Paul Jaquith, Director f Broward Addiction Recovery Center (BARC)

NARD COUNTY HUMAN SERVICES DEPARTMENT BROWARD ADDICTION RECOVERY CENTER (BARC) DIVISION - ADMINISTRATION 115 S. Andrews Avenue, Room 318 Fort Lauderdale, Florida 33301 954-357-5444 FAX 954-357-5468 To: Thru: Thru: From: Dated: SUBJECT: Board of County Commissioners /a Bertha Henry, Interim County A Marlene A. Wi Human Servic Paul Jaquith, Director f Broward Addiction Recovery Center (BARC) May 14,2008 t Response to the Office of the County Auditor Performance Report No. 08-1 1 dated April 15,2008 of the Broward Addiction Recovery Division (BARC) The Broward Addiction Recovery Division (BARC) has reviewed Report No. 08-1 1, from the County Auditor's Office dated April 15, 2008. This Memo serves as the Division's response to the Auditor's recommendations resulting from the Performance Review. The Auditor's report reveals operational challenges which need to be addressed. The Broward Addiction Recovery Center (BARC) has been in operation for over 35 years providing Substance Abuse Treatment services primarily to the medically indigent, homeless population within Broward County. Broward County is unique in that it is one of a handful of counties throughout the State that provides substance abuse services and stands alone in the level and intensity of services provided to those individuals with a substance abuse addiction who have been unable to help themselves. National research reported by the Substance Abuse and Mental Health Services Administration (SAMHSA) indicates that the rate of illicit drug dependence in Broward County is greater then the rates of dependence in Palm Beach and Miami-DadelMonroe and that Broward has one of the highest rates of cocaine use in the state of Florida. However, it also shows that Broward County has greater access to treatment for illicit drug use than DuvallJacksonville, Pinellas, Hillsborough and Orange Counties. In other words, people in other counties who need treatment have difficulty obtaining treatment services. The - Recipient of NationalAa$M&tion Through The Joint Commission Broward County @~acf D'f Co~nty Commissioners Josephus Eggelletion, Jr. Sue Gunzburger. Kristin D. Jacobs. Ken.KseoM* Ilene tiebmlpxna Sb~xm@T*John E. Rodstrom, Jr. - Diana Wasserman-Rubin. Lois Wexler w. browdr&gj

of 10 SAMHSA report also points out that there is a high degree of variation among counties statewide in funds expended for substance abuse treatment. The Performance Audit report questions the cost of services provided by BARC in comparison to other counties and points out the need for the Division to more efficiently provide services and decrease costs. The Division is committed to more cost efficient methods of delivering services and has proposed a realignment of admission and outpatient services in the FY 2009 budget that will reduce costs. The Division will improve business performance so that the high quality of substance abuse treatment services currently delivered to county residents is complemented by an efficient administrative organization. Recommendation 1(Page 15): Establish criteria defining the appropriate relationship between client service fees and BARC s actual cost of providing services by September 30, 2008. 1. Agree. The criteria for defining client service fees was established based upon the Florida Department of Children and Families (DCF) rates and a market survey of other providers within the community. BARC has historically served the homeless and medically indigent in the community so the Division s Published Fee Schedule includes a sliding fee scale based on National Poverty Guidelines. The Published Fee Schedule (maximum fee to be charged per service), reflects the most that the Division would charge a payer. The Division will be adjusting its fees as necessary to more accurately reflect the costs of services while keeping fees in line with local standards, Medicaid billing, and established DCF rates. The sliding fee portion must also continue to account for the fact that the Division serves a large number of homeless and indigent clients. Currently, BARC s caseload is comprised of 30% homeless individuals. This is significantly higher than the state average of 5%. However, the Division will continue to bill those clients who initially present as indigent but through their course of treatment and the recovery process and attain the ability to pay for services provided. By keeping these clients in the billing system, the Division can maximize the collections it receives from clients who eventually gain the ability to pay. The Division has always ensured that clients help pay for the cost of their treatment. Payment encourages personal responsibility and commitment to treatment leading to more positive outcomes. Due to the transient nature of the clients served by BARC the recovery of fees is unpredictable.

