DISTRICT 8 BEHAVIORAL HEALTH NETWORK READINESS-ASSESSMENT AND RECOMMENDATIONS Thomas E. Lucking, EDS August 2003

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1 DISTRICT 8 BEHAVIORAL HEALTH NETWORK READINESS-ASSESSMENT AND RECOMMENDATIONS Thomas E. Lucking, EDS August 2003 Summary PART I: INTRODUCTION District 8 is one of three Florida Districts piloting different methods to improve publiclyfunded behavioral care services. The District 8 Pilot features the development of a providersponsored network that is augmented by an administrative services organization. The consultant reviewed documents that described District 8 service and payment trends and the development of the network. On June 9, 10, and 11 of 2003, he visited network providers, interviewed District 8 staff members, and met with representatives of network member organizations. This report describes the network s readiness and presents recommendations for consideration by the Florida Department of children and Families (DCF), District 8, and providers. Context DCF is working to improve public behavioral health care by better integrating Medicaid and DCF resources and policies and redesigning systems of care. This legislatively mandated effort includes pilot network-development efforts in District 8 and in two other Districts. The District 8 Pilot effort is testing the development of a provider-sponsored network and a timelimited administrative services organization (ASO) as vehicles for improving care and, eventually, managing a capitated Medicaid contract. As of this writing ( July 2003) DCF was about to release an Invitation to Negotiate to contract with an ASO to provide the information and reporting infrastructure the provider network needs to meet DCF goals. Like behavioral-health policy makers undertaking similar initiatives in other states, DCF has focused most of its network-development attention on mental health services. This attention to mental health issues is understandable because Medicaid funding is much more important to funding mental health services than it is to funding substance-abuse services. Yet effective substance-abuse services are essential to behavioral healthcare networks. This project is designed to focus more attention on substance-abuse services network developmental issues and to provide a general assessment of the network s readiness. Product of the consultation The product of the consultation is this report, a readiness assessment for the Substance Abuse Service Office and District 8 Alcohol, Drug Abuse, and Mental Health (ADM) with recommendations to help DCF, the District 8 ADM office, and the provider network with the implementation of a refined system that will maximize and enhance the delivery of substance abuse services. District 8 Network Readiness, Thomas E. Lucking, EDS, August

2 Methods The consultant reviewed documents and conducted telephone interviews (1.5 days) before visiting District 8 on June 9, 10, and 11 of The visit included meetings with District 8 staff members and network members, and on-site meetings three provider organizations, with a review of the providers management of substance-abuse treatment. After this visit, the consultant reviewed documents and conducted telephone interviews (1.5 days). In November of 2001, the consultant worked on a network development readiness project with the Florida Alcohol and Drug Abuse Association (FADAA). This engagement included a visit to District 8 on behalf of the District 8 provider network. The 2001 visit provided a point of reference for observing subsequent network development. General limitations The review was brief and therefore relied heavily on the self reports of District 8 and provider staff-members and the reports of others who had reviewed different aspects of the District 8 Pilot. The brief review did not permit a visit to Florida s Agency for Health Care Administration (AHCA). The review addressed treatment only, not prevention, even though the effective delivery of prevention can be important to long-term network success. PART II: CONTRASTING ISSUES FOR MENTAL HEALTH AND SUBSTANCE-ABUSE TREATMENT SYSTEMS Mental health and substance abuse providers have contrasting funding and developmental issues relevant to network development. Several issues important to network development are listed below. Different priority populations and the impact of people with co-occurring disorders Issue: Community-mental health systems must focus a high proportion of its resources on adults with severe and persistent mental illness (SPMI) and children with serious emotional disturbance (SED). Publicly funded substance-abuse treatment systems give priority to groups identified by federal and state policy makers (such as pregnant women and intravenous drug abusers) regardless of the severity of their conditions. Instead of directing resources to consumers with the most severe conditions, many substance-abuse treatment systems also focus on individuals in the early stages of addiction because doing so improves results and prevents problems. Also, a remarkably high proportion of the mental health system s priority populations have co-occurring substance-abuse disorders that must be addressed for treatment to be successful. A significant but much lower proportion of the people served by the substance-abuse system have co-occurring mental-health disorders that must be addressed for treatment to be successful. District 8 Network Readiness, Thomas E. Lucking, EDS, August

