From a medical model perspective, a Center of Excellence (COE) is defined as an organization that demonstrates leadership and the highest clinical quality in a field of specialized treatment. This definition by nature includes not only leadership but also demonstrated best practices, progressive treatment modalities, a solid infrastructure, utilization of a personalized team approach that includes both the patient and family, staff development, and academic research that generates outcomes guiding not only best treatment practices but also measures quality. Increasing the quality of addiction treatment is now more critical than ever. At present, the addiction treatment industry is fragmented with no consistent operating principles or regulatory requirements. Some states require no regulation, which leaves treatment centers unaccountable for the services they provide. In addition, the industry is seeing an upswing in for-profit centers that offer exclusive, spa-like environments that “guarantee” success, but offer little in the way of evidence-based treatment or demonstrated outcomes.
Two leading non-profit organizations, Caron Treatment Centers and the Hazelden Betty Ford Foundation, co-authored this article to outline criteria necessary for an addiction treatment provider to qualify as a Center of Excellence. We hope this begins a national dialogue around this important issue and leads to further action in establishing a clearinghouse to identify the industry’s centers of excellence.
Key Attributes of a COE in Addiction Treatment
Determining the characteristics of a COE requires identification of the minimum standards necessary to deliver outstanding quality of care. In other words, an obvious starting point is to define the characteristics and practices that are minimally required in order for a provider to demonstrate it is delivering adequate services. This section of the paper will list and describe each of these criteria.
Accreditation. The first essential characteristic is receiving and maintaining accreditation from external regulatory organizations, such as the Joint Commission (JCAHO) or the Commission on Accreditation of Rehabilitation Facilities (CARF). It is also important to maintain a state license and meet the expectations at the highest standard of care. Hazelden Betty Ford and Caron are accredited and licensed facilities. Surprisingly, many addiction treatment providers throughout the United States have not received accreditation, and there is no mandate in the field requiring providers to have accreditation in order to operate. Because accrediting agencies are vital in establishing rigorous standards for quality of care, organizational performance, and evaluating whether providers meet these standards, accreditation should be a “minimum requirement” of any organization offering addiction treatment.
Qualified Clinicians. Well-trained and credentialed clinicians are critical to providing quality care. COEs hire and retain clinicians with the appropriate degrees and licenses, such as addiction medicine physicians, doctoral-level psychologists, and licensed or certified addiction counselors. As the field of addictions counseling has increased in complexity and sophistication over the past decades, so too have the licensing and certification requirements across the United States. At present, few states will license counselors at the associate’s level. COEs hire addictions counselors that have, at a minimum, a baccalaureate degree from an accredited institution with a preference for those prepared at the master’s level. COEs also implement clinical training programs that keep clinicians up to date in their fields and continuously advance their clinical skills.
Technology and Data Systems. COEs use state-of-the-art tools for conducting all aspects of business, including clinical operations. These include a well-designed, integrated electronic health record that allows information to be shared across all stakeholders, including direct providers of care. Organizations should have solid Information Technology (IT) platforms, case management systems and other data systems that facilitate care and allow quick and seamless communication among staff and stakeholders. It is also important for these platforms to provide accurate and reliable data that can be used for benchmarking and quality performance assessment. Advances in technology have led to its use during treatment. Both Caron and Hazelden Betty Ford utilize technology as part of their treatment. At Caron, the IT team worked with the clinical team to develop a program called Passport. This program is electronic and allows the patients to interface with their patient-centered treatment plan, track progress, keep their treatment homework, work on their treatment work digitally, interface with their addictions counselor when not in group or individual sessions, and be part of a peer community. At Hazelden Betty Ford, the My Ongoing Recovery Experience (MORE) web-based program helps discharged patients track their recovery process, interact with recovery coaches, and participate in a peer community of support.
