Cincinnati Sobering Center Business Plan Final Draft

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Cincinnati Sobering Center Final Draft Business Plan August 2013
Business Plan
Cincinnati Sobering Center
Presented to:
The Greater Cincinnati Health Council

2100 Sherman Ave., Suite 100
Cincinnati, OH 45212
By:
Pat Bridgman, MA, LICDC

ocbridgman@aol.com
August 21, 2013

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Table of Contents
1. Executive Summary 3
2. Cincinnati Sobering Center Description and Goals. 6

a. The Problem 6
b. Sobering Center Vision/Planning Grant. 6
c. Sobering Center Definition. 7
d. Goals. 8
e. Guiding Principles 8
3. Marketplace Analysis. 9
a. Hospital Alcohol and Drug ED Admissions/Public Detox 9
b. Other System Impact/Cincinnati Area Support. 9
c. Target Population/Admission Criteria...10
d. Review of Other Sobering Centers.12
4. Organizations and Management.....13

a. Management Structure.13
b. Community Relationships...15
5. Operations17
a. Programming..17
b. Facility.17
c. Legal/Accreditation....18
d. Personnel...20
6. Budget..21
a. Start-up Expenses and Operating Budget..21
b. ROI..22
c. Future Funding...22
7. Evaluation..23
8. Endnotes.25
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1. Executive Summary
The primary goal of the proposed Cincinnati Sobering Center (Center) is to divert
inappropriate Emergency Department admissions from the downtown hospitals to a
cost effective alternative. In one year, the downtown Medical Centers: University of
Cincinnati Medical Center and Psychiatric Emergency Services, Christ Hospital and
Good Samaritan Hospital spent $3.57 million on 5,410 people admitted to the
Emergency Department (ED) with a primary diagnosis of an alcohol or a substance
use disorders (SUD). The estimated hospital cost per patient admitted was $660.
While the figure does not include the small amount of private and public
reimbursement received for some services, it also does not include any cost for the
professional physician services, which would increase the costs by more than
$50,000 to $100,000.
The Center would provide an alternative front door for intoxicated (alcohol or
drugs) individuals who are currently seeking services from downtown Cincinnati
ERs. These individuals need assistance but often do not require acute medical or
psychiatric care. Many of these substance-impaired individuals are loud, unruly and
can be a significant drain on hospital ED staff. While a few of these patients require
ED assistance for other acute medical conditions, most do not need the intense
medical or psychiatric services of the ED and they are not as effectively helped at
this level of care.
The Center would require an operating budget of $1.15 million a year to run the
32-40 bed unit and provide a four-day social detox program to appropriate
candidates. The first year of operation would require an additional $68,000 for
start-up expenses but by the second year the Center would be able to serve
3,640 clients with an episode cost of $317 per client for the four-day stay.
Assuming the Center is able to serve a good percentage of those people who are
eligible to be diverted from the ER, it is cost effective to create and fund the program
based on the fiscal considerations alone.
While the goal of the Center is to reduce inappropriate ED admissions, the mission
of the program is to welcome and engage chronic alcohol and drug impaired
(impaired) individuals and kindle their desire to return to meaningful and
productive lives. Similar programs across the country demonstrate that such a
program does not have to operate as a medical model to afford impaired individuals
a place to detox and seek a reprieve from the streets. The Center would provide an
alternative level of care to stabilize impaired individuals, rather than to medically
detox and treat, which is expensive and can be wasted on someone not ready to
commit to further treatment or sustained recovery.
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The proposed Center will be open 24 hours a day, seven days a week to individuals
who are alcohol and/or drug impaired, have vital signs that fall within an acceptable
range (but not necessarily normal), are unable to provide self-care and are without
shelter. These impaired individuals would be transported to the Center primarily
by Police and Emergency Medical Services (EMS) and provided a bed, meals,
shower and laundry facilities, case management and medical monitoring. Some
programming could be offered but the population may be resistant or unwilling to
attend formal SUD treatment. If desired, protocols could be developed that allow
the transfer of semi-stable clients directly from the Hospitals EDs to the Center. i
The Cincinnati Police and Hamilton County Fire Departments EMS are very
supportive of developing the Center and their support is critical to accomplishing
the Centers primary goal. Clear admission criteria inform police, EMS and other
potential referral sources as to who is (and who is not) an appropriate admission to
the Center. It is important that these agencies are trained to bring the candidates
directly to the Center, rather than to the ER. Once in the ED, EMTALA rules require a
medical work-up which means a referral from the ED to the Center would occur
after the ED expense has already been incurred.
For its initial start-up and first two years of its operation University of Cincinnati
Medical Center and Psychiatric Emergency Services, Christ Hospital, Good
Samaritan Hospital and Mercy Health (the Hospitals) would pool funding for the
Center, create a Cincinnati Sobering Center Advisory Board and hire a short term
Project Manager, who would be charged with implementation of the details of this
plan. A Request for Proposal (RFP) would be developed and a company hired to
operate the Center. That company would staff and manage the Center; seek
appropriate certifications/licensures for services; and assume the risk of running
the Center. A possible location is at the ADAS Center (311 Martin Luther King Drive
East), which is near the Hospitals that seek to have inappropriate ED admissions
diverted. There are several addiction treatment programs at the suggested location,
which will reduce problems with zoning. The Hospitals may also have potential
locations that would fit the site criteria.
While the primary goal of the Center is to divert inebriates away from the ER, the
secondary goal is to safely stabilize, assess and refer patients to appropriate social
services to include addiction treatment. It is recommended that the Managing
Organization vendor seek appropriate Ohio Department of Alcohol and Drug
Addiction Services (ODADAS) Addiction program certification. This could allow
the billing of relevant Medicaid services, such as assessment and case management
to occur for eligible clients.
The start-up budget reflects costs to include 40 beds, lockers, furniture,

communications, linens and other equipment purchases. The primary operational
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costs associated with the Center will include personnel, facility rent and utilities.
The Center needs to have nursing coverage and several case aides on all shifts to
assist with client activity. The initial capacity of the Center will be 32 clients for the
first year and 40 by the second year but it should be noted the need may be much
higher. It is challenging to determine whether 40 beds will be sufficient given that
Center clients include not only those diverted from the ED, but potentially diverted
from the Hamilton County Justice Center and/or the Drop-Inn or other homeless
shelters.
Evaluation protocols will be developed to measure whether the Center is an