3 Implications: Behavioral health networks are under enormous pressure to respond to the substanceabuse problems of the SPMI population. This pressure intensifies when the networks accept capitated contracts because untreated substance-abuse among the SPMI population increases the network s financial risk. (The District 8 Pilot is intended to lead to a capitated contract for Medicaid) Provider networks dominated by mental health organizations, like the District 8 network, might be inclined to put a disproportionate share of substance-abuse treatment resources toward the treatment of the SPMI population. However, redirecting scarce substance-abuse treatment resources to this population would undermine the contributions that the substance-abuse treatment system can make to its priority populations and the communities served by the behavioral-care networks. An alternative that better addresses the needs of most people with co-occurring substance abuse and mental health disorders is increasing the capacities of existing providers to assess and treat people with these co-occurring disorders, such as equipping substanceabuse providers to treat individuals with mental health disorders and adding substanceabuse treatment specialists to FACT teams. This alternative also applies Medicaid resources to the care of SPMI individuals, an appropriate use of Medicaid resources, while conserving substance-abuse treatment funding for other priority populations. The relative importance of different funding streams Issue: Community mental-health systems rely heavily on Medicaid funding, and the improved integration of Medicaid and other funds is a driving force behind the DCF network development initiatives. While Medicaid funding matters to substance-abuse treatment systems, it is no more than a fraction of substance-abuse treatment funding. Similarly, federal block-grant funding, with its specific population priorities and developing outcomes requirements, constitute a large proportion of funds for substance-abuse treatment. Federal funding (apart from the federal Medicaid match) is a less important source of support for community-mental health systems. Implications: Just as the mental-health service system must be particularly attuned to the needs and priorities of the Medicaid system, substance-abuse providers must be particularly attuned to the changing requirements of the federal block grant system. The network will need to address the needs and requirements of both funding streams, including the outcomes reporting and priority populations of substance abuse grants, such as intravenous drug users and parents whose substance abuse puts children at risk.) Different needs for detailed service protocols Issue: Nationwide, some substance-abuse providers have had a tendency to error on the side of detailed treatment protocols delivered in sometimes overly-prescribed ways. Also District 8 Network Readiness, Thomas E. Lucking, EDS, August

4 nationwide, some mental-health providers have had a tendency to error on the side of over-relying on the clinical judgment of individual care givers and not adequately defining clinical protocols. Implications: Some mental-health systems must develop more detailed and defined clinical protocols. By contrast, some substance-abuse treatment providers must begin to apply their protocols with greater sensitivity to the needs of individuals. Clinical paths and best practice protocols have important uses. However, most substance-abuse service providers already have well developed criteria and protocols. The network will need to take care that clinical paths do not become another version of overly-prescribed treatment. Volume of persons served and quality-management requirements Issue: Substance-abuse service systems usually serve more people than mental health systems, with the greatest volume being legal system referrals who receive in low-intensity outpatient treatment. Publicly-funded mental health services usually serve a smaller number of individuals for longer periods of time. Implications: The design of outcomes, quality, and satisfaction management-systems need to take into account the relatively high volumes of many of the court-mandated individuals seen by the substance-abuse system and the relatively brief involvement of many of them. Outcomes, quality, and satisfaction management-systems should devote their most intensive efforts to people receiving longer term, intensive treatment. Also, penetration targets established for substance-abuse treatment systems need to distinguish between people who are court mandated to receive brief outpatient episodes of care and people who are not court mandated and receive intensive, longer term treatment. PART III: NETWORK PLANNING AND SERVICE DELIVERY REQUIREMENTS The District 8 Pilot network has three design features that merit close attention as the network develops. First, the network is managed by community-based providers who have taken a leadership role in the development of services within their respective counties. To succeed, the network will have to be responsive to the needs of consumers, purchasers, and the District 8 communities. Nationwide, most healthcare systems, including behavioral healthcare systems, must make significant changes in organizational cultures and capacities to become more directed by the needs and preferences of consumers, communities, and purchasers and less directed by the preferences of staff members and historical positions of organizations. Second, the providers making up the governing body District 8 networks have been county-specific providers with county-specific planning efforts for most of their services. Yet the network planning efforts and the development of service systems must encompass all of District 8. Finally, the District 8 Pilot District 8 Network Readiness, Thomas E. Lucking, EDS, August