of 10 Recommendation 1 (Page 15): Develop unit cost data for both individual and group outpatient treatment to ensure client service fees for these services are appropriate; any proposed client service fee changes should be submitted to the Board of County Commissioners for approval by September 30, 2008 Agree. BARC is reviewing its calculations of unit cost data for both individual and group outpatient treatment in response to the most recent budget figures. BARC has been collecting and analyzing unit cost data by cost centers each year, in accordance with DCF standards established for unit cost measurement throughout the state. All providers surveyed by the Division utilize the DCF format for calculating their unit costs. During the audit, the Division provided the cost per unit for the prior fiscal year. BARC will be reviewing these costs and adjusting the maximum to reflect the actual costs. Any required adjustments in the fee schedule will be presented to the Board for review and approval. Recommendation 2 (Page 17): Discontinue the use of time-consuming manual data collection, where possible, by developing reports within ECHO that will allow supervisors to efficiently and effectively monitor staff productivity and client outcomes by September 30, 2008. Agree. The Division agrees that manual collection of data is time consuming and has discontinued this practice. The Division has an electronic data collection system (ECHO). The ECHO software system has the ability to provide the reports necessary to assist supervisors and administrators to monitor staff productivity, client outcomes, and service delivery. The Division is working with staff to utilize the ECHO system more effectively. Currently, the following reports are available to staff within the ECHO System: Case Tracking, Census Report, Cost Center Activity, Client Listing, Enrollment Detail, Episodes and Client Data, Length of Stay, Staff Schedule Activity Logs, Full Claim on Inquiry, Summary Claim on Inquiry, and Aged Receivables. Additional reports will be developed as staff identifies the need identifies the need, and these reports will be funded through the Drug Abuse Trust Fund.

of 10 Recommendation 3 (page 20): Identify appropriate peer agencies (or industry standards) that can be used as reasonable benchmarks of BARC s performance in future evaluations. Agree. The Division agrees with the recommendation and has engaged in extensive efforts to identify private and public peer agencies. The research revealed that there were no local public or non-profit agencies delivering a similar complement of services at the same level of intensity as BARC for comparison purposes. Private providers such as Transitions, Hanley, Holistic (Miami-Dade), and The Village, charge between $7,000 and $25,000 for a month of residential treatment. The cost of detox treatment in Broward, Palm Beach, and Miami-Dade ranges from $550 to $750 per day for treatment. These numbers highlight the cost of treatment to the client and the market value of substance abuse treatment. Services to the homeless and medically indigent in Broward County are limited to 16 publicly funded residential treatment beds, other than those beds provided by BARC. Memorial Hospital is the only other provider of detox for indigent clients, with 12 beds, for persons who reside within their hospital taxing district. Recommendation 3 (page 20): Identify appropriate performance measures to benchmark, including service cost and staff productivity comparisons. Agree. In the past, the Division has surveyed other providers in order to compare and benchmark performance. The Division has contacted 23 publicly funded substance abuse providers throughout Florida in order to obtain benchmarking information regarding levels of service, staffing, and budgeted costs. Research conducted among other agencies has yielded little information on appropriate benchmarking data. The Division also contacted the South Florida Provider Coalition (SFPC) which is the managing entity for 28 substance abuse agencies for DCF in Miami-Dade for benchmarking data. Only the benchmarking data provided to DCF is available, however this data is aggregated for all 28 agencies, and does not indicate staffing or budgeted costs. As noted by the auditor in their attempts to find comparisons, they also experienced difficulty due to the limited number of service providers. The Division will continue to research and survey to identify other providers who provide treatment programs of the same intensity, and who work with special populations, such as those individuals with mental illness, pregnant or post-partum women, and mature adults.

of 10 Recommendation 3 (page 20): Report the results of Division s initial benchmarking analysis to Board of County Commissioners by September 30, 2008. Agree. The Division will continue its efforts to identify agencies for benchmarking analysis. Recommendation 4 (Page 25): Develop data reliability controls, such as written measure definitions and supervisory review, to ensure that accurate client count data is reported to the OMB as part of the County s performance measurement and reporting system. Disagree. Division staff identified data reliability control issues previously and determined the definitions to be used to track performance measures. The data was corrected immediately and accurate client counts are reflected in the ECHO system. Quality Assurance has been assigned the task of reviewing and reporting the data from ECHO and communicating this information to supervisors to ensure that information is reported in a consistent and accurate format to OMB. Recommendation 4 (Page 25): Ensure the use of reliable unit cost data in future service cost comparisons submitted during budget development process. Agree. The Division has reliable unit cost data as referenced by the auditor on page 23 of the report. Following the submission of the FY08 budget, the Division carefully reviewed the process utilized to compute its unit cost data. While inaccurate data was inadvertently submitted as part of last year s budget process this has been corrected. The Division submits reports to the DCF on an annual basis which includes Personnel Detail, Projected Cost Center Operating and Capital Budget, and Agency Capacity Report as part of the contract requirements. The Division will continue to calculate costs based on actual revenue/expenditure as well as using the State formula.