effective strategy to appropriately divert intoxicated persons from the ED and track
whether client outcomes, including satisfaction with services and functional
improvements. Rather than rely on the Cincinnati Sobering Center Advisory Board
to set benchmarks, it is recommended that experts be used to perform these tasks.
For example, researchers from the Cincinnati Addiction Research Center (CinARC)
at the University of Cincinnati Department of Psychiatry and Behavioral
Neuroscience could develop research protocols to systematically track outcomes.
CinARC is the site of the National Institute on Drug Abuses Clinical Trials Network
Ohio Valley Node and the staff has significant experience in program evaluation,
addiction research and behavioral health care outcomes monitoring.
A significant number of ED patients who have an alcohol and/or drug diagnosis

should be successfully diverted from the downtown hospital EDs to the Center,
which should improve hospital budgets and work environments. Because the
Center offers a missing level of care in the Cincinnati community, the Hospitals,
through their leadership, are also providing an important community benefit by
establishing and initially funding the Center. It is recommended that the Hospitals
and other sustaining funders consider a long-term framework for this project. That
would strengthen the stability and marketability of the Center for potential clients
and referral sources.
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2. Cincinnati Sobering Center Description and Goals
a. The Problem
In 2011, the Greater Cincinnati Health Council (GCHC) identified the need for a
community-wide substance abuse unit in which clients who are intoxicated or under
the influence of drugs are taken for stabilization and appropriate evaluation, care
and connection to community resources. Several Cincinnati hospitals (University of
Cincinnati Medical Center, Christ Hospital, Good Samaritan Hospital, Mercy Health)
were seeing more alcohol and drug-impaired individuals seeking care in the EDs
and have played a key role in the development of this plan.
The problem identified by the four medical center emergency rooms and the psych
emergency room in the Cincinnati area is this: too many people who are impaired
come to the ED for care and assistance without having a true medical emergency
beyond their impairment. They wait at the ED to be seen but there is no acute
medical problem which needs to be addressed other than their alcohol/substance
abuse issues. They come to the Psychiatric Emergency Services (PES) claiming to
be suicidal (because they know that will ensure adequate attention) but by the time
they sober up there is no apparent primary psychiatric condition that needs to be
addressed beyond their addiction.
This is not only a waste of valuable health resources but the impaired individuals
are very disruptive and not well tolerated by ED staff. Thus, they do not receive the
time and attention, which might direct them to the next treatment steps.
Additionally, Cincinnati Police arrest a significant number of individuals for public
intoxication partly because there is no other place to take them. The person is then
being detoxed in the county jail at county expense because the offender is impaired
at the time of their arrest.
Some of the impaired individuals are admitted to the CCAT House detoxification
program. In one month (May 2013) CCAT had 94 people on a call back wait list
which is kept for those who are turned away because the detox unit is full. Of those
on that list, only 34 were eventually admitted - 62 people or 66% were not
admitted. Annualized, this means that approximately 744 people who asked for
detox services could not access them because of limited system capacity. Some of
the individuals are presenting at the ED and could be successfully diverted to the
Center to be stabilized.
b. Sobering Center Vision/Planning Grant

GCHC envisioned that the Greater Cincinnati region would benefit from the creation
of a community resource, which provides clients with substance abuse disorders a
timely and appropriate level of care, evaluation and referral to resources. These
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clients would be helped by services, which engage and provide motivational

counseling to move them towards the next step of recovery. Police, EMS and other
potential referral sources would refer clients to this program for appropriate
stabilization, screening and case management and these services would be provided
by nursing, case managers and case aides trained and experienced in caring for
clients with substance abuse disorders.
Late 2012, GCHC secured a planning grant from the Health Foundation of Greater
Cincinnati to: perform an assessment of successful programs in other regions;
gather and analyze data supporting community need; convene members of the
planning team; write and introduce a business plan to the Hospital leadership to
develop a Sobering Center in Cincinnati. A project manager was hired in March
2013 and review and planning activities proceeded (see Appendix I) with a goal of
project completion by October 2013.
c. Sobering Center Definition

Many of the Sobering Centers interviewed were formed outside of a normal
treatment or housing system framework to some degree they have flown beneath
the radar of normal governmental regulation. They tend to look like homeless
shelters or addiction treatment centers, but they are neither. While they have some
focus on the homeless population, they are not a traditional drop-in center or
transitional housing center, in part because it limits who can come in. While many
of the Sobering Centers serve those with addictive disorders, they are not traditional
treatment centers or medical detox programs because the length of stay is so short
and the client is not interested in formal treatment.
One of the questions that the planning group focused on was how medical should
the Center be? The Center could be set up as a full medical detoxification program.
The concern in doing so is that it would be focusing expensive medical detox
resources on a population that is not very interested in lasting abstinence and in
some ways it would be as wasteful as the present situation of impaired individuals
crashing in the emergency rooms.
Therefore, it is recommended that the Cincinnati Sobering Center should be a social

detox program. Most of the other sobering centers around the country provide
medical monitoring and focus on client stability social detox. While ODADAS
certifies medical detoxification programs, there is no formal category for social
detox programs. The selected vendor can evaluate whether to seek appropriate
ODADAS program certification that could allow limited billing for services such as
assessment and case management. It should be stressed that all Sobering Centers
warned that the population resists programming and that such services need to be
subtle.
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d. Goals
The primary goal of the Center is to reduce the wasteful, unneeded and expensive
use of hospital resources on inebriates and/or drug impaired individuals by
transferring them to an appropriate social detox setting. Hospitals and the region
benefit because the Center reduces the problem of overcrowded EDs, which are
clogged with patients with substance abuse disorders who would be better served
in a more specialized setting, and it will free up beds for other patients. The
Hospitals ED staff are helped by the appropriate reduction of their more disruptive
clients from an already crisis oriented environment. Additionally, the Hospitals can
reduce readmissions that naturally occur with chronic alcoholics and drug addicts
an advantage with full implementation of the Patient Protection and Affordable Care
Act, which brings increased scrutiny on patients that recirculate.
A secondary goal is to provide medical stability for the impaired population and
improve how Cincinnati deals with chronic alcoholics and/or drug addicts who are
not very interested in treatment. Cincinnati is lacking in alcohol and drug
detoxification beds. While the Center is a social detox model rather than a medical
detox model, it would still be providing a much needed service.
e. Guiding Principles
The framework for the Sobering Center is based on evidence-based practices to
include Prochaskas stages of change framework (1) as well as Millers
motivational interviewing techniques (2). Most of the individuals entering the
Center will likely be in pre-contemplation stage of change not yet willing to
commit to a treatment plan of action.
Several overarching principles frame the Centers success:

- The program is a harm reduction model that addresses community safety
and appropriate use of resources while kindling the desire of the participant
to begin a program of recovery.
- The Center offers hospitable engagement over time the population gets
treated with respect and kindness
- Repeat visits are encouraged rather than discouraged
- Motivational interviewing techniques are used - staff accepts the clients level
of change readiness but encourages forward movement towards recovery
- It is a hand up, not hand out program - a principle of the Healing Place, a
Sobering Center in Louisville, Kentucky, which makes it clear that its services
are not an entitlement.
- The program requires a long-term commitment from the Hospitals and other
sustaining funders to ensure stability and marketability within the Greater
Cincinnati community.
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3. Marketplace Analysis
a. Hospital Alcohol and Drug ED Admissions/Public Detox

The need for a Sobering Center came directly from hospitals in the Cincinnati area,
based on concerns of the overwhelming number of individuals in the downtown EDs
with an alcohol or other drug (AoD) impairment. Below is a summary of the total
number of people admitted to the four EDs who had a primary diagnosis of alcohol
and/or substance abuse disorder and the costs of those admissions.
Hospital Total AoD Avg. Cost per AoD Total Costs

Admissions (1 year) Admission (1year) (1 year)
U of C Medical Center 657 $1,162 $ 763,434
(5/12-4/13)
U of C PES (5/12-4/13) 1,032 $ 862 $ 889,584
Good Sam Hospital
(6/12-5/13) 826 $ 443 $ 531,118
Christ Hospital (6/12-
5/13) 2,895 $ 480 $1,389,600
Total 5,410 $ 660 $3,573,718
Total costs do not reflect possible revenues received from public or private payers
for the services, but it has been established that many of these AoD patients do not
have any insurance coverage and the reimbursement is low. The costs are a
conservative reflection of the problem since it does not include people admitted to
the ED who have a secondary substance abuse issue or the number of people that
were initially turned away from the ED, only to return soon after. The cost does not
include billing for ED physician services. It also does not include public relations
cost of impaired individuals that sleep it off in the lobbies and hallways of the
hospitals.
b. Other System Impact/Cincinnati Area Support

There is clear support for a Sobering Center in Cincinnati. The Sobering Center in
San Antonio shared that its police were not very supportive of the concept and
preferred to arrest the non-violent intoxicated individual rather than transport to
their unit. The Cincinnati police are extremely supportive of this project and
indicated that it would not be an issue to get officers to refer to the Center, which
is key to the programs success. In Cincinnati in 2012, 734 people were arrested for
Disorderly Conduct/Public Intoxication and 744 people were arrested for Operating
a Vehicle While Intoxicated (OVI). Many of those arrested would be candidates for
the Center and some of the arrests (particularly the public intoxication arrests)
could be avoided altogether.
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The Hamilton County Sheriffs Department is also supportive. The average number
of inmates detoxing from either alcohol or drugs in the Hamilton County Justice
Center is about 50 per day for an average detoxing period of seven days. While the
detox is a relatively inexpensive service (they only treat withdrawal symptoms such
as nausea withdrawal medications are not used); this still means that they are
detoxing approximately 2,607 inmates a year in a more expensive jail setting. Of
those, 28 inmates were referred to the University of Cincinnatis ED because they
could not be adequately cared for in a jail setting.
The Hamilton County Fire Department (EMS) is also involved and supportive of the
Center. The program would provide them with another option for emergency-runs.
While many inebriated and/or drug impaired emergency-run patients clearly need
assistance because they are drunk or high, they do not need the high level of acuity
provided by the ED.
Several factors will be key to the success of developing the police and EMS systems
as a referral base:
- Admission criteria must be clear regarding who should be taken to the
Center versus the PES or a Medical Center ED. This clarity reduces the
number of individuals brought to the Center that eventually are determined
not to be appropriate for admission.
- Training is developed that markets the Center as a better alternative than the
ED or jail.
- The issue of opiate overdose and the use of Naloxone (3) will need to be
worked out between the Center and the EMS/police systems. The Center
should be able to stabilize an opiate impaired individual but is not intended
to be an opiate detox clinic.
- Finally, the front door process needs to be efficient so that an officer or EMT
are not having to wait long once they have dropped the Center candidate off
for admission. A tight admission protocol is a must.
The Cincinnati homeless system is also very interested in the development of the
Center. Many homeless impaired individuals visit the Cincinnati Drop-Inn Shelter
and other homeless shelters, which are not social detox facilities but are often the de
facto detox programs for this population. The shelter has done a great job in dealing
with inebriated drop-ins but is already stretched with run-over populations in both
their overnight shelter and their step up transitional living program. According to
the most recent report, Homeless in Cincinnati 2012, at least one quarter of the
homeless staying at the emergency shelter and a third of the homeless in
transitional living are alcohol and drug abusers.
c. Target Population/Admission Criteria

