The Public Health Management Corporation (PHMC) manages 17 behavioral health treatment programs in the Delaware Valley through its behavioral health services component. The mission is to help people of all ages develop the knowledge, skills and supports necessary to: recover from and manage emotional and behavioral issues; promote sobriety; choose and maintain healthy lifestyles; and develop healthy relationships with peers, family and the community.
PHMC’s behavioral health services programs work individually with clients to address all aspects of their addiction, mental illness and/or abuse. Each program utilizes a comprehensive, holistic and culturally sensitive approach that focuses treatment on the emotional, physical and spiritual effects of recovery from addiction and/ or mental illness.
To best illustrate the real-world challenges associated with meeting the complex needs of the individuals we serve, we highlighted three of our unique and accomplished treatment programs that continue their efforts to meet the challenges of the current changing health care climate—an environment with shrinking dollars for behavioral health initiatives—while promoting an emphasis on treatment integration, primary care and behavioral health systems without a financial structure to support integration initiatives. We present The Bridge; Interim House, Inc. and Interim House West.
The Bridge was founded in 1971. The Therapeutic Center at Fox Chase (a.k.a. The Bridge) is the only residential substance abuse program for adolescents in Philadelphia and serves some of the highest-risk youth (ages 14–18) in the state. These youth present with a formal diagnosis of substance-abuse dependence and a secondary diagnosis of a mental health disorder. Over half are referred from juvenile probation or juvenile treatment Court.
The Bridge’s comprehensive continuum of services consists of a residential substance abuse treatment program for adolescents; an outpatient treatment program; a licensed private school; a home-based continuing care program (to support its residential program participants); the West Philadelphia E3 Center (which helps out-of-school youth and youth returning from juvenile justice placements develop academic, vocational and life skills); and Bridge Intensive Prevention Services (a DHS-funded intensive delinquency prevention program for youth between the ages of 10 and 17). All are designed to help Philadelphia youth develop the skills, supports, and self-esteem they need to become academically successful, enter the work world and become productive citizens.
As part of priority efforts to ensure that treatment interventions are effective, the program leadership has invested in training and skill building for staff in evidenced based practices. Program Director Michael Ogden, MPH, stated, “we have never lost focused of evidenced-based practices” and that the Bridge, “is the only residential program in which all of the staff are trained and certified in cognitive behavioral therapy, a clinically recognized modality that delivers proven outcomes.” In addition to holistically addressing the behavioral needs of the residents, the program strongly emphasizes the integration of behavioral health and primary care services to the individuals in the program. The program provides onsite medical services because as Ogden further acknowledges, “neglected physical health has a huge impact on all other issues of well-being in the recovery process.”
Interim House, Inc. (IHI) was founded in 1971 as the first specialized residential program substance abuse treatment program for women in Pennsylvania and one of the first in the nation. IHI’s mission is to empower women to recover from drug and alcohol addiction, pursue healthy lifestyles and find purpose and meaning in their lives.
IHI has a documented track record of its success. For example, the number of women who complete residential treatment, 66 percent, is much higher than the national average of 45 percent. Interim House was the highest-scoring residential long-term program in the City of Philadelphia's Department of Behavioral Health annual pay-for-performance review for the two consecutive years, 2011 and 2012.
Interim House’s program philosophy has evolved over the past 40 years in response to the changing needs of the women it serves and dramatic advances in the field of substance abuse treatment. IHI’s treatment approach is trauma-informed, strengths-based and grounded in scientifically proven treatment modalities. Its gender-specific, holistic and diverse services—including individual and group therapy, art, dance and music therapy, vocational training, therapeutic knitting, biking, yoga, spirituality groups and peer mentoring—are designed to help women build skills in a variety of domains (educational, vocational, spiritual, drug refusal and more). Since 1993, women have also been able to participate in continuing care at Interim House once they complete their residential stays.
While there continue to be challenges within the current health care environment, Program Director Kathy Wellbank, MSS, LSW, points out, “Recovery is nothing new. It has been part of our culture for a very long time.” The active recovery movement within Philadelphia has certainly provided heightened awareness to the principles of recovery, but there is not open discussion about some of the practical challenges of support initiatives. As Wellbank states, “peer specialists need a great deal of supervision, especially initially,” and there must be careful consideration and support for these individuals; many peer specialists, “have histories of not making good choices, have been in jail and need some distance before coming into the field.” Furthermore, the funding and reimbursement for delivering recovery services to this highly needy population is not adequate to successfully maintain therapeutic outcomes that will positively enhance the women’s opportunities for economic self-sufficiency and ultimately healthier lifestyles.
Women at Interim House are among the neediest and most underserved in the region. All have substance abuse problems, and many use multiple substances. Most are single mothers and are poor and formerly homeless with histories of involvement in the criminal justice system. Most have histories of intense physical and sexual abuse, 95 percent have a co-occurring psychiatric disorder and more than half have attempted suicide.
