Shifting the Culture of Substance Abuse Recovery

Substance abuse disorder treatment has come a long way and has gone through a great deal of evolution in recent decades. Heartland House has continually worked hard to adapt to this dynamic environment.

In this article we cover how two important acts of the last decade have helped us shift our approach to substance use disorder treatment as an element of mainstream healthcare, what that looks like in California, and how we at Heartland House have adapted and molded our team and practices to evolve into a person-centered, non-time bound recovery treatment program.

Healthcare & SUD Shift

Two important healthcare policy shifts in recent years have shaped our planning and actions.

Federal Policy Shift

Federal legislation has opened the way for easier access to treatment, as outlined in this excerpt from the Surgeon General’s Report on Alcohol, Drugs, and Health:

“…The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) requires the financial requirements and treatment limitations imposed by most health plans and insurers for substance use disorders be no more restrictive than the financial requirements and treatment limitations they impose for medical and surgical conditions.

Further, the Affordable Care Act, passed in 2010, requires that non-grandfathered health care plans offered in the individual and small group markets both inside and outside insurance exchanges provide coverage for a comprehensive list of 10 categories of items and services, known as “essential health benefits.” One of these essential health benefit categories is mental health and substance use disorder services, including behavioral health treatment. This requirement represents a significant change in the way many health insurers respond to these disorders. The Affordable Care Act also reaffirmed MHPAEA by requiring that mental health and substance use disorder benefits covered by plans offered through the exchanges be offered consistent with the parity requirements under MHPAEA.”

These federal acts have begun shifting the cultural views of substance abuse disorder treatment by providing the same considerations for treatment as are provided through mainstream healthcare services. Although Heartland House has a number of bureaucratic requirements to do so, we will soon be able to accept Medicaid and Medi-Cal.

State of California Policy Shift

The State of California implemented Section 1115(a) Medicaid Waiver Renewal, entitled the Medi-Cal 2020 waiver, which conveys broad authority to allow experimental, pilot, or demonstration projects “likely to assist in promoting the objectives of [the Medicaid statutes].”

Heartland House applied for this waiver in order to be a part of the paradigm shift in Substance Use Disorder in California because certain contractual obligations require a specific number of treatment days. Heartland House is now the first treatment program, in San Diego County, to implement a non-time bound, multidimensional assessment of an individual client’s program.

Getting the Team Onboard

This new and exciting incubator project required a number of changes on our part to our staff preparation and our approach to treating clients:

Staff Preparation

We obtained copies of the American Society of Addiction Medicine (ASAM) text and conducted training and webinars for our staff on the ASAM criteria, a multidimensional, comprehensive set of guidelines for risk assessment with placement and continuing care.

Client Approach

When developing recovery goals with our clients, we follow the SMART formula, meaning that client goals are to be Specific, Measurable, Attainable, Relevant and Time-limited. Our clients work through “The Change Companies Interactive Journal” and develop a change plan. In surveying client goals, we realized that we needed to reconcile the “Time-limited” criteria for goals with the practice of a non-time bound program.

Ultimately we concluded that by partnering with our clients using Motivational Interviewing and Enhancement Techniques an equality occurs that lead to a team or partnering approach and enrich the experience supporting their change plan goals. We could partner with our clients to make life goals that can be near, mid, and long-term, such as getting their GED, a job, or an apartment by a certain date, all while continuing to work, without time bounds, toward their recovery.

In January of 2016, we were noted for having a 90 – 120-day program. This was true after extensive internal training, embracing the ASAM multidimensional model of change. We realized that we continued to “rubber stamp” each client with a time-bound program. We were not being person-centered, after all, what if one client’s change plan was accomplished in less than 90 days? What if they need 366 days? Really what we were saying to each man was “well, this is our program, if it doesn’t fit come back when you’re ready,” as if we could determine their course.

Obviously, this construct was not supportive of our “meeting a person where they are” and had many implications “contractually” with the elimination of being time-bound. In July of 2016, we officially eliminated all time-bound lengths in our program descriptions.

Culture Shift

In implementing these new approaches, we saw an opportunity to shift the culture at Heartland House in terms of how we talk about substance abuse disorder. Semantics are important. We no longer use the word “relapse” but have shifted to “recurrence.” We took out of our policy and procedures the term, “zero-tolerance.” If clients have a recurrence, we explore the triggers that led to a recurrence and allow the client to identify solutions available to them supporting their belief and immediately re-introduce them to the program where they share this new found information in group sessions. The client returns to the group to share where they are physically, mentally and spiritually, and why they believe they had a setback on their journey.

We don’t penalize our clients for a recurrence. We partner with them, helping them assess and implement relapse prevention techniques.

Looking Ahead

In assessing our services, we discovered in the past that in assessing our services, we discovered in the past that the hierarchical structure within our organization was a barrier to taking the actions needed to shift our paradigm without losing our identity. It was challenging, however, to find, an alternative structure in use within the healthcare profession. After reviewing various possibilities we decided upon a horizontal structure. Other than in the case of regulatory matters, each staff member from the relief cook to the licensed professional has independent discretion in matters affecting their area of responsibility. While this model can pose an entirely new set of challenges, we are experiencing the greater good made possible by establishing an environment that better inspires each staff members passion and, as a result, adds to the strength of our team and program.