Making Recovery Real transforming behavioral health organizations

1. nadamsmd@pacbell.net alipar@charter.net Making Recovery Real�transforming behavioral health organizations Neal Adams, MD MPH nadamsmd@pacbell.net Diane Grieder, M.Ed alipar@charter.net

2. NealNeal

3. Surgeon General Establish the scientific case for effective mental health practice Identifies gaps between current practice and potential Highlights inequities based on race and culture Lays the groundwork for President�s New Freedom Mental Health Commission NealNeal

4. President's MH Commission Call for transformation of the mental health system �Consumers of mental health services must stand at the center of the system of care. Consumers needs must drive the care and services provided.� NealNeal

5. President's MH Commission Goal 2 Mental Health Care is Consumer and Family Driven Recommendation 2.1 the plan of care will be at the core of the consumer-centered, recovery-oriented mental health system providers should develop customized plans in full partnership with consumers NealNeal

6. IOM Quality Chasm Report Health care system is failing needs more than incremental change Problems are structural and systemic views healthcare as a complex adaptive system Proposes new paradigm 6 aims that define quality 10 operational rules 4 domains of change 4 levels within a system NealNeal

7. IOM Six Aims Healthcare should be Safe avoiding injuries from care that is intended to help Effective providing services based upon scientific knowledge and avoiding those not likely to benefit Person-Centered respectful and responsive to individual and family preferences, needs, values, and includes individual's values in clinical decision making NealNeal

8. IOM Six Aims Healthcare should be Timely reducing waits and sometimes harmful delays for those who receive and give care Efficient avoiding waste equipment, supplies, ideas and energy Equitable care that does not vary in quality due to personal characteristics gender, ethnicity, geographic location, or socio-economic status NealNeal

9. Our message Things need to change Re-examining the role of treatment planning in the service delivery process provides an opportunity to create, foster and sustain the systems change that needs to occur There are concrete steps that you can take to make this happen Neal �what needs to change? Define this: lack of individualized, person-centered treatment being delivered, lack of value of the planNeal �what needs to change? Define this: lack of individualized, person-centered treatment being delivered, lack of value of the plan

10. There is often a lack of choice and selection in services; the system decides for you what you want or need. There is a lack of access to services that are based on self-defined need. A lack of individualized services, and the absence of individual service plans hinder recovery. Systems lack the needed range of program/treatment options, e.g. psychotherapy, case management, psychosocial rehab. There is lack of funding for supportive employment and lack of emphasis on higher-level employment Recovery: What Helps, What Hinders SAMHSA Diane In this monograph written by consumer leaders from SAMHSA the current state of affirms in the behavioral health system of care is clearly stated. This is true for all parts of the country. This statement introduces the not that not having an individualized treatment plan gets in the way of the individual�s recovery � an important notion and one that we support (although not yet evidence based).Diane In this monograph written by consumer leaders from SAMHSA the current state of affirms in the behavioral health system of care is clearly stated. This is true for all parts of the country. This statement introduces the not that not having an individualized treatment plan gets in the way of the individual�s recovery � an important notion and one that we support (although not yet evidence based).

11. Consumers want� A voice in the behavioral health system wishes, hopes and dreams reflected in their treatment experience to be listened to More control over their treatment, with meaningful options, preferences and choices available to them Real-life change goals not treatment goals and outcomes Diane �so what changes are needed? What are consumer saying they want????Diane �so what changes are needed? What are consumer saying they want????

12. Choice Diane �although we say the consumer has input into the plan because they met with the clinician and signed the plan, the key word here is �meaningful� � it�s really not occurring in the field.Diane �although we say the consumer has input into the plan because they met with the clinician and signed the plan, the key word here is �meaningful� � it�s really not occurring in the field.

13. Independence Diane � Tom and the employment program. Staff believing in consumers- believing they are capable of decision-making, capable of accomplishing goals, capable of providing input into their treatment and the treatment planning process. Give example of Tom and the employment program.Diane � Tom and the employment program. Staff believing in consumers- believing they are capable of decision-making, capable of accomplishing goals, capable of providing input into their treatment and the treatment planning process. Give example of Tom and the employment program.