5 calls for providers conducting their own utilization management. Successful internal utilization management hinges on the willingness and ability of network providers to enforce their own conformance to the District 8 protocols. (Conducting utilization-management according to the needs of consumers and purchasers is difficult enough that many healthcare purchasers hire external managed-care organizations to force changes in service and practice patterns.) PART IV: DISTRICT 8 OBSERVATIONS This section presents the consultant s observations about the progress of District 8 in developing more consumer-focused, recovery oriented services, improving the utilizationmanagement systems of its providers, and the development of a network capable of responding to the needs of consumers, purchasers, and District 8 communities. Purchaser methods Purchaser contracting methods can help or hinder the development of improved systems of care. Some purchasers rely on aggressive purchasing and care-management practices, such as paying rates below reasonable costs, frequently changing vendors, and the extensive use of external managed-care organizations. Aggressive methods can attain rapid compliance with new practice standards, but it does so at the cost of the health of the provider system, stable access to care, and the ability of providers to collaborate as mature partners in service design, development and delivery. The other extreme, protecting the financial interests and traditional service offerings of traditional providers, delays improvements. Successful purchasers make careful judgments about situations that might require changing contracts and services from one provider to another, using dialogue and contractual terms to encourage new or changed service, and broadening the array of providers as needed for consumer choice. General observations: District 8 ADM, provider-network planning and development District 8 s ADM staff members and provider network are making steady and significant progress. As described in its 2002 Annual Report, District 8 is moving from a heavy reliance on residential models of care to one in which a broad array of services are individualized, community-based, and recovery oriented. Important examples include the development of four Florida Assertive Community Treatment (FACT) teams, new services for children and adults with co-occurring mental heath and substance-abuse services, improved supportive living which has decreased the need for acute mental health care, and contracts with county NAMI affiliates for consumer-based initiatives. Administrative development progress includes further development of the provider-sponsored network, contracts with a wider array of providers, contract changes according to provider performance and community need, and sharp increases in Medicaid funding for mental health services. While these improvements highlight important gains, District 8 ADM staff members and provider network leaders also acknowledge that much work remains to be done. They also acknowledged the need to improve care coordination across service lines and provider organizations and to integrate care across systems, such as child welfare, school systems, and criminal justice systems. District 8 Network Readiness, Thomas E. Lucking, EDS, August

