Overflow Responsiveness - 3
7. Days to treatment and early retention among patients in treatment for alcohol drug disorders from the Network for the Improvement of Addiction Treatment (NIATx) data base show that reduction in the time from intake to the first clinical intervention, group or individual, has been shown to decrease the number of people that drop out of substance abuse treatment. We began the program utilizing principles similar to the Strengthening Treatment Access and Retention–State Implementation (STAR-SI) program, that identifies a problem, sets an identified goal, implements a small pilot project and then the initial outcomes are evaluated. In 2003, the Network for the Improvement of Addiction Treatment (NIATx), began to work on reducing wait times for treatment and retention. The STAR-SI program was started in 2006, and has shown to be a scientifically sound. While there is only a small sample from which to work with, we believe it is a good start, and a place from which to move forward. The Colorado Office of Behavioral Health works with providers to insure, Community Behavioral Health C‐Stat Performance Measures: Access to treatment within 3 days is the standard from C-STAT in the state of Colorado that holds treatment providers to a 72 hour window in which to engage clients from the initial point of contact. We reduce the time to no wait time, based on the fact we admit the client immediately when they decide to enter the TRT program.
All TRT clients are offered tobacco cessation services, in a highly incentivized attempt to reduce the long-term impact from smoking. With studies showing that 90 days in treatment shows increased lengths of sobriety and improvement in daily living, we also know that the brain begins to heal from the impact of nicotine in substantial ways after 90 days of abstinence. Most all TRT clients smoke, and we have decided to reward good behavior and choices with incentives such as food, pizza, cosmetics, books, and whatever else we can use to hel[p move them along the stages of change.
The LHD should have a role in the practice’s development and/or implementation. Additionally, the practice should demonstrate broad-based involvement and participation of community partners (e.g., government, local residents, business, healthcare, and academia). If the practice is internal to the LHD, it should demonstrate cooperation and participation within the agency (i.e., other LHD staff) and other outside entities, if relevant. An effective implementation strategy includes outlined, actionable steps that are taken to complete the goals and objectives and put the practice into action within the community.
In the boxes provided below, please answer the following:
1)Goal(s) and objectives of practice 2)What did you do to achieve the goals and objectives? 2a)Steps taken to implement the program 3)Any criteria for who was selected to receive the practice (if applicable)? 4)What was the timeframe for the practice 5)Were other stakeholders involved? What was their role in the planning and implementation process? 5a)What does the LHD do to foster collaboration with community stakeholders? Describe the relationship(s) and how it furthers the practice goal(s) 6)Any start up or in-kind costs and funding services associated with this practice? Please provide actual data, if possible. Else, provide an estimate of start-up costs/ budget breakdown.
1. The goal of the program is reduce the impact of high utilizers on the emergency and safety net services in Boulder County. Leaders from Boulder County Public Health Addiction Recovery Centers (BCPH ARC), Boulder Shelter for the Homeless, Boulder Community Hospital, Aging Services, Center for People with Disabilities, the SAFE House (Domestic Violence Program), Mental Health Partners, Bridge House (drop-in services for the homeless and working poor), Clinica Campesina (FQHC), and other community members met to target the clients that accessed at least three of our programs in the past year. Hospital admits, Detox admits, and police encounters were used to determine the people on the list.
