Dr. Candace Hodgkins on Inevitable Changes in Behavioral Health
May 23, 2017
Dr. Candace Hodgkins has spearheaded many changes in behavioral healthcare, both in her agency and in her state. For the past 20 years, she has worked at Gateway in Jacksonville, Florida, promoting and creating changes where she saw fit. She is now CEO of the agency and making changes at the state level.
We were thrilled to talk to Dr. Hodgkins about what changes she’s seen in the industry, which ones she’s personally driven, and what changes she’s looking forward to next.
Before we get started, here are some background stats on Gateway:
- Founded in 1978
- Annual revenue: $12,000,000
- Patients served annually: 6,000
- Visits per year: Over 150,000
- Staff of 200 comprised of MDs, PAs, RNs, psychologists, licensed mental health counselors, licensed social workers, BA and MA certified addiction professionals, BA and MA level counselors, case managers, peer specialists, and administration staff
- Recognized go-to leader in the treatment of addictive diseases
- Received 5 Best Practices from DCF/FADAA for programs to treat homeless with substance abuse disorders, pregnant and postpartum women seeking recovery and recovery support services
- Qualified research center for NIDA Clinical Trials Network
- Local affiliate & trainer for NIDA Child Traumatic Stress Network
On Prioritizing and Planning for Change
VALANT: Since you joined Gateway in 1997, you’ve done so much in turning it into a lean, efficient treatment center and you, yourself, are a renowned leader in behavioral health. What were your priorities getting there?
CH: Since I started in the field back 1983, my end goal has always been to serve people who are in need of help with either their mental health issues or addiction issues. I never really thought about moving up the ladder or being a CEO. In fact, I like the hands-on aspects of any organization I’m working at, and I don’t like to be in the limelight.
My end goal has always been to provide quality services to the clients and patients that walk through the doors; to make sure their needs are satisfied so they can be back in the community, living a productive, healthy life. So, that’s really been my end goal. And it remains my end goal.
VALANT: What tactics did you use to get there?
CH: Before Gateway, I came from Colorado, and Florida was comparatively behind in the sense that mental health and addiction were separate silos both in funding and in delivering services.
When I got here, I ran the adolescent residential program. The counselors would say to me, “We can only do substance abuse services, so we don’t talk about anything else that goes on with these kids.” I said, “So, you mean, if they have mental health issues, you don’t talk about those? You’re not allowed to talk about those?” “Oh, no, no. We’re not allowed to talk about those.”
You can’t just separate out one slice of their behavior and treat all of what’s going on. It took a few years to diminish that mindset and move my team forward, thinking about treating the person holistically. It’s very hard to change big, statewide-driven issues, which that definitely was and still is. The funding is still separate. The state is moving towards that but because it’s not there yet, I had to find ways for my agency to move in that direction independently.
Over the last 20 years I’ve worked on creating a team approach, raising the bar for training and professionalism, and of course making sure that we were above the curve in our data management. We’re also focusing on the research we’re doing in conjunction with the National Institute on Drug Abuse clinical trials network as well as moving towards evidenced-based practices. These things take training and money, but we’re always progressing.
VALANT: How did you make changes both within Gateway and within the state?
CH: For me it’s about building relationships, empowering those that I’m managing to strive to be the best they can be, whatever that level is. Everybody has different strengths and different liabilities, so I try to play to people’s strengths.
I like to empower the staff and I think that’s what’s made Gateway successful. The staff can run with their ideas without being micromanaged and second-guessed. I’m not going to be intimidating if they’re smarter than I am because I don’t know everything. Not one person knows everything, and I think that for organizational leadership you, as a leader, have to choose people that are experts in whatever it is they’re doing. They may have more expertise than you and that’s okay.
And we have very dedicated staff. We have staff that have been here for 30 years. They work here because they believe in the mission and they want to help people get clean and sober. Because we have so many with co-occurring disorders, we can’t separate them out anymore and just treat their addiction; our organization just wants to provide quality interventions so people have a good chance to get their behavioral health issues under control. Right now we’re having an opioid epidemic which is very distressing, but that’s going to be the next challenge for the next few years; to get a handle on the best way to provide services and prevention for that particular disorder.