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The Sobering Centers target population includes individuals who are inebriated
and/or drug impaired who need a place to stabilize because they are too intoxicated
to take care of themselves or find their way home. The population will be diverse
and could range from a down and out homeless alcoholic to a university college
coed who drinks too much one evening and is picked up by the Cincinnati police for
public intoxication. Because they set a clear parameter of who can be admitted to
the Center, well defined admission criterion does two things: (1) it reduces the
number of people brought to the ED that would have been appropriate for the
Center; and (2) reduces the number of people that need to be turned away from the
Center because they are too at risk for admission and need to go to the ED or PES.
Sample admission criteria can be found in Appendix II. The Center candidate is: 18
years or older, actually inebriated or impaired, not violent, not pregnant, and is
voluntary. Addiction treatment centers are experienced with obtaining voluntary
consent from highly impaired individuals for many years this will not be an issue.
Initially it is recommended that walk-ins not be permitted to ensure capacity for
referrals from EDs, Police and EMS and to focus on the population that currently
needs to be diverted from the ED.
The Center will need to develop a clear range of acceptable vital signs and medical
exclusions (such as untreated bone fractures, severe lacerations or high glucose
counts) that can be used by EMS staff as an indicator of who may come to the Center
versus who needs to be taken to a medical ED. While Sobering Centers are
careful about their front door to ensure the safety of the participant and
diminish risk, it needs to be noted that these units can deal with pretty sick
people and get to know a portion of their population well over time, which
helps to predict medical risk.
A percentage of the Centers clients will have chronic psychiatric and medical
disorders, but unless these are acute conditions, they will likely not prevent
admission. The other sobering centers reported that dealing with missing and
needed medications presented a challenge but they worked it out for each
individual client. Some clients will have prescription medication when they arrive
at the Center. These meds will be locked up and treated as personal possessions
and given to the client for self-medication when appropriate. The Center will not be
in the position of dispensing meds (this is not a medical model) but could develop a
relationship with the local FQHC to augment client medical and pharmaceutical care
while they are in the Center.
Almost every system represented thought that the idea was overdue and a less
expensive level of care made sense for the target population especially in light of
the large urban population. The only concern (expressed by a staff member of a
homeless system agency) was that Hospitals were simply trying to get rid of
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undesirables from their emergency rooms. That concern is quickly mitigated if the
Hospitals initially fund the Center since the program would be a much better clinical
setting for the impaired population than what it is experiencing at present.
d. Review of Other Sobering Centers

An important part of the planning process was to understand how other sobering
centers across the country operate. A review of the literature shows no longitudinal
research which demonstrates cost effectiveness or efficacy of sobering center
programs. While there are a number of these programs scattered throughout the
country, four were selected, in part, because they had been operating for a decent
length of time and because they represented differing models of programming and
funding. The four centers closely reviewed were:
- The Healing Place, Louisville, Kentucky
- The Engagement Center, Columbus, Ohio
- The Sobering Center, San Francisco, California
- The Sobering Unit, Center for Health Care Services, San Antonio, Texas
The summary of the centers reviewed (see Appendix III) compares variables of the
four programs to include how they are funded. Most receive some, if not all, of their
funding through city and county budget allocations. One center was funded by
Federal HUD housing money and state alcohol/drug funding. One center had
received a state budget allocation and privately raised funds. Since most services
are not billable to public or private insurance, programs were not able to cover the
cost of the unit through generated revenues.
A few highlights:
- All centers focused on medical monitoring but were not medical detox units.
All but one center was a social detox unit, which encouraged participants to
consider the next step towards recovery. The San Francisco center, after ten
years operating purely as a social detox model (no meds) recently began to
prescribe withdrawal medication to the few clients who are waiting to be
transferred to a formal detox program. They assist clients with discomfort
associated with alcohol and/or drug withdrawal but make it clear that the
client is not completely detoxed in their center just transferred to the
program where the detox is completed.
- All sobering centers identified that they were cost effective and diverted
impaired populations from the emergency rooms and jails, but little data
existed that supported this position.
- Two of the centers differentiated between the overnight resident (with a
length of stay of 5-6 hours) and the social detox resident with a length of
stay of 3-4 days). They would encourage the overnight residents to stay for
detox but not all chose to do so. The San Francisco Center had a 6-hour
length of stay.
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- The centers did not fit into a clear government regulation category some
were HUD certified; others were treatment certified; still others did not
have much governmental scrutiny.
- The centers had little to no formal treatment programming. They embraced
the motivational engagement approach to their population and stressed
the importance of hiring staff that understand addiction and the chronic
relapsing nature of the population. It is through repeated stays that
therapeutic relationships are developed which can result in getting them on
to a treatment level of care. Louisvilles center did include an option of
moving into a long-term residential program that was separate from the
social detox program.
- The centers relied on LPNs, Physician Assistants, EMTs, case managers and
trained caseworkers for staff. Two of the units had a medical director and
more formal medical protocols; the other two facilities did not have a
medical director directly overseeing the program but used one when needed.
- All centers felt that the successes of the programs were related to the
tightness of the admission criteria. The centers are clearly voluntary and do
not accept persons who are violent.
4. Organizations and Management
a. Management Structure
The Hospitals will need to decide the most effective way to proceed with a
management structure suited to their interests. It is proposed that the Center would
be funded initially by the four hospitals that are currently experiencing the highest
number of alcohol and drug-impaired visits: University of Cincinnati Medical
Center/PES; Christ Hospital; Good Samaritan Hospital and Mercy Health. The
Hospitals would pool the capital for initial start-up, likely create a separate 501(c) 3,
which would house the RFP development/project funding and develop a general
two-year operating budget. Anything less than two years would limit the Centers
marketing ability to convince the community that it is a viable and lasting ED
alternative.
An Interim Project Manager would then be hired to handle the initial

implementation details of the project. One of the hospitals could designate an
internal person who would serve as the Project Manager or the four Hospitals could
collectively decide on a Project Manager outside of the hospital system.
Additionally, a Cincinnati Sobering Center Advisory Board with hospital and

community representation might be created. The Advisory Board would include
fiscal and operations representatives from the Hospitals as well as a few community
representatives who understand addiction and the targeted population. Once the
project was underway, this Advisory Board could add representatives who could
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help with future funding of the project, such as representatives from the Hamilton
County Justice Center, Strategies to End Homelessness and the Hamilton County
Mental Health and Recovery Services Board.
Management Structure:
University of Cincinnati
Medical Center/PES