2 and2A. In Boulder County, there are two major groups that work toward reducing the impact of these high utilizers. In Boulder, we have the High Utilizer Group that addresses clients that access services from Boulder agencies. In Longmont, LHOT is the main group with all the relevant agencies delivering services to high utilizers in that city. Boulder and Longmont are about 15 miles apart. In Boulder, we met as a steering committee to develop a shared release, with all the providers agreeing to work together. We reconciled HIPPA, CFR 42, and the mental health statutes into one shared release. This took some time in order to get the hospital, public health, and the mental health center to gather attorneys, and to come up with a release acceptable to all. Think about a meeting with attorneys from the hospital, Public Health, and the Mental Health Center. Getting three attorneys to agree on anything is a challenge! We were able to develop a release that allowed case managers from multiple agencies and behavioral health workers to communicate together in a way that increased access to services for shared clients. The example of the attorneys in this case show how people can come together for a common cause, with the end result being better care for the people of our community. While it certainly was not easy, we think the leadership from our county attorney, set the stage for what we now see as an integral part of the service community, and holding a key role in the development of relationship between the case managers and clinicians involved with these complex cases and clients. With CFR 42 being the most restrictive as far as disclosure issues, her leadership in this program was critical to our success. This has allowed seamless communication on shared clients. There were a number of key players in this collaboration. In the City of Boulder the key players in this program were: Boulder County Public Health Addiction Recovery Centers, Boulder Shelter for the Homeless, Boulder Community Hospital, Boulder County Department of Aging services, Center for People with Disabilities, the SAFE House (Domestic Violence Program), Mental Health Partners, Bridge House (drop-in services for the homeless and working poor), Clinica Campesina (FQHC), and other community members. In Longmont it was Longmont Housing Opportunity Team (LHOT), H.O.P.E., Longmont Housing Authority, the Senior Center, OUR Center, Veterans Helping Veterans, City of Longmont, Longmont Police Department, and AGAPE Ministries, a faith-based program that provides services in a warming center during the winter months. It took a solid commitment from the community in order to make the program work efficiently and effectively.
The following programs and agencies are on the shared release to help facilitate services for our complex clients:
Clinica Family Health Services
Mental Health Partners
Addiction Recovery Centers (ARC)
Boulder County Public Health
Boulder Shelter for the Homeless
Boulder Community Hospital
The Carriage House Community Table
Medical Respite Boulder
Safehouse Progressive Alliance for Nonviolence
Center for People with Disabilities
Emergency Family Assistance Association (EFAA)
We also established twice monthly case manager meetings where the direct service providers would meet to discuss and strategize on shared, complex cases. The steering committee meets quarterly. In Longmont LHOT has a sub-committee dealing with the chronically homeless, and their impact on community resources. The Emergency Response Sub-committee meets monthly to go over specific issues related to the impact of high utilizers on the public safety and social service network. In a study conducted by Longmont Police Department (LPD), the top two clients cost the City $95,000.00 for services rendered by LPD, Longmont Fire Department (LFD), and the ambulance services provided by American Medical Transport (AMR). This did not include the cost to the ER at Longmont United, or to the Detox facility. While the cost to the hospital is difficult to calculate, they use a minutes per client calculation. They took the top 10 clients from Longmont, as referred by LPD and LFD. In 2011-2012, these 10 clients had a total of 174 visits, with an average time in minutes of 244 per admission. The cost for an admission to the Detox facility is $420.00 per day. The top two high utilizer clients from Longmont had 72 admits in the previous year. That is a cost of $30,000.00 added from the totals of LPD, LFD, AMR, and our Detox program. As it is clear to see, the impact of just two clients is substantial.
According to the National Prevention Information Network, at least 643,000 persons were homeless on a given night in 2009, while roughly 1.56 million people, or one in every 200 Americans, spent at least one night in a shelter during 2009. The National Alliance to End Homelessness estimates that 3.4% of homeless people were HIV-positive in 2006, compared to 0.4% of adults and adolescents in the general population (2). One study found that 26% of homeless people report acute health problems other than HIV/AIDS, such as tuberculosis, pneumonia, or sexually transmitted diseases.