of 10 Recommendation 4 (Page 25): Work with DCF to ensure that complete and accurate performance data is reported as contractually required. Agree. The Division continues to work closely with DCF on the issue of data collection reliability of the State s One Family reporting system. Training has been developed for staff on issues such as appropriate coding and discharge data. A thorough analysis of the upload of data to the One Family system is underway in conjunction with DCF. Procedures that will improve the acceptance and reliability of data being reported to One Family have been implemented. Recommendation 4 (Page 25): Standardize employee productivity reporting for outpatient services to ensure the accuracy and comparability of data across units. Disagree. The collection of employee productivity data that was previously collected and tracked manually is currently available and tracked through the computerized client information system. The Division has standardized the process and is ensuring that all services which reflect employee productivity are accurate and comparable across units. Recommendation 5 (Page 26): Develop a list of additional performance measures that are critical for monitoring program accountability and effectiveness by September 30, 2008. Agree. BARC does have performance measures that are tracked such as staff productivity. The Division will work to develop additional measures. New measures introduced include tracking the number of clients who leave treatment against medical advice (AMA), tracking readmission rates, and comparing global assessment of functioning (GAF) scores of clients at admission and discharge.

of 10 Additionally, BARC is currently reviewing data published by the SAMHSA noted as National Outcome Measures to obtain additional measures which will support best practice. Recommendation 5 (Page 26): Develop reports within ECHO that will allow supervisors to access new performance measures by September 30, 2008. Agree. Currently, the following reports are available to supervisors within the ECHO System: Case Tracking, Census Report, Cost Center Activity, Client Listing, Enrollment Detail, Episodes and Client Data, Length of Stay, and Staff Schedule Activity Logs as well as fiscal reports. The Division will utilize the Drug Abuse Trust fund to develop additional reports as needed by supervisors. Recommendation 6 (page 33): Provide detailed explanation of the need for a new facility by September 30, 2008; defer further action on the new facility until an evaluation of facility utilization and costs is made that justifies the capital investment and increased operating costs of the proposed new facility and expansion of the detoxification program. Disagree. In 2002, the recommendation to pursue a new facility was based on the physical condition of the existing facility as well as the need to increase future capacity. If the policy of the County Commission is to continue to provide substance abuse services, a new facility is needed. BARC s central detox facility is over 55 years old, and had major deterioration issues and cannot be brought up to code without a major renovation, which is not permitted by the city. The Auditor s recommendation to defer action on the new facility is premised on an incorrect determination of the utilization rate for detox beds. The total number of detox beds in the current facility is 34 not 35. Under an agreement with the DCF, BARC is designated as the Marchman Act (court ordered clients) receiving Facility for Broward County. Therefore, BARC sets aside 2 beds for Marchman Act Court referrals. This requirement must be factored into any analysis of utilization. The auditor cites a national average of 91% utilization for residential and detox substance abuse in The National Survey of Substance Abuse Treatment Services (N-SSATS).