Evidence-Based Treatment. Clinical services offered to patients should be “evidence-based,” serve as “practice-based evidence” and/or be rooted in research and aimed at establishing new innovations in practice. In addition, the treatment provider should have a hard-wired process for routinely reviewing the ongoing research literature and exploring ways to incorporate new practices and methods as the evidence base for these develops. Hazelden Betty Ford and Caron both have robust training programs and affiliations with leading universities to ensure employees are knowledgeable and trained in current trends in the industry, age and gender specific treatment issues, along with recognized evidenced-based practices such as Motivational Interviewing and Dialectical Behavioral Therapy.
Care for Co-Occurring Disorders. It is well known that the majority of individuals with a substance use disorder also have a co-occurring mental health condition or other co-existing addiction. An addiction treatment provider should therefore offer formal treatment for these co-occurring disorders (in addition to treatment for the substance addiction) and do so using evidence-based practices. To ensure proper treatment of co-occurring disorders, addiction treatment providers should have medical or psychiatric staff available to treat the presenting co-occurring disorder and clinical staff trained in the treatment of these disorders. An integrated approach to treatment is the best practice. At Caron and Hazelden Betty Ford, there is a comprehensive behavioral health team bolstered by full-time medical, psychiatry and psychology staff.
Performance Measurement Systems. Another area vital to a COE is performance measurement. Increasingly, substance use treatment centers are being called to task to provide measurable outcomes demonstrating the success of their programs. At the industry level, addiction treatment centers are facing a rapidly expanding competitive environment and increasing pressure from government and health care insurance industries to show demonstrated success. Individuals seeking treatment are also becoming progressively savvy in their search for a treatment center that will give them the best possible outcome. A COE should have formalized, proven methods for measuring several aspects of organizational performance, including patient outcomes.
While there appears to be field-wide acknowledgement that such measurement is important, addiction practitioners and scholars have yet to agree on the precise metrics that should be collected and reported within the addiction treatment field. If outcomes are collected at all, most treatment centers rely solely on patient self-reporting without methods and structures in place to reduce bias and demand characteristics. Centers of Excellence have robust measures, which include reports from families, information from other professionals and science-based, physical measures, such as urine drug screens in addition to self-reports. This is an area where both organizations have been pioneers. For decades, Hazelden Betty Ford and Caron have collected patient self report, but recognized the limitations of distal-outcomes measurement and designed programs to manage and monitor patients during treatment and after discharge for a year or more. It is not uncommon to find providers with little to no evidence of measuring patient outcomes or organizational performance as it relates to the quality of services provided. Centers of excellence pave the way toward standard outcome measures for the addiction treatment field, so that one day all programs can be compared based on the same measures – a development strongly urged and supported by both Caron and the Hazelden Betty Ford Foundation.
Commitment to Quality and Process Improvement. A first-class treatment provider must engage in quality and process improvement, and have reliable, valid measurement systems to track improvement efforts and demonstrate quality of care. After much-needed industry-wide consensus around measurement has been reached, a COE would lead this effort and encourage peers to adopt and share metrics results. In this way, national benchmarking can occur, which is currently lacking in addiction treatment but vital in terms of demonstrating accountability for care quality. A few examples of benchmarking criteria include satisfaction rates, average length of treatment, successful treatment completion, abstinence rates, re-engagement rates, and integration of family into treatment.
At a minimum, a COE needs to participate in national benchmarking efforts and help drive adoption and compliance with such activities throughout the field. Both Caron and Hazelden Betty Ford participate in a national benchmarking group where they are measured against other treatment centers. Both have also agreed to participate in a first of its kind pilot study through NAATP (National Association of Addiction Treatment Programs) which has the goal of setting the standard of practice for collecting outcomes.
There should also be transparency in sharing information regarding the quality of care and outcomes, and educating the consumer about services and expected results. It is important for this information to be valid, so the use of outside agencies to evaluate the data is essential. Both Hazelden Betty Ford and Caron collaborate with leading university-based researchers in the field to create measurement systems, analyze data, and publish them in peer-reviewed research journals. Data should be displayed in a forthright, appropriate way so they are not misinterpreted.