6 AHCA, the Medicaid office, is not involved in the planning and development of the pilot. Providers identified the leadership of District 8 s ADM staff members as responsible for many service improvements. For example, District 8 s ADM Program Administrator is encouraging the development and delivery of more community-based services and supports, the use of best practices, and the development of improved care-management capacities. She has encouraged improvements with sensitivity to provider stability and health. On several occasions, the District 8 ADM office has described needed changes in services along with the time needed to change from one service method to another. This method of changing services gave provider organizations a chance to take a mature, cooperative approach to service improvement while preserving relatively stable employment and revenues. The consultant had individual discussions with the CEOs of four of the five provider organizations that formed and now govern the provider-sponsored network. He also had a meeting with twenty-four representatives of member organizations. The discussions, meetings, network progress, and changes in services provision all suggest that the network in total has moved toward improved collaboration with the District 8 office and with other provider organizations. Great variations in planning orientations remain across provider organizations and among service lines within organizations, yet the support of most network provider leaders is at a sufficient level to enforce network support of purchaser and consumer-focused services. Although difficult to measure objectively, it appears as if the leaders of the network are willing to plan services that are responsive to the needs the consumer, purchaser, and communities served. District 8 is relying on the ASO for the clinical pathways to help guide care-management decisions according to evidenced-based standards and provide benchmarks for retrospective reviews of care management decisions. Clinical pathways can be valuable tools for these purposes, especially since many of the clinicians available to provide care lack extensive clinical experience. Most of the District 8 s service improvements have been within provider organizations. In other words, District 8 improvements have occurred within organization-specific service-line silos. With the help of a cross-provider information systems supplied by the ASO, the network could undertake cross-provider, District-wide service improvements. The five founding partners appear to be ready to undertake more cross-organization, District-wide service planning. Planning such initiatives would not have to await a functioning ASO. In addition, the network could undertake systematic efforts to integrate care with other systems, such as schools, criminal justice, and primary healthcare systems. Network providers have developed such integrated care relationships individually. The network provides the District with opportunities for comprehensive, District-wide integrated care efforts. The network s addition of a representative of the District s child welfare network to its governing body should help with integrated care planning. The table on the following page is a general summary of the District 8 s planning progress. The continuing progress from internal, service preservation planning to customerfocused planning is encouraging and predictive of further success. District 8 Network Readiness, Thomas E. Lucking, EDS, August

7 General Summary, District 8 Planning Progression Continue service development in the direction of consumer- Service planning Current functioning Next steps Provider-centered preservation of historical services. Providers acknowledge that service delivery is uneven. Some service lines are more or less consumer and focused, others are not. centered services. Consumer, purchaser, and District centered planning. Cross-provider planning of systems of care. Integrated care across service systems. The network founding partners are working with the District 8 ADM staff to expand community-based, recovery oriented care. Some examples of cross-provider efforts exist, but partners agree that this needs to be a focus of development. Individual provider efforts and the addition of a representative of the child welfare network to the governing body. Continuation of service upgrades aided by clinical path technology. Clinical paths and the ASO should increase cross-provider and District-wide planning. The network provides a vehicle for District-wide integrated care systems. Substance-abuse treatment services DCS has requirements important to network development. One is the use of the patient placement criteria sponsored by the American Society of Addiction Medicine (ASAM). Another is the identification of priorities for certain service populations. Some of the priority populations are federally mandated. The ASAM criteria are widely accepted as the standard guide for utilization management, and thereby form an important part of clinical-path management for substance-abuse treatment. The consultant interviewed clinical staff members from three District 8 providers and interviewed the director of a fourth provider via the telephone (He had reviewed this provider s program eighteen months earlier.) The interviews focused on care-management and capacity of providers to treat special populations. The four substance providers demonstrated widely diverse service capacities. While all four providers screened out people incapable of participating in treatment because of certain acute conditions, two of the providers used the ASAM criteria meaningfully to govern initial placement decisions. The other appeared to ignore ASAM criteria when making initial placement decisions. The two providers using ASAM criteria for admissions also described the application of population-specific service methods and enhancements to address the particular needs of federal and state priority populations. With the exception of a well conceived school-based adolescent program, the same general services, regardless of subpopulation, were described by the other two providers. The two providers using ASAM for initial placement decisions also used ASAM criteria for making continuing stay and transition decisions, although both struggle against the momentum of historic lengths of stay. The other two did not use ASAM criteria for managing lengths of stay. In District 8, more than half of substance-abuse funding is contracted with organizations that follow ASAM guidelines, and this proportion is increasing. The District 8 experience reflects some of the strengths and vulnerabilities inherent in combined mental-health and substance-abuse service planning and delivery systems. District 8 is well positioned to address the needs of persons with co-occurring mental-health and District 8 Network Readiness, Thomas E. Lucking, EDS, August