In their fact sheet entitled Homelessness and Health: What's the Connection, the National Health Care for the Homeless Council states: "People experiencing homelessness have complex health problems. Without homes, people are exposed to the elements, disease, violence, unsanitary conditions, malnutrition, stress and addictive substances. Consequently, their rates of serious illnesses and injuries are three to six times the rates of other people. These conditions are frequently co-occurring, with a complex mix of severe physical, psychiatric, substance use and social problems. Resolving health problems is critical to resolving homelessness."According to the Health Care for the Homeless Clinicians' Network report, HIV and Homelessness: Recommendations for Clinical Practice and Public Policy: "Homelessness and HIV/AIDS are widespread and intersecting problems that occur in both urban and rural populations throughout the United States. Conditions associated with homelessness make HIV prevention and control especially difficult. Limited access to medical care severely restricts HIV/AIDS prevention, risk reduction, and treatment for homeless persons.
Adherence to complex HIV treatment regimens presents special challenges for homeless patients and their caregivers."Homelessness presents many barriers to healthcare. However, homeless persons can receive effective healthcare if it is delivered in the context of their usual life activities by professional providers who recognize and respect the autonomy of the individual patient and clearly communicate this respect to their patients to foster trust.
4. The timeframe was not limited, rather looking for individual success, that on their own would reduce the use of emergency services in a significant way.
5.a An expectation of Boulder County Public Health managers is intentional and deliberate collaboration with community partners, to facilitate effective partnerships that address local public health issues and needs. We are evaluated on it, and our time is dedicated to meetings, collaborations, and relationship development with peers in the community. When our Public Health Improvement Plan was developed, over 57 different people and agencies were represented in our efforts to assess the needs of our community. This shows the reach of our LHD, and the environment that has been established in the collaborative environment in Boulder County. We are represented in the Complex Client Group, Integrated Treatment Court Steering committee, PACE (dually diagnosed criminal justice system clients), Longmont Medical Network, Addressing Alcohol Concerns Together at the University of Colorado, LHOT, Colorado Behavioral Health Council, Colorado Providers Association, Office of Behavioral Health, Department of Housing and Human Services, and many more.
6. The Emergency Commitment Immediate Access program had little start up cost. By leveraging our State and Federal funds with support from the County Commissioners, the ARC has always been able to treat people that have been unable to pay. The ARC is an iconic program that started in 1975, and it is a program that the community came together to support 6 years ago with a bond measure to fund our new building, and to provide continuity to our services to the underserved populations in our county. The County Commissioners funded a case manager position that works in both our TRT program and Detox facility. His time is evenly split, making a good connection between the two programs, and helps the chronically homeless engage much more quickly. The only extra cost associated with the program is some additional case management dollars. With a cost of $18.00 per hour, during the course of the program, we have used 113 hours on case management work. The minimal cost was $2034.00 for services that greatly impacted the project. Much of this is sending a case manager to the FQHC to enroll them into services. We also have Detox staff trained on HIV/Hepatitis C testing, and all TRT clients are offered free testing and counseling at the time the results are given. This is a major harm reduction and preventative action that decreases the impact of HIV/Hep C infections in the community. These activities can take a good amount of time, and we have found that having a staff member with them increases the odds that the chronically homeless will stay during the process. It also includes waiting at the DMV, Social Security Office, and other agencies needed to get documentation that speeds up the delivery and acquisition of services.
In summary, collaboration is absolutely essential to the success of our program. There is a shared vision within our community of service providers,and a commitment to meet on a regular basis to develop the types of relationships that help us make an impact on our community. It is intentional, and a daily part of our jobs in public health. This is a continuous process that always needs attention. People know when a community is involved in power struggles over funding and personalities, but they also know when it is working right. It is not something that happens organically. It takes work, commitment, and a desire to be the best.
Funding for the program is listed below. We wrap this service into our existing budget, with the exception of some case management funds.
Source of Funds Amount % Of Program
County Funds $224,574 19%
MSO Contract1 514,688 44%
Substance Abuse Inpatient Fees2 382,608 33%
Detox Walk-In Monitoring3 30,894 3%
Monitoring Fees4 8,531 1%
Miscellaneous Revenue 671 <1%
TOTAL $1,161,966 100%
Evaluation assesses the value of the practice and the potential worth it has to other LHDs and the populations they serve. It is also an effective means to assess the credibility of the practice. Evaluation helps public health practice maintain standards and improves practice.