Full Continuum of Care. Regarding service offerings, a COE must offer a full continuum of care that provides a complete range of services that offer the patient an array of treatment opportunities based on acuity level and need. These services span a wide range of areas, including prevention and education, formal treatment and management of addiction issues, and post-treatment services, tools and resources that support ongoing recovery. Caron and Hazelden Betty Ford believe that not all of these levels of care need to be offered by a single addiction treatment provider. Rather, some services can be offered through strategic affiliations with other providers that are transparent with their clinical outcomes and business practices, operate ethically, and are committed to providing quality care.
Treatment is only one component of a continuum of care. A COE should have services offered to the patient and family prior to admission to treatment. Examples include education, intervention, and supports for families in the community and in the schools. COEs have extensive programming for families, which includes education, support and referrals to professionals for their own treatment when warranted. The continuum of care should continue post treatment. Both patients and families require additional support as they navigate early recovery. Transitional recovery care programs based on physician monitoring programs have been shown to be highly successful. Both Hazelden Betty Ford and Caron offer ongoing monitoring of patients post discharge for 1 year or longer. Caron’s program, My First Year of Recovery, and Hazelden Betty Ford’s program, Connection, focus on recovery transitions, overall wellness, monitoring through random urine drug screens, and assisting families with their own transition issues when their loved one returns home. The goal is not only promoting continuous abstinence, but swiftly re-engaging the individual back on the recovery path if a relapse occurs.
Student Assistance Programs, whether delivered in schools or in the treatment setting, provide resources to children impacted by a parent’s or sibling’s addiction. School-based programs can also be a great support when an adolescent patient returns to school after the completion of treatment.
Education and Scholarship. An addiction treatment provider that aims to be a COE should also engage in ongoing education and scholarship through collaboration with local academic centers and universities and the delivery of educational programs, fellowships, internships and opportunities for further professional development (such as continuing medical education offerings). Scholarship and research are both important and can be accomplished through collaboration with other institutions. A COE should also conduct primary, prospective research on the topic of addiction and publish findings in peer reviewed scientific journals.
Advocacy. To the extent possible, a COE in addiction treatment should engage in advocacy efforts and be a leading voice in the field. Some of this activity can be accomplished through membership with national trade associations. A first-class provider can educate people in local communities by hosting and sponsoring events and conducting interviews with the media.
Sound and Ethical Business Practices. Though it may sound obvious, Hazelden Betty Ford and Caron believe the core business practices of a provider should be sound and ethical. Marketing, advertising and promotional activities should be ethical, truthful and legal. Paying organizations for patient leads is highly inappropriate, as is presenting misleading data or results. Regarding financials, a world-class provider should also be well-capitalized.
A Broad Reach. Lastly, the reach of services should be extensive in order for a provider to qualify as a COE. Compared to acute care providers, the addiction treatment industry has been slow to serve underprivileged individuals who do not have economic resources. To the extent possible, services should be available to people of all socioeconomic backgrounds. COEs like Hazelden Betty Ford and Caron offer extensive scholarships and patient aid programs to ensure access for all. A first-class treatment center also practices diversity and inclusion, including having culturally appropriate symbols and employing staff who are diverse and bilingual.
Staff Development. A COE should also be invested in the development of staff, which creates a pipeline for growth within the organization. Growing staff from within is not only cost effective for the organization, but allows individuals to expand their leadership skills, creating a staff better equipped to meet the needs of an ever-changing and complex healthcare system. It also creates a loyalty to the organizational mission.
These characteristics represent, at a minimum, what is needed for an addiction treatment organization to consider itself a Center of Excellence. With the ever-changing landscape of the American healthcare system, providers are challenged to meet evolving expectations, which will continually increase over time. As an industry, addiction treatment centers are in a position to set the highest standard of care for clients. This is accomplished with accreditation, performance management, and evidence-based care with the capacity to treat co-occurring illnesses, an investment in education and research, transparent and ethical practices and marketing, availability to all individuals, and advocacy in the field.
It is time for accountability in the addiction field. It is time to set standards that all treatment organizations should strive to meet. While Caron and Hazelden Betty Ford uphold the highest standards required to be a Center of Excellence, both organizations call upon others to adopt similar standards which promote overall quality of care.