8 substance-abuse disorders, and the District ADM office and providers are making substantial gains in the district s capacity to serve persons with such co-occurring mental health and substance abuse disorders. It is probably no coincidence that the two providers not applying ASAM criteria were operated by community-mental health centers for which substance-abuse has been a relatively small line of service. Choice of providers Consumer choice is an important feature of systems that value consumer empowerment. In District 8, the provider sponsored network will be the single plan available to service recipients. Without choice of provider network, consumer choice, and therefore consumer empowerment, rests with choice of provider within networks. Choice of provider is a feature that remains controversial with the five founding partners of the District 8 network. Yet the continued expansion of consumer choice is inevitable, given the interest of the Centers for Medicaid and Medicare Services (CMS) in supporting consumer options and the goal of consumer empowerment. For some District 8 services, limited resources, populations, and provider capacity limit the extent to which consumer choice will be available. Network governance The network has become incorporated, and has established a governance structure with a core membership of its five founding partners. The founders have agreed to reserve additional governance seats to stakeholder representatives, including a representative of the District s child welfare network. However, some member providers who are not founding partners have questioned the appropriateness of the network governance structure. Network stability is related to the appropriateness of the network s governance structure. District 8 has a powerful stake in network stability. Network instability or dissolution, or the need to develop another network, could jeopardize reliable services and would require the application of more resources to administrative development. Among other variables, the network s ability to be a stable vehicle for consumer, community, and market driven services depends on the extent to which its governance reflects market and community forces and the market and community positions of the organizations participating in governance. Organizations could leave the networks and establish competing networks if they become dissatisfied with roles not commensurate with their market and community positions. Market position can be defined by market share and the ease with which services can be replaced. Now, the five partners have dominant market share in their communities, and challenging and replacing many of their services would be difficult. Community position can be defined by the ties an organization has with its community, including the provision of match funds and other resources by local governmental entities, United Way funding, other philanthropic funding, and the extent to which the community looks to the organization to solve its problems. District 8 s five partners have positions within their communities that are reinforced by long term economic support and other ties. Yet market and community positions are dynamic. Organizations may gain and lose market share and gain and lose favor with community institutions. Therefore, stable networks District 8 Network Readiness, Thomas E. Lucking, EDS, August

9 must make an organization s role in governance conditional on its market and community positions and have mechanisms to change governance positions accordingly. Network governance should be treated as a position continually earned by favorable market performance and community ties. If network governance becomes a way to defend market or community position, the network will assure its eventual irrelevance. Relationship of the network to diverse and changing communities Nationwide, some community behavioral-health systems risk becoming disconnected from some service populations, especially when communities undergo rapid demographic changes. Provider-sponsored networks can loosen already weak community ties for two reasons. First, network leaders tend to be long-term staff members and community stakeholders and therefore are unlikely to be representatives of groups that have yet to establish themselves within the power structures of communities. Second, provider-sponsored networks are often reluctant to subcontract services to any providers, including niche providers specializing in culturallyrelevant services. The District 8 network appears to be at risk for such disconnections. The apparent under-utilization of some District 8 mental health services by some ethnic groups is already a concern for policy makers, and some counties within District 8 are undergoing rapid demographic changes. The network founding partners have begun to discuss this issue. Outcomes management Stakeholders expect the outcomes management system to help inform consumer choices, provide accountability information to federal partners and the state legislature, identify best practices, signal importance to clinicians, inform contracting decisions, reinforce consumercentered care, support national accreditation efforts, and inform service improvement efforts. Rather than achieve these worthy objectives, many outcomes management efforts get crushed under the weight of data collection and reporting. Effective systems adopt the principle that less is more when establishing measures, thereby reserving some limited quality-improvement resources for data analysis and improvement. Streamlined outcomes systems also have the advantage of allowing the system s most important values to stand out and communicate their importance as opposed to being lost among dozens and dozens of performance indicators. District 8 s ADM office has introduced the use of the Personal Outcomes Measures, an approach usually associated with developmental-disability service systems. The District 8 ADM Administrator hopes that the use of these measures will help focus provider attention on the service recipient s preferred outcomes. The District is working with NAMI of Collier County so that consumers and family members are taking the time to conduct interviews with a sampling of people receiving services. This approach minimizes the amount of provider resources directed to the outcomes measurement effort. Federal block grant funding is making the transition from block grants to Performance Partnership Grants (PPG. States can be expected to collect required data for core indicators and add other optional indicators. PPG measures will include drug use, criminal justice involvement, and employment, and special attention will be paid to the HIV/AIDS, TB, and homeless populations. District 8 Network Readiness, Thomas E. Lucking, EDS, August