14. What do people want? Commonly expressed goals of persons served manage their own lives ? quality of life social opportunity ? education activity / accomplishment ? work transportation ? housing spiritual fulfillment ? health and well being ? fun satisfying relationships ... to be part of the life of the community Diane � if the consumers had an opportunity to be involved in goal setting , they typically identify these goal areas, yet we still write on the plans �be medication compliant�, �commit to abstinence and life long recovery�, Diane � if the consumers had an opportunity to be involved in goal setting , they typically identify these goal areas, yet we still write on the plans �be medication compliant�, �commit to abstinence and life long recovery�,

15. The Right Balance Diane Patricia - Degan at BU- intentional careDiane Patricia - Degan at BU- intentional care

16. Intentional care Clients should have the dignity of risk and right of failure Providers are advocates of client choice Clients are not abandoned to suffer �the natural consequences�of their choices Provider or client not a failure if choice results in failure Use reinforcers to support client choice Assure true choice over a wide range of options DianeDiane

17. Person-centered There is agreement on goals tasks participation and roles The relationship with the provider is experienced as collaborative ? empathic respectful ? trusting understanding ? hopeful encouraging ? empowering NealNeal

18. Example Goal Stuart will receive the assistance he needs to make decisions that best meet his needs and to keep his entitlements current Objectives Stuart will be� compliant with meds compliant with scheduled appointments compliant with having his blood drawn Diane Goal � �I sometimes find it difficult to manage my needs and often get depressed due to my back problems� Objectives � �keep all medical appts.� �will attend Clubhouse�Diane Goal � �I sometimes find it difficult to manage my needs and often get depressed due to my back problems� Objectives � �keep all medical appts.� �will attend Clubhouse�

19. Example Goal Decrease depression Objectives assess medication needs improve finances develop appropriate vocational goals Diane �goal not framed in positive language. Objectives written like goal statements, not specific enough, measurable, �Debbie will display appropriate behavior.�. Goal - �Ms. �.will maintain improved mood and functioning.� Objectives: �will report he is maintain an overall positive mood�, �will maintain current level of functioning "will report she is doing better at not internalizing stress� Diane �goal not framed in positive language. Objectives written like goal statements, not specific enough, measurable, �Debbie will display appropriate behavior.�. Goal - �Ms. �.will maintain improved mood and functioning.� Objectives: �will report he is maintain an overall positive mood�, �will maintain current level of functioning "will report she is doing better at not internalizing stress�

20. Provider perspectives Concerned about productivity treatment planning focus is on paperwork Lack training, preparation, time and resources required competencies not clear Quality is NOT always a perceived value Don�t really believe in recovery one more model rather than fundamental shift Uncomfortable with realignment of consumer / provider relationship NealNeal

21. Provider perspectives Paternalistic �I am the expert� Consumers not capable/competent to make informed choices Large caseloads and not enough time Increasing accountability via documentation �Solo practitioners� � no plan of treatment or based on evidence or best practices NealNeal

22. Mission driven Mission statements typically say that our mission is to provide services NOT to help people change! Recovery and a person-centered orientation is a fundamentally different approach to the mission of the organization Neal�for change to occur at the organizational level we need to start at the beginning �with our mission statementsNeal�for change to occur at the organizational level we need to start at the beginning �with our mission statements

23. Typical mission statements �The mission of the ABC Center is to assess, treat and prevent the conditions of mental illness, mental retardation and substance abuse through the provision of services to citizens of �� �The mission of The Department of Behavioral Healthcare Services is to provide high quality mental health, and substance abuse prevention, treatment and support services.� NealNeal

24. What�s is your mission? To provide excellent services� or To promote and support recovery and resilience� NealNeal

25. Carter Commission NealNeal

26. Challenges Limited experience in transformative change need for leadership is a major concern system organization is highly fragmented Inequity of financial and human resources Much of current planning, policies, and practices do not support recovery vision Major differences and discontinuities between public and privately funded care systems specialty and primary care delivery systems mental health and addictive disorder fields Neal - Consumers are increasingly fragile, medically unstable since being discharged from the state hospitals. Funding has been in silos, as has staff training, consumers are with us for �life� �no hope of being discharged. We are the provider of last resort in the community public sector �can�t discharge these consumers- they have no where to go! Financing has been disability/diagnosis/services driven, not based on an individual's needs. Financing also has been pay for services delivered by level of care Neal - Consumers are increasingly fragile, medically unstable since being discharged from the state hospitals. Funding has been in silos, as has staff training, consumers are with us for �life� �no hope of being discharged. We are the provider of last resort in the community public sector �can�t discharge these consumers- they have no where to go! Financing has been disability/diagnosis/services driven, not based on an individual's needs. Financing also has been pay for services delivered by level of care

