For the large and nationally prominent nonprofit treatment organization Phoenix House, preparing for change in the healthcare marketplace involves a number of careful balancing acts. The effort requires prioritizing evidence-based practices without discarding other historically useful interventions; demanding a more clinically qualified workforce while also establishing a track for recovery support specialists; and becoming capable of operating less-restrictive levels of care while maintaining a foundation in residential treatment.

The changes in an organization that now operates in six regions of the country have been unfolding for years: It might surprise some to know that only 29 percent of Phoenix House’s programs (covering 38 percent of its clients) employ a residential therapeutic community (TC) model. But the changes have taken on a sharper focus in the past two years with the arrival of senior vice president and chief clinical officer Deni Carise, Ph.D., who was hired to broaden Phoenix House’s clinical mission and to formalize an evidence-based approach to treatment.

The breadth of Phoenix House’s mission is evident in the first sentence of the organization’s clinical three-year plan, a detailed working document that is updated annually: “The Three-Year Plan for clinical services is designed to put Phoenix House well on the path of being a thriving, sought-after leader in behavioral health, primarily in the substance abuse field, but also in the mental health field.”

Incorporated into the plan are seven specific activities that are being conducted to prepare for healthcare reform. While increasing use of evidence-based practices is one of the seven, the work plan also includes infrastructure activities such as fully executing an electronic health record (EHR) system and transitioning large residential programs into more comprehensive service sites.

Phoenix House

Founded: 1967

Regional operations: New England, New York, Mid-Atlantic, Florida, California, Texas

Employees: More than 1,600

Clients served: 16,000 a year in adult and adolescent programs

Payer mix: More than one-quarter insurance and self-pay, with the rest public funding

“I wrote a three-year plan to get 123 programs serving 6,000 people a day ready for healthcare reform,” Carise told ADAW. “It’s an incredibly exciting and new time for treatment centers, but there are incredible challenges.”

Clinical competencies

Over the past year, Phoenix House has worked to take closer inventory of its multiple sites’ commonly used clinical practices and then to broaden its staff’s ability to offer the most clinically effective of these interventions. Carise said that the organization selected the top 20 services that its sites were delivering, from the Seeking Safety curriculum to Dialectical Behavior Therapy (DBT) to contingency management, and found that 16 of the 20 are classified as evidence-based practices.

Phoenix House then went about creating toolkits for each of the practices in order to enhance staff members’ ability to deliver the interventions. The toolkits summarize the goals of each practice, the ways to evaluate success using each, and the training available in each discipline. Employees who receive training are quizzed on their content knowledge, and clinical supervisors are given checklists of what to look for when counselors apply the knowledge in their everyday work with clients, Carise said.

The organization has instituted several quantitative goals in clinical practice. For example, all staff members in residential or outpatient programs are expected to pass a test on at least three of the commonly used clinical practices. Also, there are rules in everyday operations, such as that every program with at least seven women enrolled must include a women’s group as part of treatment. But Carise emphasizes that Phoenix House administrators avoid telling individual programs or clinicians which particular curriculum to employ in treatment.

“I want to give them as much choice as possible; I don’t want to go around telling them what to use,” she said.

And the formalizing of an evidence-based approach has not left behind all previously used interventions that have not reached the evidence-based standard. For example, Phoenix House still is using a homegrown curriculum in “emotional cartography” (involving the identification and mapping of emotions) that has proven extremely popular with clinicians and clients.

“People love doing it, and my thought was that taking that away was unnecessary,” Carise said.

Also part of the clinical improvement process at Phoenix House is the design and piloting of a performance monitoring system applicable across its locations in New England, New York, the Mid-Atlantic region, Florida, Texas and California. Examples of current performance targets in the system include 80 percent of residential treatment clients receiving at least one evidence-based practice per day; supervisors using the checklists based on the clinical toolkit information at least 80 percent of the time when supervising counselors; and intake/assessment appointments being scheduled at least 80 percent of the time within two weeks of the first call.

Much of the performance measurement effort is tied to an organization-wide implementation of an EHR system from Welligent. Carise said the system has been fully implemented in New England, Florida, Texas and California program sites, with New York and the Mid-Atlantic region scheduled to be on board by next April.

Preparing for reform

Two critical areas that Phoenix House is prioritizing in preparing for healthcare reform are improving the overall qualifications of its workforce and progressing toward a more balanced approach to care that does not rely heavily on long-term residential stays.

Phoenix House’s workforce plan makes a clear distinction between the qualifications of clinical services professionals and those of recovery support specialists, with important roles for each in the organization’s growth. Carise said the organization is encouraging more of its staff to pursue advanced degrees, using inducements such as tuition reimbursement and planned salary increases based on level of education attained.

Besides the intensive clinical training occurring through use of the various toolkits, clinical staff also is receiving structured training in the implementation of the EHR. The process involves one week of clinical training, one week of education on the Welligent system, one week of entering the clinician’s clients into the system, and one week mirroring the “go live” scenario to come, Carise said.

Carise said Phoenix House already is shifting its approach to treatment stays significantly in response to concerns about the viability of residential care under health reform. “We have always said that clients need a minimum of 90 days in treatment, and I stand by that,” she said. “But it doesn’t all have to be in residential care.”

One area of focus has involved changing what a Phoenix House client’s first 30 days in treatment looks like. When the expectation was that a typical client would remain in treatment for several months, clients were acclimated to treatment fairly deliberately, but that approach doesn’t work in today’s times, Carise said.

With about one-quarter of Phoenix House clients leaving within the first 30 days of treatment (some against medical advice), programs now attempt to engage clients early in relapse prevention strategies and other critical information. “We try to make sure they get their immediate needs met, such as education about their illness, and medical and psychiatric stability,” Carise said.

Phoenix House clearly is growing well beyond the confines of the traditional TC approach. Carise said the organization has introduced buprenorphine treatment into its operation, soon will be ushering in use of the injectable form of naltrexone, and is operating medical and dental clinic sites in New York.

The three-year plan clearly states that the organization cannot wait to see whether residential treatment benefits will be preserved or will cease to exist in the next couple of years. The plan states that “we should react proactively by assessing the ability to transition our larger residential programs to more comprehensive service sites that might include a community residence/sober-living wing, intensive and traditional outpatient services floors, etc.,” which “may enable us to keep these sites active if residential funding is scarce.”