10 Reporting requirements At the consultant s June 9 meeting with provider-network members, the providers expressed concern about the increasing resources absorbed by the billing, authorization, and reporting systems of various purchasers. This concern about increased indirect costs is especially appropriate to bring to bear on a developing network because networks add administrative activity. Apart from the cost of the ASO, which will not be borne by the providers, the clinical and economic advantages of provider sponsored networks come at a cost of indirect management effort. Networks can become sinkholes for additional administrative costs unless all parties take regular action to consolidate and streamline reporting efforts. Utilization of Medicaid resources Florida s community-based providers have used Medicaid resources at comparatively low rates compared to community-based providers in other states. However, Medicaid billings have more than doubled since the consultant s visit in November of At the consultant s June 9 meeting with network provider members, providers attributed statewide problems in using Medicaid funds to a Medicaid Manual not easily applied to intensive community services and low Medicaid rates. The consultant reviewed the manual and concurs that these factors depress the application of Medicaid funds to community-based services. PART IV: RECOMMENDATIONS Continue the successful purchaser-provider network developmental process. The District 8 ADM office and the provider network are making steady and significant progress. The District 8 ADM Administrator s continued use of what is sometimes referred to as relational contracting should continue to produce successful results. DCF statewide training and benchmark sharing for District ADM staff members Behavioral care purchasing that encourages steady improvements while it supports the health and stability of provider organizations is a difficult art. DCF might consider providing best-practices in purchasing training to District ADM staff members and convening cross- District ADM workgroups to share best purchasing practices and experiences. Greater AHCA involvement in the District 8 Pilot Greater AHCA involvement in the District 8 Pilot might help reduce the present barriers to the use of Medicaid resources for community-based services and help prepare for behavioral care networks in other Districts. District 8 Network Readiness, Thomas E. Lucking, EDS, August

11 District wide planning using clinical paths Now that District 8 providers have made gains in the use of best clinical practices within their organizations, the stage is set for the further application of best-practices in District-wide systems of care. A brief review of the origins of clinical paths can help identify their potential benefits in integrating care across providers and systems. Clinical paths were derived from "critical paths," a project management tool first developed by the United States Navy, widely used in industry, and applied to healthcare since the nineteen eighties. Critical paths originated with the Project Evaluation Review Technique (PERT), a method that charts relationships among project tasks over time. PERT charts are diagrams that resemble process charts, with lines, circles, diamonds, and squares illustrating the sequence and interdependence of tasks over time. In the language of PERT, the "critical path" marks the sequence of activities -- the path through the diagram -- with the least amount of slack time and shortest possible sequence of activities. Healthcare organizations have used critical paths (or clinical paths, as they became known in healthcare) to improve the coordination of care, increase efficiency, reduce unfavorable variations, increase quality, contain costs, illustrate the whole process for teams involved in parts of the process, and monitor activities and results. District ADM office can work with local provider networks to develop their own versions of clinical paths, incorporating the process charting and therefore forcing the identification and resolution of care integration problems. Consumer-focused systems of care are best developed bottom-up, with the process charts added to the ASO s clinical paths on a county-by-county basis, according to the needs of specific individuals. Developing the clinical paths county-by-county, according to best practice standards, will encourage the greater cross-provider and cross-system collaboration that distinguishes systems of care from silos of care. These expanded clinical pathways can incorporate specific process steps that describe how individuals in each county, including rural counties, are given systematic access to full continuums of care, including levels of care and specialized care not provided in their counties but instead provided by the network in other counties. (A one hour drive time or less for inpatient care is usually considered adequate access to care.) While District ADM offices can certainly learn from the clinical paths, protocols, and utilization management criteria developed in other states, involving network clinicians in the design of clinical paths could improve the clinical paths and their use. Develop treatment-access process charts to augment clinical paths for priority substanceabuse treatment populations Substance-abuse providers could build on ASAM criteria to design evidenced-based practices 1 and clinical paths for priority populations in each county. Requiring the development of critical paths in each county (as described in the section above) according to the needs of state and federal priority populations could help open continuums of care that people could access from each county. 1 The document 2003 Best Practices developed by the Florida Alcohol and Drug Abuse Association (FADAA) with funding from DCF summarizes sources for evidenced-based practices in substance abuse service delivery. District 8 Network Readiness, Thomas E. Lucking, EDS, August

