While the president and CEO of New York City-based Odyssey House remains convinced that residential treatment will receive a place in the basic health benefit under the Affordable Care Act (ACA), he at the same time presides over a treatment organization much more equipped than it was several years ago to adjust to any diminution of residential care in the treatment system.
Although Peter Provet, Ph.D.'s organization has by no means abandoned its roots as a program governed by the tenets of the residential therapeutic community, it has arguably done as much as any TC-based provider to diversify its operations into far-ranging areas such as community housing with supports and even mental health-focused services.
"From the time 12 years ago when I came in, we began thinking of ourselves as an enhanced therapeutic community, and that's largely because of our services to special populations," Provet told ADAW.
Provet prefers talking about populations over process, saying that the client is often the only subject that fails to get mentioned in discussions of health reform and the emerging healthcare marketplace. With a broad client base ranging from parenting women to seniors to persons with HIV/AIDS, Odyssey House serves a population that Provet says defies a one-size-fits-all solution for how to deliver services cost-effectively.
He believes any appropriate continuum of care will have to include some residential treatment services, though he also is open to the thinking that as more innovative outpatient programs are developed, the focus on residential can be lessened. In fact, about two-thirds of Odyssey House's overall programming is now in residential care, even though the assumption about an agency identified with the TC movement is that it offers 100 percent residential services.
The average length of stay in Odyssey House residential programs is about 9 to 12 months, though that represents a significant departure from the TC traditions of the past. "The old TCs had stays of 18 to 24 months," Provet said. "There was some lethargy there, some fat."
New housing model
Just over 600 of the 1,100 treatment slots in Odyssey House's New York City treatment system are residential slots funded by the state Office of Alcoholism and Substance Abuse Services (OASAS), targeting populations ranging from adolescents to women with young children to seniors. But another 110 are funded by the state Office of Mental Health (OMH), involving housing with wraparound services.
Odyssey House actually has a fairly lengthy history with supportive housing initiatives, having first provided such services back in 2001.
Provet explained that Odyssey House currently operates OMH-funded housing developments on 121st Street and 123rd Street, and two other projects in the South Bronx are in the works. Individuals with co-occurring disorders constitute an ideal population for these developments, but having a dual diagnosis is not a requirement - the requirement is actually that the resident must have a chronic mental illness.
The programs operate under a "Housing First" model that wraps services around safe and stable housing. Could this type of arrangement take hold in the substance abuse arena as well, with less supervised housing with support services eventually supplanting traditional residential care? Provet finds the premise interesting, but urges caution.
"My argument is that the disorders are very different," he said. "Drug abuse disorders have a personality element with antisocial behavior. With mental illness, you don't generally have the antisocial overlay involving the justice system." As a result, he sees the Housing First approach as being much more challenging to implement with the addicted population.
"We talk in our field about habilitation vs. rehabilitation," Provet added. "Some clients bring resources such as family support, an education, a job. With others, it's an empty suitcase. They've been abused, they've been homeless." For that group, Provet sees traditional residential treatment as essential. And he believes the role of a treatment center CEO such as himself will have to include a large share of advocacy activity on behalf of residential service options, in conjunction with national groups such as the Legal Action Center (see ADAW, Aug. 15) and the National Association of Addiction Treatment Providers (NAATP).
Several aspects of the TC ethos remain powerful elements in Odyssey House's programming, even as its prioritization of services for special populations makes its program offerings increasingly diverse.
"Much of our residential and outpatient services have a peer component," Provet said. In a recent example, Odyssey House last year received a three-year, $1.2 million grant from the Substance Abuse and Mental Health Services Administration (SAMHSA) to establish mentoring networks in the community, using the same peer influences that have governed the everyday workings of TC residential programs.
The community-based initiative started last December, with peer mentors who have at least six months of post-treatment stability being trained at a recovery coaching academy to work with individuals in early recovery. The mentors are expected to assist mentees in developing concrete recovery plans that address domains that include social support and financial independence.
Odyssey House expects to have 300 mentees enrolled in this "recovery oriented system of care" initiative by the end of 2012.
With some experience in working with OMH and with a variety of outpatient-based service models, Odyssey House believes it is better positioned than some of its colleagues to adjust to changing market demands - especially if that pace of change accelerates. "We pride ourselves on being forward-thinking, not dogmatic," Provet said. One model doesn't work for everybody, he adds.
But traditional residential works for enough people that it must be fought for by the field's leaders, Provet adds. "From a policy perspective, it's hard to look at the ACA and the parity law and then say, 'For your back pain or your cancer, you can have four months, but for residential treatment for a substance abuse disorder? Sorry, we don't pay for that.'"