27. The road to transformation� NealNeal

28. Creating the solution The treatment / recovery management plan can be the bridge between the system as it exists now and where we need to go in the future NealNeal

29. Hypothesis Person-centered treatment plans are a key lever of personal and systems transformative change at all levels individual and family provider administrator policy and oversight NealNeal

30. Setting the compass Neal Our framework for understanding the value of the treatment plan. We will talk about all 4 perspectivesNeal Our framework for understanding the value of the treatment plan. We will talk about all 4 perspectives

31. Current practice Plans viewed as administrative requirement not relevant to clinical process Goals and objectives are often the same Goals are provider�s not the consumer�s �take medications as prescribed�� do not take into consideration the individual�s preferences, needs, strengths, culture, etc. Objectives are often the provision of services Interventions are program focused, not individualized Diane � how could this lead to improved outcomes for consumers? Goals: �things to be worked on� �dreams� �desired results� Interventions- what about natural supports, not just professional supports that may lead to dependence on the systemDiane � how could this lead to improved outcomes for consumers? Goals: �things to be worked on� �dreams� �desired results� Interventions- what about natural supports, not just professional supports that may lead to dependence on the system

32. What�s critical Service plans must be developed with the person served and family as a partner identify the person's own expectations be consistent with culture and personal (and family as appropriate) preferences recognize that participation may vary personal style age and development cultural traditions and expectations severity of needs DianeDiane

33. �Transformed� consumers The consumer is at the center of person-centered recovery planning Educated about the planning and goal development process Consumers may use technology plan and access person-centered services The consumer feels valued and empowered is a partner with their team NealNeal

34. �Transformed� providers Coach / mentor / collaborate with consumer Utilize natural supports Recognize the ultimate outcome for the consumer is to exit from services Are knowledgeable of treatment planning and evidence-based practices Competent in integrated dual diagnosis tx Accept that documentation of clinical care is part of the job and know how to do it Value having a planned approach to care NealNeal

35. �Transformed� organizations Mission includes a recovery and person-centered orientation values, goals and services that support recovery are explicitly identified and affirmed Value individuals and families participation at all levels Provide most services in the community, along with natural supports Offer a wide range of choice employment, living arrangements, services Clinically / administratively competent in co-occurring disorders and person-centered planning NealNeal

36. �Transformed� organizations �Pay now or pay later� philosophy person-centered approach to planning can lead to improved outcomes for the individual and help them to exit the system of care Appropriate treatment plans address medical necessity ensures taxpayer dollars are well spent reduces the risk of recoupment Plans become �needs assessment� for organization helps to identify new services that the organization should be offering NealNeal

37. �Transformed� policy Standards, regulations, rules, codes promote good planning practices and quality practice mandates for �recovery systems of care� and �person-directed planning� accreditation reviews, payer audits, licensing inspections all base decision-making on the individual plan for assessment and planning include identifying the individual�s strengths, needs, preferences and abilities Financing supports self-directed care individuals choose services via independent brokering and coaching NealNeal

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39. Next steps� Align mission with recovery / resiliency principles Conduct a fearless inventory of current attitudes, beliefs and planning practices review charts Integrate outcomes into treatment planning discharge / transition criteria in every plan Provide necessary resources / tools for staff time and caseload training Diane �to sum up and provide a framework for change we believe these are the necessary steps for agencies to take. There needs to be consistency between values that are advocated by the organization and values that are practiced by the organization. In the literature on organizational effectiveness, there is large body of research which generally supports the hypothesis that employees (and hence their organizations) perform better when organizational values and culture are clear and consistent and aligned with expectations for employee behavior Diane �to sum up and provide a framework for change we believe these are the necessary steps for agencies to take. There needs to be consistency between values that are advocated by the organization and values that are practiced by the organization. In the literature on organizational effectiveness, there is large body of research which generally supports the hypothesis that employees (and hence their organizations) perform better when organizational values and culture are clear and consistent and aligned with expectations for employee behavior

40. �If you don�t know where you are going, you will probably end up somewhere else.� Lawrence J. Peter NealNeal