Two types of evaluation are process and outcome. Process evaluation assesses the effectiveness of the steps taken to achieve the desired practice outcomes. Outcome evaluation summarizes the results of the practice efforts. Results may be long-term, such as an improvement in health status, or short-term, such as an improvement in knowledge/awareness, a policy change, an increase in numbers reached, etc. Results may be quantitative (empirical data such as percentages or numerical counts) and/or qualitative (e.g., focus group results, in-depth interviews, or anecdotal evidence).
In the boxes provided below, please answer the following:
1)What did you find out? To what extent were your objectives achieved? Please re-state your objectives from the methodology section. 2)Did you evaluate your practice? 2a)List any primary data sources, who collected the data, and how (if applicable) 2b)List any secondary data sources used (if applicable) 2c)List performance measures used. Include process and outcome measures as appropriate. 2d)Describe how results were analyzed 2e)Were any modifications made to the practice as a result of the data findings?
1. What did we find out? We discovered that the EC statute is good in its intent, but rather weak in its implementation. Most clients will agree to stay for the 5 days, but were really waiting to leave. The focus for them was to ‘do their time’ on the EC, and planned what to do after they left. We decided to intentionally engage the clients about entering our TRT program as soon as they were sober. Instead of just waiting for the EC period to end, they began actively working on their substance abuse issues. Of course, not all clients were amenable to treatment, and they were released at the end of the hold. But, by immediately engaging them in a guaranteed treatment opening, we were able to get more clients to agree to stay. Of the 24 clients that were on the list of high utilizers with significant substance abuse issues, and that were placed on an EC, we had some interesting numbers. 24 clients met this definition, and of the 11 female and 13 male clients, their total number of days in residential treatment was 1370. The average length of stay was 57 days. This is a significant number. We obviously want to keep them engaged in treatment for a minimum of 90 days, but with this population, 7 weeks of housing, treatment, and case management is significant. All 24 of the clients were enrolled in our local FQHC, or were re-engaged with a primary care provider in their program. All 24 were given HIV/Hep C tests, tobacco cessation services, and solid relationships were built between Detox staff and the clients. This increases the likelihood that they will come back again if they need further treatment. The importance of the clinical interview by a trained drug and alcohol counselor cannot be overstated. By doing the assessment as soon as the client is sober, we were able to engage them at a point where they are more likely to look at the consequences of their actions. When people are at a low point in life, like those on an EC, it is an ideal time for a thoughtful, clinically sound intervention. Talking to them about treatment options, and doing a full assessment, has led to more long-term commitments to residential treatment, and better outcomes for our EC’s. It has also shown us that we have increased the length of time that these high utilizers stay in treatment. Another component of this program is that former TRT clients can attend groups, meet with a case manager, and have individual sessions indefinitely. In the past, the EC was usually over at the 5-day mark. We met the objectives of reducing the number of admits for the chronic utilizers. By keeping them in treatment, we were able to dramatically reduce the number of admits to the ER, police contact, and ARC detox admits. The top two Longmont clients referenced earlier had a total of 5 admits to detox since their TRT episode. The number one high utilizing Boulder client has transitioned to the Shelter, after getting some medical issues taken care of (hip replacement), and has had no Detox admits since the TRT episode.
2. The evaluation for the practice was relatively simple, in that we have existing systems in place to gather data. The length of the client’s EC stay from detox to TRT with 90 days in treatment thought to be key. Clients that stay in treatment for at least 90 days show an increased level of reduced substance use, and the negative consequences that accompany this behavior. The Office of Behavioral Health in the State of Colorado tracks the length of stay for clients that are admitted in an episode of care. We used their statistics to determine how long a person was in treatment. While we do the initial work with a client, we look to Outpatient Services to extend their treatment episode. We looked at the LPD data on services rendered by law enforcement, the fire department, and the ambulance service. Due to confidentiality issues, we will need to further discuss and implement a process that will allow us to report back on outcomes after clients complete treatment. If they are unwilling to sign a release to other agencies, which is fairly common with this population, we will be hard pressed to get the complete data analysis and data set. One goal for the future would be to incentivize the signing of the release to other parties. While most of the clients in Boulder will sign the release, they often sign only for those that they feel comfortable with. This gives us data that is less than robust, and we will need to try to figure out a way to improve this process.