of 10 Actually, the report states that 60% of agencies surveyed presented with a residential utilization rate of 91%, and 40% had utilization rates under 90% for residential services only. There was no data available for detox averages. However, DCF established a statewide standard for detox\residential service utilization of 85%. This is the more appropriate standard to use as it is a statewide comparable standard. BARC s 80% utilization rate closely approximates the state standard, and the rate is variable when the two beds designated for Marchman Act are factored in. Clients served by BARC have high rates of mental illness, medical issues, and social problems that require specialized interventions and skilled staff. Staffing ratios also impact bed occupancy and must be carefully monitored to minimize risk and ensure the safety of both clients and staff. In 2007, 5,386 individuals were triaged for detox services and 3,827 were not admitted. The need for a new facility is crucial to address the needs for substance abuse treatment. A new facility will allow for growth. It can be staffed and operated to meet demand, as demand fluctuates, and as available funds permit. Recommendation 7 (page 38): To reduce the cost of providing substance abuse treatment services, we recommend that the Board of County Commissioners direct the County Administrator to take the following actions: Conduct further comparative analysis with similar detoxification and residential programs, including Miami-Dade County s residential program, to analyze service cost, bed utilization, staffing ratios/composition and develop a plan to reduce treatment costs in accordance with results; report the results of this analysis to the Board of County Commissioners by September 30, 2008 Agree. The Division expects unit costs to decrease as services are realigned and will further investigate additional cost cutting measures. The Division will research appropriate comparable programs to analyze service cost, bed utilization, and staffing ratios/composition. However, the Division does not concur with the reference to Miami-Dade County s residential program as an appropriate comparison. There are significant differences in the standards of care that make it difficult to compare staffing and costs of the two agencies. The Report correctly notes that BARC staff expressed concern that the article Economic Benefits of Drug Treatment: A Critical Review of the Evidence for Policy Makers should not be used as a reference in determining costs and in determining appropriate levels of utilization. However, this concern was not based merely on the belief that BARC s Level 2 residential program provides a

of 10 higher level of service, more importantly, it is based on the article s own assertion that it is not representative of national data and should not be relied upon in making policy decisions. The national average costs for residential treatment as $103 per day, and for detox as $250 per day was extrapolated from this article. In a review of the article, the authors note that only 4 out of 47 studies reviewed were of high design quality, which impacts data validity and reliability. In addition, the authors state that the information presented was not normalized for geographical differences in cost of living and for treatment of special populations. Therefore, it cannot be used for comparison purposes as a national average. It especially cannot be used as a comparison cost model for BARC services, as BARC treats a large percentage of persons with co-occurring disorders and other specialized population in a community with extremely high costs for daily living According to the National Institute for Drug Abuse (NIDA), there are no national averages that accurately measure the cost of substance abuse treatment. NIDA also indicates that currently available cost studies are not fully guided by sound economic theory. Recommendation 8 (page 41): Determine the potential effects of implementing various delivery models used in other large Florida counties, such as contracting with community providers for the provision of treatment services, providing less intensive residential treatment to clients and not funding the existing level of treatment service; this analysis should include, at a minimum, a comparison of service costs and quality (effectiveness); provide the results of this analysis to the Board of County Commissioners within 60 days of the adoption of this recommendation. Agree. The Division understands that the services provided by BARC are a matter of Board policy decision. BARC has over the past thirty-five years had a major impact in alleviating the financial impact of substance abuse upon tax-assisted hospitals and the criminal justice system. Currently, there are only 12 publicly funded Detox beds and 16 publicly funded Residential Level II beds, aside from those provided by BARC. Staff will prepare a report analyzing service costs and quality as well as the appropriate levels of treatment service. Recommendation 9: (page 43): Determine the additional revenue that could be generated by participating in Medicaid reimbursement programs, such as the Local Match initiative, and develop an action plan by September 30, 2008 to ensure Medicaid revenues are maximized each fiscal year.

of 10 Agree. As recommended, Broward County is now one of 29 Florida counties that have agreed to participate in the new Medicaid Local Match Initiative, which was developed in response to traditionally low substance abuse Medicaid draw-downs throughout the State. Broward is in a unique position as a direct provider of substance abuse treatment to be reimbursed for its services. By contrast, counties providing services by outsourcing will have increased costs as a result of their required agreement to match funds. The Medicaid Local Match Initiative is a new program so the Division is presently unable to accurately predict the additional revenue which might be generated. As part of the Division s current plan, efforts will be made to increase Medicaid billing. The anticipated revenue amount through participation in the Medicaid reimbursement programs and the Local Match Initiative will be calculated and tracked to insure that Medicaid revenues are maximized. Recommendation 10 (page 44): Implement a corrective action plan to increase the collection rate of client service fees by September 30, 2008. Agree. The Division is already in the process of increasing the collection rate of client service fees. Some of the actions being implemented are: Posting new signs referencing fees for all units of service Including references to fees in a new brochure to be given to all clients Establishing a requirement for proof of income upon admission Providing comprehensive training and a script to staff, particularly at Admissions, to ask probing questions to obtain accurate information about client living situations, employment status, and income Requiring clinical staff to discuss the payment of BARC fees as part of any living skills groups cc: Evan Lukic, County Auditor Pam Madison, Assistant County Administrator Pete Corwin, Assistant to the County Administrator