Managing Organization Christ Hospital
Project Manager
---------
Advisory Board Good Samaritan
Hospital
Mercy Health
The Interim Project Manager with the assistance of the Advisory Board would
develop a start-up and operating budget based on the Hospitals budgeting
commitment. They would then develop the RFP for a Cincinnati Sobering Center
Managing Organization (Managing Organization), which would run the program.
The deliverables of the RFP would include, but not be limited to:
- Working with the Cincinnati Sobering Center Advisory Board to ensure that
the goal of ED diversion is met
- Defining benchmarks for performance
- Locating the facility in an accessible building that can pass zoning scrutiny
- Remodeling the site for Center use and bringing the chosen location up to
city code (this varies depending on the final location selection)
- Staffing the facility
- Ensuring appropriate medical oversight or develop relationship with FQHC
- Seeking appropriate ODADAS certification for addiction services
- Providing or subcontracting meals, laundry and housekeeping
- Working with hospital EDs, city police, EMS and homeless systems to develop
referral protocols and marketing of the program
- Developing admission protocol specifics that meet the goal of ED diversion
without jeopardizing the care of the Centers client
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While the Hospitals might maintain some control of the program, it may limit risk to
outsource the entire operation. There is, however, a way that the Hospitals could be
involved indirectly including:
- Assisting with medical protocols

- Dedicating resources through the University of Cincinnatis Addiction
Fellowship
- Assisting with evaluation
- Identify additional funding sources
- Assisting with purchase of medical equipment and beds
- Considering a relationship between the Center and University of Cincinnati
Suboxone Clinic after the unit is up and running
- Providing administrative resources, such as marketing materials and/or
office supplies
- Providing operational assistance, such as meal delivery or laundry services
for the Center
b. Community Relationships
The Center will need to develop immediate and lasting relationships with a number
of key agencies and systems. As mentioned, the two primary referral sources to the
Center will be the Cincinnati Police and the Cincinnati Fire Departments EMS
providers. The ideal situation is that a Center candidate does not get taken to
the Hospitals ED they are taken directly to the Center if they meet the
criteria.
It would also be helpful if the EDs could directly refer to the Center. What limits this
is EMTALA rules that require a full medical work-up on a person being brought into
the ED before they can be referred. A recommendation is for the Hospitals to seek
legal clarification on the EMTALA rules. If there was a way for the ED (or other
hospital entity) to briefly screen an impaired person brought to the ED, while in the
custody of the police or EMS, then they could be directly diverted to the Center. It
would need to be a brief screen that is done prior to a formal hand-off to the ED.
Additionally, protocols could be developed that allowed the ED to transfer semi-

stable clients directly from the ED to the Center for further monitoring and
addiction evaluation and education. This would free up beds in the ED for more
acute patients but would not generate the costs savings that results from bypassing
the ED altogether. It would be a way to educate the EDs about the Center
particularly as it becomes operational. This model could work as long as there was
still capacity for the Police and EMS to bring in the more acute Center referral. If
this access becomes blocked, the Police and EMS will quickly stop referring.
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The Police, EMS and ED providers will need to understand the admission criteria
and who the right candidates are. Marketing and educational materials about the
Center will need to be developed and ongoing training with the police and fire
departments as well as ED personnel will need to be scheduled. Police will need to
be called in occasionally to assist with unruly admissions and EMS will need to be
called in to transport Center participants who are in medical crisis to an ED.
Protocols will also need to be developed that address what the EMS or police do if
the Center is at full capacity.
The Cincinnati Sobering Centers length of stay should remain brief likely between
3- 5 days. This is short, considering the acuity of the clients who will be served in
the Center. Many of the participants will not want to be formally referred to another
program for continued care and some will only stay for a couple of hours. They are
the chronic inebriates and/or drug addicts who choose the streets over a
recommended pathway of recovery. Some of the participants will be interested in
and able to move to another level of care. Many of these referrals will be to existing
addiction treatment providers in the Cincinnati area (based on need and capacity)
as well as other social services to include the Drop-Inn Shelter and Jimmy Heath
House (which specializes in permanent housing for chronic alcoholics). Opiate
addicts will be referred to Suboxone clinics if they are interested in a more
comprehensive opiate detox.
There are a number of other agencies which will be important to the Centers
success. Decisions will need to be made regarding how formal or informal these
lateral relationships are and whether Memorandum of Understandings (MOUs)
are used to spell out roles and responsibilities for the Center and partner
organization. The chart outlines a sample of community relationships:
17
Alcoholism
Council's
Pre-
Treatment
Primary CCAT
Care/MH House
Sobering
Other
Center Drop-
Treatment Inn
Providers/AA
Shelter
Prospect Talbert
House House
5. Operations
a. Programming
The Center is a social detox program, which uses a motivational interviewing
framework to help clients recognize that they have a substance abuse disorder and
consider reasons to change their behavior. Immediately upon entry, participants
will receive a nursing assessment, a clean change of clothes and will be assigned a
bed. Once they are better able to move around, they will be able to shower, launder
their belongings and eat. The staff will perform periodic checks throughout their
stay, measuring vitals and engaging them when appropriate to do so. While the
clients are not going to be very approachable in terms of therapeutic exchange,
there will be, however, a soft sell of recovery that is omnipresent throughout the
program.
While the recommendation is that the Center will initially employ a social detox
model (no medications are given to lessen withdrawal symptoms) the unit could
add medical detox or a withdrawal management protocol in the future. The unit
would house people until they choose to leave and/or are stable enough to leave or
be transferred to a treatment setting. Many people coming into a Sobering Center
are not interested in treatment, but the program could host Alcoholics Anonymous
12-step meetings (or similar alcohol/drug recovery support groups) to encourage
exposure to people leading successful lives in recovery.
One program option is to tier the unit, similar to the design of the Healing Place in
Louisville. One level could be for an overnight stay (5-6 hours), thus giving
18
intoxicated individuals a place to sleep, shower and have a meal while being
monitored for a potential medical crisis. They may leave and may not be completely
stable but are able to ambulate. If they were considered to be a risk to themselves
or others, then the police would be called.
The next level would permit a Center client to secure a bed for 3-5 days by agreeing
to participate in minimal programming, Alcoholics Anonymous or other similar
recovery-oriented content in the social detox setting. This level of detail would need
to be determined by the selected Managing Organization, since the success of a
tiered program will depend on the number of beds initially opened and the flow of
patients through the Center.
b. Facility
Locating the facility will likely raise zoning issues due to the undesirable nature of
the population being served. This issue is a key challenge for the start-up phase of
the project. A possible location for the Center would be at the ADAS Center located
at 311 Martin Luther King Drive East. This space was used as a placeholder to
develop the operational budget for the Center. The Hospitals may also have a
location that would meet criteria important to the Centers operation. Criteria for
the location would include:
- A location where zoning will not be an obstacle to getting the Center open
and operational.
- A basic residential lay out with open doors and an open floor space to
facilitate medical monitoring and easy access to clients
- A big enough unit to house a significant number of men and women
- Close proximity to the downtown hospitals and
- Drive up access to accommodate police and emergency vehicles
Some minimal renovations would be required to open up doors to sleeping rooms