The measureable objectives were to 1. Identify the highest utilizers, which we have done. Out of the list of 66, 24 clients were placed on EC’s, for a total of 1370 days. That is an average of 57 days per treatment episode. 2. Count the number of admits, ER visits, and police contacts in the previous year, which we have done. We had 174 admits in Longmont at LUH, for an average length of stay of 244 minutes. 3. Measure the total number of days that the client was in care after the EC expired, to see how long the average length of stay was. Our role in this process was the treatment component for drug and alcohol issues. We have done this. The average length of stay for clients on the high utilizer list was 57 days. While not at the recommended stay of 90 days, we feel that the length of stay created a significant improvement in over-utilization of services by historically difficult to treat population in our county.
2a. The practice was evaluated in a number of ways. We were able to collect encounter data from the city of Longmont that included the use of public safety services. The organizations involved in this process were: BCPH, Boulder Shelter for the Homeless, the OUR Center, HOPE, Longmont PD, City of Longmont, American Medical Response, and the Department of Housing and Human Services. We had the total cost of the ambulance service, ER admits by minutes, and police contacts or transports. From this list, we were able to identify the top utilizers that had a primary substance abuse disorder.
The data from public safety was originally collected by the City of Longmont to identify clients that would be good candidates for Housing First, and other Housing Authority programs. The goal of this working group was target the heaviest users of services, and target them for intervention. While they may have had a co-occurring mental health issue, the primary focus for us was on clients that had been placed on an EC previously, up to a year in the past. We were also able to pull the length of stay from the State of Colorado DACOD system, the data base that tracks all treatment encounters that are funded with federal block grant dollars. We also implemented an electronic medical record two years ago, so it was easier to gather data electronically, rather than going through paper charts. We also used the Point in Time Survey to note the increase of homeless people accessing services in Boulder County, and specifically Longmont. Please see the numbers in the previous section.
The process measures used in our program was to make sure that 90% of all EC clients were opened up TRT episodes of care. By doing this, we are able to engage the clients in more intensive and intentional interventions, moving from seeing the hold as required by statute and moving toward the hold as an opportunity to engage clients, moving them toward treatment. We had 123 TRT episodes in 2012-2013. 60 of these were not on EC’s. 63 of these were on EC’s. 52 of these were opened in a TRT level of care, missing the goal of 90%. We continue to look at ways to improve on this number. We are looking at a goal of 95% in the coming fiscal year, and putting in place policies that will get us there.
The outcome measures used are related to number of days in treatment. While we averaged 57 days in treatment, we are still short of the 90 day recommended stay for increased periods of sobriety. Anecdotally, the top three clients in the county, one in Boulder and two in Longmont, are doing well. Two of the three have had no Detox admissions, and one has had five.
3. The 10 Essential Services that are relevant in this program are: Mobilize community partnerships to identify and solve health problems. Link people to needed personal health services and assure the provision of health care when otherwise unavailable. Assure a competent public and personal health care workforce.
4. The results were analyzed by seeing how long people stayed voluntarily after the EC ran its course.
5. Modifications were made to our internal process in a number of ways. Using Motivational Interviewing techniques early on in treatment, allowed us to respond immediately to the change talk, and work on moving them along the Stages of Change. Since we do not get to pick when someone gets clean and sober, we need to be intentional in every encounter with the clients. We also trained staff in prevention strategies and techniques, helping staff members get their license as Certified Prevention Specialists in the State of Colorado, and continuing to train and educate staff on addiction treatment, ultimately leading them to licensure as Certified Addiction Counselors in the state.