The infrastructure at Gateway, like most nonprofits, works on a very, very tight budget of resources, and that is usually the last thing to get attended to. Approximately 80% of our revenue goes to salary to provide the services for the clients, so infrastructure starts to deteriorate over time. Gateway had not put any great amount of money into making things work better. It was more of a band-aid approach; something broke, we’d fix it.
That’s not how I view things. It’s very important for staff and patients to be in an environment that expresses healthy self-esteem; that “I’m worthy to have a good work space and a good office; not an environment that is filled with more hand-me-downs and donated items that are broken.”
We have a lot of partners in the community, which is really a key for successful nonprofits; however, Gateway traditionally had not done a very good job of fostering those relationships. We are a safety net organization for the state, and that is part of our mission, but we weren’t going after private donations or private partnerships, or doing very well at the commercial insurance or Medicaid collection for that matter. The old saying was, “Well, that’s just the Gateway way.”
We’re not saying that anymore. We’re improving the infrastructure, changing the culture of the board with active members doing training around what governance means and the responsibility of board members, management, and the executive staff; these three groups are the linchpin of keeping our organization vibrant and supporting our mission. With that and great philanthropic partnerships, we built a new Children’s Learning Center, which is now a 4-star rated early learning center. We also renovated our detox center, which was desperately needed, and then began the current capital campaign to build our new outpatient-administration building that is just about ready to open. We’re continuing to raise funds so we can renovate our 108 hotel rooms, 40 of which will become transitional recovery housing. There is a lot of good going on that will continue to reduce the stigma of addiction and mental illness.
It’s about finding the need, where’s the gap, and now if we want to be professional we have to look professional. Our new building is a pre-tilt concrete, pre-cast building so you can hardly hear the trains. It doesn’t matter what your funding force is. All people, even in the safety net, indigent folks, need a hopeful and warm place to come to say, “Hey, you can get better here. This is the place for healing.” So, I just beg for money, whether it’s at the legislative end or if it’s from private donors.
I have a great capital campaign chairperson, and in a year we’ve raised almost $6 million, which none of us thought was possible. But we did it and so we’re going to keep going.
CH: The productivity of your clinicians is very important. No-show rates is an example. Are they no-showing because they’re not ready, because the counselor is not doing what they need to do within the sessions, or because they need a different type of intervention? Those are all things you’d look at to see where your success is at any given moment in time. We pull those numbers weekly, monthly. How many clients we’ve served, how many people come through detox in a year, how many of those come twice, how many come three times.
As the data got better, we’ve been able to figure out where our efficiencies and deficits are, then try to jive what to do differently to fix liabilities. I’ll take detox as an example. You have to be a special kind of person to work in detox. That is probably the hardest place, and where I have the most dedicated staff that have been there for years, because you’re seeing people at their worst. You know, they’re coming in high, sick, belligerent, they stink, maybe they’ve been out living on the streets. They’re usually at their worst at this point in time.
So, detox staff felt like they were always full, like they never got a break. And once we had data that I could pull, thanks to electronic health records, the data is better and better. When we took a look at our detox program, the reality was we were only full 64% of the time. That’s 30% people we’re not serving so we weren’t that full; we feel like we’re full because it’s really stressful and it’s crisis oriented and it feels like it never ends. People come; people go. The police are there, and it’s stressful, which makes the staff feel overworked. One thing that helped that was by renovating the detox. Less people leave now because it’s very inviting. It’s not punitive looking and old and dirty-looking. You know, it’s warm, it’s inviting, it’s new, and because of our electronic health records we can track that people are staying longer and we’re full all the time. Now we REALLY are full all the time!
VALANT: What are some of the key performance indicators, the KPIs, that you or your colleagues use to measure and show those improvements?
CH: 20 years ago, our KPIs were what the state required, which were things like maintaining employment when you left residential treatment. That’s ridiculous because if you’re in residential treatment, you’re not usually employed at that point in time. So, we had to work hard with the state to figure out what the key performance indicators are in our field and how to move to capturing data that assessed that. Tracking engagement, retention, no show rates, waitlist times, number of times admitted to detox or residential (high cost utilization) in a year and days of abstinence are good KPIs.