and partition space between male and female units. The general facility should
include:
25 beds (or mats) for men - 7 beds for women build capacity to 40 by the
end of the first year. The more flexibility there is regarding gender
designation of beds, the better
Nursing station Blood Alcohol Content; vital sign machine and other
monitoring needs
Showers preferably at least 2-3 for men and one for women
Washers and dryers on the floor that residents/staff can use to wash the
clients personal clothes
Recreation area chairs/games/TV/literature
Secure lock up for meds that are brought in and small personal items
19
Full laundry facilities for gowns/towels/sheets, if not contracted out

Meals need to be provided
Center clients can be very messy - cleaning services will be required that can
tolerate the disorderly nature of the client
Should the ADAS facility be considered, it should be noted that the available floor is
not on the ground floor level and it will be important that there be a clear path of
access to and from the unit to the street. There is an area for ambulances to pull up
but an efficient pathway into the building and up to the unit is a requirement. Also,
the ADAS Center houses a child-care facility in the building. A more formal legal
analysis would to ensure that this would not pose any problems with opening the
program.
c. Legal/Accreditation
It is recommended that a professional legal assessment be sought to more closely
examine issues such as corporate formation, tax, regulator compliance and risk
assessment. The start-up budget does not include a line item for this cost.
Because of the nature of the population being served, getting the initial zoning
approval from the city of Cincinnati may be an obstacle and may require legal help.
The Center resembles a drop-in shelter to a certain degree so it is recommended
that the Managing Organization comply with the Emergency Shelter Program,
Operations and Facility Accreditation Standards, which serve as the minimum
standards for housing projects seeking public funds in Cincinnati. It may not be able
to technically meet all of the standards and may not initially receive public housing
funds, but it needs to be in close step with Strategies to End Homelessness, the
Cincinnati organization that regulates homeless shelters in the area. Strategies to
End Homelessness works closely with the Cincinnati zoning and health departments
on matters relating to housing organizations. Kevin Finn, Executive Director, was
included in the planning discussions and shared support for the Center.
If formal addiction treatment services are being provided (such as assessment, case
management or counseling) than the program will need to be ODADAS certified (4).
The selected Managing Organization would determine the best type of certification
based on the Centers programming. Certification may allow the program to bill
Medicaid for those clients who are Medicaid enrolled (5). Becoming ODADAS
certified will not be a difficult process for any currently certified addiction
treatment program.
Addiction treatment program certification will require the Center to abide by

federal law with regard to confidentiality of the client. 42 CFR Part 2 is the federal
rule (in some ways more strict than HIPAA) that closely regulates a treatment
programs ability to disclose whether a client is in treatment and what can be shared
20
about the client with other entities. There are exceptions to the law that are
important for the Center if there is concern that the client is at risk to themselves
or others, information can be shared. This issue will come up when needing to
transfer a client to the ED for more acute care or when calling the police because
they have left the unit and are not capable of self care or are violent.
The selected vendor will also need to have the appropriate professional and
program insurance coverage. This would be part of the RFP deliverables. The
Sobering Centers interviewed were asked about their perception of liability risk in
light of the difficult population they are serving. None reported that as an issue
they had the normal insurance policies that non-profits carry.
The city codes, which guide how the police and EMS interact with people in crisis,
also could be reviewed for needed changes. It is possible that a few updates to the
code could lower the risk for the people transporting clients to the Center as long as
they followed the admission protocols which were developed. This would be a
future issue after the Center has been operational for a period of time.
d. Personnel
Predicting the exact number of staff needed for a start-up program is always a
challenge. The plan is to open up with a capacity for 32 but the program needs to
quickly grow to 40 in order for it to operate at a cost-efficient level. The Center
would need at least the following staff:
- Director: manages the operations of the program to include staffing, budget,

certification compliance, policies/procedures, and general duties. Also
manages the external relationships with the Hospitals, the Cincinnati
Sobering Center Advisory Board, city and county officials and referral
sources and works with the Hospitals on budget matters for the programs
continued operation
- Nursing, Physician Assistant or EMT: makes admission/discharge
recommendations based on medical condition of sobering center participant;
monitors medical condition and coordinates the transfer if a higher level of
care is needed; provides assessment and counseling; documents needed
information; understands addiction and can tolerate the medical risk
associated with a social detox environment (Physician Assistant may not be
needed depending on the level of medical oversight by a Medical Director)
- Case Manager or Licensed Chemical Dependency Counselor: engages the
participants and provides assessment, counseling, case management and
housing case management with an eye towards the next right housing and/or
treatment placement (i.e. medical detox at the CCAT House/pre-treatment at
the Alcoholism Council/transfer to the Drop-Inn Center)
21
- Case Aide/Recovery Coaches: male and female caseworkers who interact

with and assist clients with self-care issues, and assists professional staff
with needed tasks. Helps to maintain order among residents and provide
encouraging guidance to participants to restore hope.
- Administrative Specialist: performs clerical duties on the unit to include
record keeping, supply and meal ordering. Assists with evaluation and
scheduling
Additionally, medical oversight would need to be provided by a physician. For

instance, the Managing Organization can allocate a portion of its organizations
Medical Directors time to the Center, if they have one. The Medical Director needs
to have knowledge of addiction and will assist in developing appropriate medical
protocols for admission. She/he would also advise on medication issues, nursing
procedures and assist with risk reduction on the unit by developing protocols for
common problems that occur on the unit.
A possible staffing for the 24 hour/seven days a week unit:
7:00 AM 3:30 PM 3:00 PM 11:00 PM 11:00 PM 7:00 AM Total FTEs