12 Cross-training among providers and provider specialization Different providers have different areas of clinical excellence. Providers might arrange for cross-training or benchmarking sessions to share their expertise across the network. Also, providers might more frequently specialize in particular services across counties. Networks accept choice of providers and extend provider services region-wide Increasing the choice of providers means one degree or another of loss of market share by long-term providers. However, such a change seems inevitable. Long term providers might accept the inevitable and cushion the change s impact by increasing their delivery of districtwide services as noted in the recommendation above. Develop mechanisms to change network governance The network governance rules should allow for changes in governance as the market and community positions of organizations change. In all cases, retention of service contracts should depend on service performance, not the position on the network s governing body. In no cases should an organization retain governance or services because of its history alone. Regular report streamlining The addition of a provider-sponsored network adds administrative transactions to a highly regulated system. State, district, network, and provider systems might consider regular audits of continued usefulness of reporting and other administrative transactions. They might consider eliminating any reports that are not required by funding bodies and have not informed decisions within the past two years. In addition, these different systems levels can also regularly consider consolidating or using complimentary reporting requirements from other systems. The network can take a step in this direction by relying on the Performance Partnership Grant (PPG) required measures as the outcomes for substance abuse. Monitor the position of the network and the ethnic communities it serves Like service systems in many regions that are undergoing rapid demographic changes, the District 8 network must connect with the changing communities it serves. The network could address this challenge by monitoring service utilization by major demographic groups and ensuring that services are sensitive to the needs of these groups. When its usual providers cannot provide effective services, it should consider subcontracting with niche providers capable of meeting the needs of otherwise underserved groups. The network should also require that member organizations maintain strong ties to various communities through their boards and advisory groups. Approach the capitation of non-medicaid public funds with great caution, if at all State policy makers will have the option of introducing risk contracting for state and block grant behavioral health funding. Although no such plan now exists for District 8, in District 8 Network Readiness, Thomas E. Lucking, EDS, August

13 considering this option statewide, state policy makers might consider that developing prepaid Medicaid contracts is easy and straightforward when compared to doing the same for state and federal grant funds. The Medicaid population is easy to define and quantify both statewide and by region. Medicaid eligibility is easily verified most of the time, and statewide Medicaid benefits can be defined and changed. However, defining and verifying eligible populations for DCF-funded services is far more difficult. More significantly, the incentives inherent in prepaid plans may impede the goals of DCF to provide evidenced-based care to the substance-abuse treatment system s priority populations. The priority groups tend to need longer term, intensive services, but prepaid plans are given an incentive to provide brief, low-intensity care. Also, many people with substance-abuses disorders tend to minimize the scope and extent of their substance-abuse problems and underestimate the intensity and duration of treatment that they might need. Their tendency to deny the full extent of their service needs eliminates a needed counterweight to a prepaid plan s incentive to minimize or deny care. The consultant observed a situation in which state and federal mental health and substance-abuse treatment grant dollars were combined with Medicaid dollars in a prepaid plan that required ASAM criteria. The plan did not often authorize care as lengthy and intensive as the ASAM criteria indicated. Providers rarely appealed to maintain good relationships with the gatekeepers, and the people receiving the shorter and lesser intensive care did not always recognize their need for more treatment. District 8 Network Readiness, Thomas E. Lucking, EDS, August