By Heather J. Gotham, University of Missouri-Kansas City
Gustafson's essay provides an engaging starting point from which to imagine a possible future addiction treatment system. In reviewing the article, three main comments came to mind, including other avenues for looking at essential ingredients, something that seems missing from the proposed list, and a look ahead.
Other avenues: Considering fields outside of the addiction or mental health treatment systems from which to garner ideas about redesign is a very compelling strategy. For example, the Jonathan Rauch article, "If air travel worked like health care" (2009, National Journal) and now near-viral YouTube video by Mary and Peter Alton, presents a parody of what it would be like to make a simple airline reservation if the airlines had the same communications, record-keeping, and business practices as health care (e.g., the traveler needs to contact separate carriers for each leg of the journey; baggage and fuel are considered specialty services; billing is handled separately for all aspects of the trip including flights, baggage, and fuel; and all transactions are still conducted via fax and paper). Although it is a negative example (meaning that it highlights what doesn't work), the Rauch article points out that one can gain some clarity about a system by imagining how it would work, or does work, in a different context. As stated, this strategy highlights what is broken in a system, whereas Gustafson's method goes more from the angle of what would work best. But that method begs the question--why does addiction treatment need to be redesigned? What exactly are the problems with the current system? How might the addiction treatment system need to be changed in light of parity and health care reform? The purpose of the redesign and parameters around which it may need to be changed are not identified, and it may be a stronger method to examine essential elements based on bringing the best from other systems and analyzing what doesn't work with the current system.
Another comment on method or avenue relates to the statement in the Introduction, that the method used is to "identify how the best systems in other fields accomplish basically the same thing." The phrase "basically the same thing" can be interpreted at different levels. Some of the essential elements listed in the current article seem positioned at a fairly broad level, meaning that 'basically the same thing' refers to macro-services or components such as emerging technologies. It would be worthwhile to look also at essential elements from other sectors within human services or health care that already provide exceptional services, but where the 'basically the same thing' is more proximal to the types of services provided through addiction treatment (e.g., what aspects of a successful diabetes care clinic can be applied to addiction treatment; similar to Gustafson's Cleveland Clinic example). These could be on the large scale of a treatment system (e.g., managed care organization, hospital network), or even within one clinic or office. Including examples that are a little closer to the current addiction treatment system may be beneficial without sacrificing the main strength of Gustafson's method, which is flying high enough above the current reality to generate innovative thoughts on redesign.
Something missing: Where is the workforce? Interestingly, although most of the essential elements refer to services and practices, none reference who will be providing the services. Workforce issues are not listed among these essential elements. What types of staff members would be ideal in a redesigned system? How much and what education will they need? It is likely that a future addiction treatment system will include a very heterogeneous population of clients, including a majority with co-occurring mental illness, and many with significant health issues or disorders. The current workforce in addiction treatment is generally a very dedicated and passionate group of people who unfortunately are aging, are overworked and underpaid, have variable education, and tend to change jobs or turnover with a moderate to high rate. How can a system redesign help to change some of these factors?
A look ahead: Even with the outline of a new addiction treatment system not fully explicated, the exercise of exploring a redesign leads to questions about how the redesign will be accomplished. That is, what type and manner of organizational change will be necessary to bring about a new treatment system? Just as Gustafson calls for the best of implementation science to assist in spreading evidence-based treatment practices, a system redesign would also need to bring to bear the best thinking and research on organizational change strategies. Moving a nationwide network of specialty addiction treatment providers to change not only how they do business, but perhaps what business they do, will require a huge effort to manage the change process. The system is already financially fragile and stressed due to budget cuts of the past decade. Without careful management, a disruptive change process could lead to a major loss of treatment provider organizations, workforce, expertise, and hence a decreased quality of services to clients.
In summary, this article by Gustafson tantalizes us and draws us in to consider future possibilities. As it is a brief overview of the larger study, it also leaves me wanting to hear more about the method and specific comments that were made through the focus group and expert leader process. I look forward to the full report.