Sustainability is determined by the availability of adequate resources. In addition, the practice should be designed so that stakeholders are invested in its maintenance and to ensure it is sustained after initial development. (NACCHO acknowledges fiscal crisis may limit the feasibility of a practice’s continuation.)
In the boxes provided below, please answer the following:
1)Lessons learned in relation to practice 2)Lessons learned in relation to partner collaboration (if applicable) 3)Is this practice better than what has been done before? 4)Did you do a cost/benefit analysis? If so, describe 5)Sustainability – is there sufficient stakeholder commitment to sustain the practice? 5a)Describe sustainability plans
1. The lessons we learned in this process are many. We learned that we need to be intentional and immediate in our interactions with this historically difficult to treat population. It means we have to aggressively work on getting clients to see the benefit of entering into a TRT treatment program. We obviously cannot force them to do so, but we can use many tools in working toward moving them to that point. The immediate access to treatment continues to be a major factor in getting people to engage. For this population, to give them immediate access to a bed is significant. It allows them the time it takes to get stabilized, and to work on a treatment plan that includes a host of issues. The enrollment or re-engagement with a primary care physician is significant on many levels. The understanding of their health care issues related to HIV/Hepatitis C is important as well. Getting the appropriate medical care will increase the life span of this population, and increase daily living skill development. We also learned how important it is to have a capable and competent staff in order to take advantage of the small windows we have with this population. Giving relatively new to the field staff members concrete tools in which to engage has been a significant component of this program. Making sure we have a capable work force to deliver vital services is a big part of what we do, and this project proved that over and over again.
2. It would have been impossible to make this program run without the collaborations in the community. Being able to call the right people in the moment has increased our ability to provide immediate solutions to problems that arise in treatment. To tell a client that we know exactly who to talk with, and then to deliver for them is significant. While the collaborations definitely take time, it is a critical element of our work in Boulder County. We are held accountable as managers for doing this, but more importantly, we all believe in it.
3. This practice is definitely better than the process we had in place before. In the past, we would look for motivation on the part of the client, in order to assess if they were serious about treatment planning. By using Motivational Interviewing techniques and strategies, we meet the client where they are at, and listen for change talk along the way. Our goal is to help them get into treatment, and if they choose not to at this time, we have set the stage for future intervention.
4. The cost benefit analysis, from our perspective, is simple. Getting more people into treatment, reducing their impact on the safety net services, and extending life are where it is at. Since we are given a block grant to do our work, it is wrapped up in the continuum of care in our program.
5. The commitment from the community is significant. We are the primary provider of services for this vulnerable population. Since we all work with the same clients, the community is committed to helping people dependent on drugs and alcohol get the services they need. The idea that we can intervene and reduce the impact of drinking that leads to early death is amazing. We are involved in multiple community collaborations, and will continue to be a part of the community wide discussions on this issue.
5a. the impact of the substance abusing homeless population continues to be an issue in Boulder County. Recent increases in this population have impacted our service network in a major way. Bridge House, the service provider for the homeless during the day, has been inundated with new homeless clients in the last year. Issues in Denver have pushed a good number of clients up to Boulder. The Boulder City Council is meeting to discuss ways to reduce the impact of the homeless on shared public spaces. Bridge House reports that 62% of the homeless they serve have been in Boulder for less than a year. As far as sustainability, our Director has committed the resources needed to provide the services this population needs. This includes increased case management time, the implementation of Medication Assisted Treatment options such as Suboxone and Vivitrol. The combination of these treatment options and cognitive-behavioral therapy options will help us sustain the services we now have in place.
Please identify the topic area(s) the practice addresses. You may choose up to three public health areas:
Practice Category One:
Access to and/or Equality of Care
I am a previous Model Practices applicant
Are you a previous applicant?:
Yes, and was awarded Promising