Director 1
LPN or PA * LPN or PA* LPN or PA* 4.5
CCDC/Case Manager 1
2 Case Aide/Recovery 2 Case Aide/Recovery 2 Case Aide/Recovery 9
Support Support Support
Physician .1
Administrative 1
Specialist
* The lead medical staff on each shift could be one of a number of medical professionals to
include an RN, LPN, Certified Nurse Practitioner, EMT Paramedic or Physician Assistant. The
budget assumes an LPN as a placeholder.
6. Budget
a. Start-up Expenses and Operating Budget

A complete draft budget is outlined in Appendix IV (see Appendix IV). The
document includes a line item operating budget (Tab 1) as well as start-up expenses
(Tab 2).
The start-up budget (Appendix IV; Tab 2) assumes the Center program will operate
with 40 beds. The costs include the purchase of beds, office furniture,
communication equipment, linens and other basic needs for a stand-alone unit.
22
The budget is basic. Some medical equipment such as a vital sign machine, blood
alcohol content (BAC) machine and oxygen unit will need to be kept on the floor
for medical monitoring and medical crisis. The design of the unit will allow the
separation of men and women, which requires two sets of recreational lounge
furniture and televisions. Leased on-site washers and dryers are needed to be able
to clean a clients clothes as soon as they are admitted to the unit. The start-up
budget total costs are estimated at $68,375.
The detailed operating budget (Appendix IV; Tab 1) assumes a staffing pattern of
16.6 FTEs for a 32-40 bed unit. There will be an obvious lag period until the unit
can run at its most productive level but the unit needs to be fully staffed for that first
year in order to deal with the acuity of clients presenting. The budget also assumes
the Managing Organization would be responsible for all payroll associated costs,
occupancy expenses, insurance and support costs such as MIS, linens and meals.
Operating Budget Summary:

Staff Compensation/Benefits/Payroll $ 701,437
Occupancy/Utilities/Housekeeping $ 123,500
Equipment/Supplies $ 18,400
Drug Testing/Food Service $ 124,000
Program Support/MIS/Administration $ 180,319
Client Assistance/Other Services $ 6,100
Total $1,153,756
Below is a chart that reflects the daily cost per client, based on that budget:
Number of Length of Total number of Client Cost per Client Cost

Clients Stay Clients per Year Day per Episode
1st year 32 4 days 2,912 $ 99 $ 396
2nd year 40 4 days 3,640 $ 79 $ 317
It becomes obvious that the program is more cost effective if the census is higher.
While the start-up year will be at a lower daily average, there is no reason why the
unit could not be at full capacity within a year of operation. The four-day length of
stay is a conservative estimate based on the experience of other Sobering Centers.
There are pros and cons to a longer length of stay. If they stay longer, their detox is
more complete and there is a better chance of being able to do a more thorough
assessment and better referral to another program. If the stay is shorter, the
program can accommodate more people, which may increase the chance of Ed
diversion.
b. Return on Investment
The Center requires approximately $1.153 million for yearly operational cost and
$68,000 for start-up expenses for a total of $1.22 million. Currently the Hospitals
23
are paying approximately $3.57 million for ED services for 5,410 people with an
alcohol and/or drug abuse primary diagnosis, which is 3 times more than the start-
up and operational costs for one year for the Cincinnati Sobering Center. The
Hospitals are currently paying well over $660 per person for treatment in the ED
versus an approximate $350 for a four-day social detox stay in the Center.
It is clear that the Center may save the Hospitals money on a niche population that is
difficult to serve. The program could also relieve some of the stress on the ED staff
by providing an alternative placement to police and EMS who have unruly and
impaired individuals who are not capable of caring for themselves. By committing
funds for two years of operations and setting up benchmarks that measure hospital
utilization, the involved hospitals would be able to know whether the Center could
accomplish the primary goal of ED deferral.
c. Future Funding
This plan was written with an assumption that the Cincinnati Hospitals in the
downtown area (those most impacted by alcohol and/or drug-impaired ED
admissions) would initially fund the program. The success of the Center will be in
part based on long-term commitment to this model of care. After start-up, other
funding could be sought. The program may be able to offset some costs by billing
for Medicaid services for Medicaid enrolled clients, but this would be a minimal
source of revenue especially with the delay of Ohios Medicaid expansion.
Unfortunately, while a number of the Centers participants would be Medicaid
eligible, the length of stay is so short that there is no time to get them enrolled. This
is an issue that would be addressed by the case manager especially for the repeat
admissions.
The Hamilton County Sheriffs Department would see a direct fiscal benefit when
individuals are deferred from jail (and in particular the medical detox beds within
the jail) to the Cincinnati Sobering Center. Currently it outsources the medical unit
of the jail to NaphCare, which then provides detox services as part of their medical
care. While the jail uses an inexpensive social detox model, there is the expense of
the actual jail stay, the added cost of the medical unit and admission, and the release
processing costs. Many arrested for alcohol and/or drug infractions are low-level
offenders that would not necessarily be arrested if there were an alternative
placement. Tracking referrals to the Center will be important to ensure that
diversion is occurring from the ED not just from the jail.
Additional support (fiscal and/or case management support) could come from the
Partnership to End Homelessness since a fair percentage of the Center clientele are
transient. In the future, a specific number of beds could be designated as drop-in
shelter beds and could potentially qualify for HUD funding. The Mental Health and
Recovery Board also needs to consider its role in future funding since a primary goal
24
of the program is to stabilize alcoholics and/or drug addicts and assist them in
finding their way to a life of recovery. If there was a high enough percentage of
Center participants enrolled in Medicaid, the regional Medicaid Managed Care
companies should be part of the discussions for continued funding since they too
reap benefits from the diversions from more expensive levels of care.
7. Evaluation
There are several ways to evaluate the Center over time. As mentioned, there is
very little research that has been done on sobering centers across the country. The
best way to set up a valid evaluation process would be to bring in an expert such as
Erin L. Winstanley, Ph.D., (Director of Services Research & Dissemination, NIDA
CTN Ohio Valley Node) at the University of Cincinnati Department of Psychiatry and
Behavioral Neuroscience to develop a research protocol. She is aware of the project
and is willing to assist.
Additionally, it is recommended that the Center contact Shannon Smith Bernardin at

the San Francisco Respite and Sobering Center. Ms. Smith-Bernardin is pursuing a
doctorate on Sobering Center studies and has set up numerous evaluation protocols
for the San Francisco Sobering Center since its inception ten years ago. She is also
working with sobering centers across the country to coordinate benchmarks and
establish better ways of measuring the success of this unique level of care.
A number of variables could be studied to include:

- Through self-report or by accessing patient records, determine the number
of ED and hospital inpatient utilization for a Center participant for one year
prior and one year post the Centers opening. This would be a patient
specific measure.
- Measure five-year longitudinal data of ED and hospital inpatient admissions
for people with the primary diagnosis of alcohol and/or drug abuse
compared to first year post the Centers opening. This would be hospital
specific. It may be best to choose one of the participating Hospitals rather
than all four to simplify data collection requirements.
- Potential reduction of arrests for public intoxication.
- Reduction in number of people needing detox in Hamilton County jail.
- The number of Center clients who are successfully connected to addiction
treatment or similar community support setting.
- Whether there was a reduction in use and an improvement in functioning for
Center clients.
In order to effectively measure ROI, the Center will need to be operational for at
least one year. Attempting to evaluate a negative (people did not show up at the ED)
is always tricky. Cincinnati is fortunate to have the resources of the research group
25
at the University of Cincinnatis Department of Psychiatry and Behavioral

Neuroscience. They have an established history of developing research criteria and
they have a deep understanding of the disease of addiction.
8. Endnotes
(1) The Transtheoretical Model of Change, a theoretical model of behavior change was originally
explained by Prochaska & DiClemente, 1983. The stages of change include:
Precontemplation (Not yet acknowledging that there is a problem behavior that needs to
be changed)
Contemplation (Acknowledging that there is a problem but not yet ready or sure
of wanting to make a change)
Preparation/Determination (Getting ready to change)
Action/Willpower (Changing behavior)
Maintenance (Maintaining the behavior change) and
Relapse (Returning to older behaviors and abandoning the new changes)
(2) Motivational Interviewing (MI) is often associated with the Stages of Change framework
and is a method of counseling. Although many variations in technique exist, the MI
counseling style generally includes the following elements:
Establishing rapport with the client and listening reflectively.
Asking open-ended questions to explore the client's own motivations for change.
Affirming the client's change-related statements and efforts.
Eliciting recognition of the gap between current behavior and desired life goals.
Responding to resistance without direct confrontation. (Resistance is used as a feedback
signal to the therapist to adjust the approach.)
Encouraging the client's self-efficacy for change.
Developing an action plan to which the client is willing to commit (if they stay long
enough).
More information can be found at:
http://www.samhsa.gov/co-occurring/topics/training/change.aspx
(3) Naloxone, also known as Narcon, is a narcotic antagonist. It works by blocking opiate
receptor sites, which reverses or prevents toxic effects of narcotic (opioid) analgesics. A
physician or EMT Paramedic normally gives it as an injection when opiate overdose is
suspected. There are also nasal injection options and Ohio law is currently being considered
26
that would broaden the number of professionals that could use this medication to reduce
opiate overdose deaths.
(4) The last state budget included a merger between the Ohio Department of Alcohol and Drug
Addiction Services (ODADAS) and the Ohio Department of Mental Health (ODMH) that
created the Ohio Department of Mental Health and Addiction Services (ODMHAS). At this
point the ODADAS standards have not changed.
(5) The Center may meet the definition of an Institution for Mental Disease (IMD) under
Medicaid. This is an issue that the Managing Organization should consider for its implication
on Medicaid billing.
7/15/2013 17119040 V.2

Cincinnati Sobering Center Business Plan Final Draft

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Cincinnati Sobering Center Final Draft Business Plan August 2013

Cincinnati Sobering Center

The Greater Cincinnati Health Council

Pat Bridgman, MA, LICDC

August 21, 2013

2. Cincinnati Sobering Center Description and Goals. 6

4. Organizations and Management.....13

The start-up budget reflects costs to include 40 beds, lockers, furniture,

Evaluation protocols will be developed to measure whether the Center is an

A significant number of ED patients who have an alcohol and/or drug diagnosis

2. Cincinnati Sobering Center Description and Goals

b. Sobering Center Vision/Planning Grant

clients would be helped by services, which engage and provide motivational

c. Sobering Center Definition

Therefore, it is recommended that the Cincinnati Sobering Center should be a social

Several overarching principles frame the Centers success:

a. Hospital Alcohol and Drug ED Admissions/Public Detox

Hospital Total AoD Avg. Cost per AoD Total Costs

b. Other System Impact/Cincinnati Area Support

c. Target Population/Admission Criteria

d. Review of Other Sobering Centers

4. Organizations and Management

An Interim Project Manager would then be hired to handle the initial

Additionally, a Cincinnati Sobering Center Advisory Board with hospital and

Cincinnati Sobering Center

- Assisting with medical protocols

Additionally, protocols could be developed that allowed the ED to transfer semi-

Some minimal renovations would be required to open up doors to sleeping rooms

Full laundry facilities for gowns/towels/sheets, if not contracted out

Addiction treatment program certification will require the Center to abide by

- Director: manages the operations of the program to include staffing, budget,

- Case Aide/Recovery Coaches: male and female caseworkers who interact

Additionally, medical oversight would need to be provided by a physician. For

A possible staffing for the 24 hour/seven days a week unit:

7:00 AM 3:30 PM 3:00 PM 11:00 PM 11:00 PM 7:00 AM Total FTEs

a. Start-up Expenses and Operating Budget

Operating Budget Summary:

Number of Length of Total number of Client Cost per Client Cost

Additionally, it is recommended that the Center contact Shannon Smith Bernardin at

A number of variables could be studied to include:

at the University of Cincinnatis Department of Psychiatry and Behavioral

7/15/2013 17119040 V.2

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