Developing a Recovery Oriented System of Care

1. Developing a Recovery Oriented System of Care Ijeoma Achara, PsyD Philadelphia Department of Behavioral Health and Mental Retardation Services

2. Developmental Change New State Old State Transitional Transition State Three Types of Change

3. Transformational Transformational Change Reemergence Through Visioning and Learning Wake-Up Calls Growth Chaos Mindset Forced to Shift Birth

4. How Transformational Change is Different Transformation is unique in three critical ways: • The future is unknown and only through forging ahead will it be discovered. • The future state is so different than the traditional state that a shift of mindset is required to invent it. • The process and the human dynamics are much more complex, unpredictable and uncontrollable.

5. Goals of this Presentation • To discuss the need for systems transformation • To describe Philadelphia’s vision of a recovery oriented system of care • To outline the framework and strategies that are being used in Philadelphia to develop a recovery oriented system of care

6. © Performance Management Company, 2004

7. Some themes include Those pushing often don’t have a Vision of the future Leadership feels isolated Goals? Vision? Goals! InefficientSystems and Processes Vision! Waning Staff Motivation? Slow Progress forward… People are working REALLY hard © Performance Management Company, 2004

8. Potential Paradigm Shift More of the Same? Transformational ideas are always around us Round Wheels are already in the wagon! Best Practices already exist within our systems

9. The real risk comes not from changing, but from trying to maintain the status quo in a rapidly changing world.

10. Behavioral Health System Transformation • The behavioral health field is undergoing radical changes in structure, service delivery approaches and management • NOT change at the margins but a fundamental shift in the way we think and act and how regulations and accountability practices shift. • Transformation is being spurred by • Voices of PIR • Scientific understanding of Recovery • Desire of advocates, providers and policy makers for more effective systems • Changing Expectations at the Federal Level

11. Current Paradigms in the Field • Pathology Paradigm • Focus on studying and understanding AOD in hopes that knowledge of the problem will lead to solutions • Intervention Paradigm • Professionally directed Tx • Learned a lot about engagement, detoxification, problem stabilization, and recovery initiation The Result? William White

12. What do We Know About Recovery? Chronic Course • Stable alcoholism recovery is not reached until 4-5 years of sustained remission, longer for other drugs. • Short periods of abstinence are really periods of brief dormancy and not sustainable recovery. Peer Support is Critical • Enhances long-term recovery outcomes for a broad spectrum of individuals. Community Variables Impact Relapse • Community recovery resources are just as important as individual factors in tipping the scales of recovery maintenance versus relapse • Recovery can be initiated in an artificial environment, but successful recovery maintenance can only be achieved in a natural community environment William White

13. What do We Know About Recovery? • Family Inclusion and Support Promotes Long-term Recovery • Addressing Basic Needs is essential for long term recovery • A strong therapeutic relationship can overcome low motivation for treatment and recovery. • Those who drop out of treatment or who are administratively discharged from treatment are those who need treatment the most.

14. What do We Know About People’s Experiences in Tx? Treatment Works!!!! Growing Body of research shows Improved Effectiveness and Outcomes • National Treatment Improvement Evaluation Study • 5 year study of treatment effectiveness of almost 4500 addiction clients nationwide reduced substance use by 50% • reduced criminal activity up to 80% • increased employment and reduced homelessness • improved physical and mental health Treatment Works, But….

15. What do We Know About People’s Experiences in Tx? Treatment works but research also highlights limitations of prevailing models • High recidivismThe majority (64%) of those entering publicly funded treatment in the United States already have one or more prior admissions, including 22% with 3-4 prior admissions and 19% with 5 or more prior admissions • High attrition during treatment ( more than half of those admitted to tx do not complete, and 18% are administratively discharged • Low percentage of aftercare participation and low dose of aftercare (less than 30% participate in 5 or more sessions) • Poor Outcomes (Of those who complete Tx, most resume substance use) • High readmission rates within 12 months

16. Conclusions from the Research • The current structure of our service systems do not maximize all that we know about recovery • The acute model that characterizes most addiction treatment conflicts with research findings on recovery stability • We need to align our systems with what we know are the critical factors necessary for sustaining long term recovery. We Need a New Paradigm!

17. ANY DEAD HORSES IN OUR SYSTEMS?

18. Dakota tribal wisdom says that when you discover you are riding a dead horse, the best strategy is to dismount. However, in human services, we often try other strategies with dead horses, including the following:

19. Saying things like “This is the way we have always ridden this horse.”

20. Appointing a committee to study the horse.

21. Arranging to visit other sites to see how they ride dead horses.

22. Harnessing several dead horses together for increased performance.

23. Creating trainings to ensure that we use best practices to ride the dead horse.

24. Finding a consultant knowledgeable about dead horses.

25. Promoting the dead horse to a supervisory position.

26. StrategiesThat work

27. VIDEO

29. The Philadelphia Transformation Initiative • $1 Billion System serving over 100,000 people annually • City manages all behavioral health funding streams including Medicaid dollars • Using multi-level approach which includes practice, program and policy level strategies Goals • To assist people in transitioning from brief episodes in recovery initiation to stable recovery maintenance • To assist people in rebuilding their lives • To connect institutional treatment to the communities it serves.