Clients’ drug addiction and mental health issues frequently contribute to co-occurring physical health problems. Medical stabilization is often the first priority when a woman enters treatment, because the path of emotional and mental healing cannot occur until physical health treatment has begun.
Fewer than 25 percent of the women at IHI have high school diplomas or GEDs. Most have resorted to prostitution for survival, and approximately 75 percent have reported having little to no legal work experience in their lifetime. Lengths of stay range from three to six months. When women graduate from residential care, they participate in the intensive outpatient program to ensure continuity of care. Services include individual and group therapy, life skills training, basic academic education, job training, case management support and housing assistance.
When women are more secure in their sobriety, they transition to the less intensive outpatient counseling program, which focuses on helping women in recovery from addiction to drugs or alcohol maintain continuous sobriety, sustain healthy support systems and achieve economic self-sufficiency.
Interim House West (IHW) is an innovative, recovery-oriented residential substance abuse treatment program for 20 women and up to three of their children (under the age of 12 years old).located in West Philadelphia, IHW was developed in 1993 with funding from the federal Center for Substance Abuse Treatment in response to the negative impact of addiction on families in Philadelphia and to the shortage of programs that could accommodate both women and children. The program model was designed to address the comprehensive range of issues and challenges facing addicted women with children and to reduce many of the barriers that have historically prevented this population from successfully participating in treatment.
IHW is primarily known for its client-centered, strengths-based approach and its focus on building strong parenting skills and promoting healthy family functioning. Unlike in other programs that offer a fixed package of services, women at IHW can choose to participate in one of several specialized support groups and are encouraged to heal at their own pace. Skills training and social services increase as women progress.
IHW is unique in addressing the needs of children who are affected by a parent’s addiction. The children of IHW clients, like the children of addicted women in general, frequently experience developmental delays, low cognitive, motor and communication skill levels and poor school performance and display ongoing behavioral problems such as attention deficit hyperactivity disorder and defiant behavior. Often these children have had limited opportunities to develop their creativity, increase their literacy or develop coordination and motor skills. Many have had only limited exposure to stable home environments. Most of these children were with their mothers during their active addiction, and they have experienced the effects of their mothers’ substance abuse. This includes being placed in the role of the parentified child, witnessing violence against their mothers or other loved ones or being victims of physical or sexual abuse themselves. In addition, entering treatment with their mothers presents yet another change or adjustment that these children must go through.
Children’s treatment is individually tailored to meet the specific needs of the child. IHW services for children include: comprehensive assessments, a clinical preschool, an after-school program for school-age children (which includes tutoring and a curriculum designed to build and reinforce basic reading and math skills), structured socialization groups and recreational activities, linkages to mental health services, nursing care, drug prevention education and an on-site summer camp. All educational programming is enhanced by special instruction in music, movement dynamics, art and computer technology.
Children in treatment with their mothers receive bimonthly group and family therapy. They also participate in twice weekly structured parent-child play. Children who present with more serious mental health problems or who require psychiatric medication are referred for outpatient mental health services at nearby children’s mental health programs.
As noted with the other programs, there are current challenges that threaten Interim House West’s sustainability as well as the efficacy of its treatment interventions. Recent changes in regulatory and treatment criteria have shortened the allowed lengths of stay for women and their children. In speaking about her innovative program, Program Director Angie Alomar-Gilbert, RN, stated, “It’s a great model, it just doesn’t go hand-in hand with our funders”. She further emphasized that, “‘It takes thirty days just to get the client oriented” and that if we require these already fragile women to “go on overload,” “you obtain very poor outcomes.” Interim House West also utilizes a number of evidenced based and supported practices including cognitive and dialectical behavioral therapy and the trauma recovery and empowerment and Sanctuary models to maximize their potential for positive outcomes. Alomar-Gilbert is clear in her conviction that in order to achieve great outcomes you need “all the tools and resources available.”
She further supports the importance of the integration of primary and behavioral health services. She too has on-site medical services for the women and children she serves and is a strong advocate for ensuring that the women under her care are well served in terms of their overall health needs.
In summary, all of the programs highlighted continue to make strong efforts to provide the highest quality of services in a very challenging and evolving health care environment. The infusion of evidence-based practices into the everyday work is a clear indication of each program’s dedication to and investment in achieving strong, positive treatment outcomes. As the behavioral health dollars continue to change and expectations for service delivery continue to rise, programs like the Bridge, IHI and IHW strategize on how to share and consolidate resources to meet the multifaceted needs of the individuals they serve. While these programs support an integrated health care model, true integration of primary and behavioral services will only be actualized when funding streams and public health systems realize that they must also share and consolidate resources in the best interests of those they are trying to serve. Not only will this necessary shift produce strong and meaningful outcomes for the individuals being served, but a more coordinated and comprehensive system of care will provide all of us with the opportunity to reduce overall health costs and at the same time strengthen our health care system.