Those kinds of indicators help us figure out how well we’re serving our population and what the current needs of our population are. We serve about 6,000 individual patients a year. We’re over 150,000 visits per year.
The opioid addiction right now has everybody in our community and in the nation trying to figure out if there’s a better strategy to help people. I think transitional recovery housing is one variable that can be helpful. If people don’t have a place to go, they’re going back to their drug-infested environment and with the current opioid and heroin laced with fentanyl issue, and they’re dying.
People are coming through detox, leaving against medical advice, and then we’re finding out that they died three days later. Or they come to detox and we have to revive them through cardiac resuscitation or give NARCAN nasal spray that resuscitates them.
This happens on a regular basis now, which is very different than even three years ago. You have to take a look at that and the data that we have helps us strategize where to go with appropriate strategies and protocols which turns into KPIs like how our clients’ health is changing, what’s working well and what’s not. For instance, we need to ask ourselves if having longer term care in a recovery setting is going to help people. Is that going to increase people’s sobriety and decrease the number of times fire/rescue has to go out to their home or they go to the emergency room? We couldn’t track things like that before, and now we can.
On Electronic Health Records
VALANT: Where do you see the behavioral health industry going within the next few years on the technology side?
CH: When we adopted an EHR, we just made our paper charts into digital charts. That’s okay, but it’s not as efficient as it could be. Some challenges we faced were getting people trained and getting people to have good computer skills. Some people had never used a computer before, so they preferred to do everything by hand. A lot of people left, which created a workforce issue. We now have millennials coming in and the challenge there is they’re very digitally savvy and they want immediate, easy results.
The way people do business is changing. We have a whole generation of people coming up who are the opioid addicted population that need to be reached in a different way. You have to do services in a different way and they desire instantaneous access. Not only does the younger workforce want instantaneous access in order to get their job done, our patient population wants instantaneous access to having somebody available to text to and have them text back or send an email to or do a video chat with in real time. So, those have been some of the challenges.
Every single client, no matter how poor they are has a smartphone. So, technology is very important today in how those services are delivered and how you connect with the patient population and how you have immediate access. We’re still working on that with our assessments. And it all has to abide by HIPAA and Federal confidentially rules regarding substance use treatment (42 CFR).
We’re headed as a society toward providing easy access to treatment that anybody can get anywhere at any time through digital technology.
I love the idea of being able to sit down at a computer and go through the process of buying something online. That is not our current EHR system. It’s very convoluted. Once you get to know it, it’s better than a paper chart, but it’s still convoluted.
So, I just think that’s where it’s all going and to have health records that are easy and fast, yet still encrypted and meeting all the compliances of HIPAA and 42 CFR…I mean I’m excited about it. I think it’s going to change the way we do things. There will still be human interaction but I think that people who can track their own progress and have somebody they can talk to right away is super important for the behavioral health field, as well as the healthcare field. It’s information driven, and the more information we have, the better knowledge base we have, therefore the better choices we then can make.
VALANT: What is it about the Platform that impressed you?
CH: I was definitely skeptical at first, and was reluctant to hear the pitch. But it was so exciting. It was like, “Oh, my God, seriously? You can do that just like that?” And it’s so user friendly.
The process of working with Valant is beneficial for my organization because we need to create new workflows and get rid of a bunch of stuff we already had in the current system.
We know that it’s possible to create a system like this because Amazon does it, all these big box stores do this kind of digital accessing, so why not us?
Where Valant is going with this platform is very exciting to me. Also, not having to spend $70,000 for a new module that might be helpful is very appealing financially, as an organization. Those two things are probably the biggest issues for me. The ease for my staff and the fact that each module is something I don’t even have to think about financially.
I’m also excited about the possibility for a community to be able to communicate with each other. We need to provide community health care better, and communication between all the providers is, in my mind, the next step we’re going to get to. We need databases to talk to each other so we can share more easily. When a client signs a release of information or consent at my organization that applies to all the providers the patient is working with for his/her healthcare needs, that is a better healthcare system.
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