30. The Philadelphia Model What are the Elements of a Recovery Oriented System of Care? It…. • Promotes Community Integration • Facilitates Family Inclusion • Facilitates a Culture of Peer Support and Leadership • Values Partnership and Transparency • Provides Individualized, Person Directed Tx which Supports Multiple Pathways to Recovery

31. The Philadelphia Model What are the Elements of a Recovery Oriented System of Care? It…. 6. Creates Mechanisms for Sustained Support 7. Eliminates Health Disparities 8. Driven by Outcome Data, Research and Experiences of PIR • Provides Holistic Care • Aligns Fiscal, Policy and Administrative Functions with the Vision

32. What Does a Recovery Oriented System of Care Actually Look Like? System Level Organizational Level Program Level

33. Peer Culture, Support and Leadership • The most undervalued/used resource is the knowledge, skills and abilities of PIR. System Level Strategies • Peer Specialists Initiative • PIR training on starting support groups • Recovery Centers • Storytelling Training • Informal and formal (paid) peer support is a part of all services in the system. • Leadership Academy • Inclusion in system development, consultants, training, program evaluation, contract requirements

34. Peer Culture, Support and Leadership • Organizational Strategies • Consumer Advisory Groups • PIR involved with change management teams • Hiring PIR and facilitating partnerships • PIR involved with program development – what helps and what hurts • Program Strategies • PIR lead groups • PIR provide continuing care/support e.g. telephonic aftercare • link other PIR to communities of recovery and community resources • perform active recovery coaching • facilitate early re-engagement

35. Clinical Implications: Holistic Approach Holistic Approach: • People are looked at as whole human beings; body, mind and spirit. • The person’s cultural background (not just race and ethnicity) but their family, community of choice, experiences with culture are all part of the relationship that is explored. • Systems are integrated and prepared to provide co-occurring services

37. Holistic Approach • System Level • Faith Based Initiative • Person First Initiative • Funding for Integrated Treatment • Targeted Programming • Organizational Level • Culturally diverse leadership team • Integrated Care • Program Level • Comprehensive assessments • Symptom reduction with a purpose • Other domains are a priority • MH needs are simultaneously addressed • Culture specific services are available

38. Sustained Recovery SupportsClinical Implications • We expand the points of intervention so that there is a greater continuum of care from pre-engagement to “aftercare” • Outreach and early identification plays a critical role - people don’t have to hit rock bottom before having interactions with system • People are viewed as being in different stages of recovery • Readiness is not an all or nothing thing, emphasis is on pre- action stages of engagement • The burden for successful engagement is on the provider and not on the person in recovery • Motivation is not a requirement of services, it is an outcome

39. Advancing Sustained Recovery Supports • Systems Level • System facilitates mechanisms for boosters, ongoing support and early re-intervention • Organizational Level • A culture of community and belonging is created • Flexible structure and roles • Commitment to figuring it out • Program Level • Low threshold engagement • Service providers have many links to and strong presence in the community which facilitates early identification and intervention • Providers recognize that early post treatment recovery is when PIR are most fragile. As such, treatment relationships do not end with graduation. • Staff and PIR conduct assertive outreach and follow-up • PIR not administratively discharged for being symptomatic

40. Community Integration • There is a recognition that people recover in communities and not in programs • As such, the focus of all services needs to support the person’s preparation to live in the community. • The locus of services and supports is developed in the community rather than in a tx program or institution. • No support that exists in the natural community is re-created in the system. • A major focus of the system is strengthening the community

41. Advancing Community Integration • System Level • Faith Based Initiative • Mini Grants Initiative • Community Coalitions • Mural Arts Initiative • Inclusive Trainings • Aligning funding so services can take place in the community rather than on site • Identifying disincentives

43. Community Integration • Organizational Level • Linkages with indigenous healers • Unit of intervention – beyond individual • Role is to build recovery capital • Address Stigma • Program Level • Success is determined by the person’s ability to participate in the community of their choice, rather than attendance at programs • Tx plans include community activities • Programs do not promote “group” field trips into the community, but instead assist people in building an individualized plan for re-integration • Employment Partnerships

44. Other Hallmarks of a Recovery Oriented System of Care • Partnership and collaboration versus hierarchical expert model • Facilitating many pathways to recovery • menu of services and supports versus universal treatment model • Promoting Family Inclusion • Family inclusion workgroup • Family friendly consent forms

45. How Do we Build This? Together

46. Aligning Concepts: Changing how we think Aligning Practice: changing how we use language and act at all levels; implementing values based change Aligning Context: changing regulatory environment, policies and procedures Conceptual Framework Guiding the Philadelphia Transformation Process

47. Strategies for Conceptual Alignment • Set the Context and Establish a Sense of Urgency • Community meetings • Recovery Asset Baseline Assessment • Form Powerful Guiding Coalitions • Recovery Advisory Committee • Developed Recovery Definition, Recovery Values and continues to generate ideas and provide guidance to the overall transformation • Office of Addictions Service Advisory Committee

48. Strategies for Conceptual Alignment 3. Create and Over Communicate the Vision • Participatory, Collaborative Process • Conferences • Day Transformation Conference, 2006 • Recovery conferences, 2005, 2007, 2008 • Addiction Services Kickoff, 2006 • Compact Kickoff, 2006 • Internal and external recovery champions

49. Strategies for Conceptual Alignment • Utilize a Participatory and Transparent Approach at ALL Times • Established New Workgroups internally • Involved people in Recovery and the Community in New Ways • RFP Review Processes • Program Development • Conference Planning • Collaboration vs. Input with Providers

50. Strategies for Practice Alignment • Establish Priorities Because the change is a radical shift in the way we think, act and structure our work, it is critical to define some jumping off points, some agreed upon core values/priorities which also guide first steps in implementation… These jumping off points were defined through the large system assessment process with input from over 2000 people.