Making Recovery Real transforming behavioral health organizations

1. Making Recovery Real�transforming behavioral health organizations Neal Adams, MD MPH Ed Diksa, ScD. Sharon Kuehn Paul Cumming

2. Although we may do a good job of teaching the best mental health practice available today� �we do a poor job of teaching ourselves how to decide when what we learned in the past is no longer good enough and needs to be changed.

3. 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

4. Two premises It�s not just about the forms Quality and cost are two sides of the same coin anything you do to one effects the other

7. 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

8. 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

9. Independence

10. Choice

11. 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

12. 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

13. 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

14. 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

15. 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.�

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

17. 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 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 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

18. The road to transformation�

19. 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

20. 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

21. Service plan functions Specifies intended outcomes / transitions / discharge criteria clearly elaborates expected results of services includes perspective of person served and family in the context of the person�s culture promotes consideration and inclusion of alternatives and natural supports / community resources

22. Service plan functions continued Promotes collaborative alliance between individual / family and provider / team empowering assures choice and attention to preference Provides assurance / documentation of medical necessity anticipates frequency, intensity, duration of services

23. Service plan functions continued Identifies responsibilities of team members--including person served and family increases coordination and collaboration decreases fragmentation and duplication coordinates multidisciplinary interventions prompts analysis of available resources

24. Building a plan

25. A plan is a road map Provides hope by breaking a seemingly overwhelming journey into manageable steps for both the provider and the person served

26. Plan Development Acquired skill / Art form not often taught in professional training often viewed as administrative burden and paper exercise requires flexibility Opportunity for creative thinking Integrates information about person served derived from formulation and prioritization information transformed to understanding Strategy for managing complexity

27. 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

28. 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

29. 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

30. 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

31. The transformed consumer 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

32. 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

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

34. 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

35. 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

37. 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

38. Plotting the course Engage all stakeholders on the compass Develop a QI plan for active changes Examine the skills of the workforce Evaluate clinical performance like economic performance Read and rate records Advocate for financing reform and pay for performance Technical compliance alone will only perpetuate past behaviors. The chart Technical compliance alone will only perpetuate past behaviors. The chart

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