We Can Solve This!

1. We Can Solve This! The Practicality, Possibility, & Inevitability of Change Anthony M. Zipple. Sc.D., MBA Seven Counties Services azipple@sevencounties.org

2. Severe Mental Illness Is A Common Disorder… And Expensive for Us All • 4 of the 10 leading causes of disability are mental illnesses • ~6% of the population has a severe and disabling mental illness at some point • There are over 500 suicides annually in KY alone (11th most common cause of death) • Social Security makes $32 billion in mental illness disability payments annually. Medicaid costs are even higher.

3. Nationally, We Are Failing People With Severe Mental Illnesses • 15% of corrections population • 25-40% of homeless population • 85-90% unemployment rate • Large majority live in poverty • Average life expectancy of 53-55 years (same as Republic of the Cameroon, lower than Haiti)

4. Kentucky Reflects These National Challenges • KY received a grade of “F” from NAMI • In 2008 we spent only $54/capita on mental health (national average was $121) • State Medicaid plan does not cover essential services: community support, ACT, supported employment, supportive housing, etc. • Medicaid rate is based on 1998 data • Non-Medicaid revenue flat since 1998 • 6,400 people in personal care homes & more in nursing homes • Lots of people with severe MI in jail and prison • 59% of resources spent on institutional care

5. We Talk About Recovery, But Do We Act Like We Believe It? • Poor • Homeless • Incarcerated • Underserved • Unemployed • Unhealthy • Dead • This is not the ideal model for a recovery oriented mental health system.

6. We Know How To Do Better • We have great evidence based practices like ACT, IDDT, WMR, supported employment, etc. that really work • We have great emerging practices like supportive housing, WRAP, peer support, etc. that have great bases of successful experience • We know how to help people with serious mental illnesses live longer & healthier lives • We have robust research, training and demonstration ability • We have great consumer & family advocacy • We have multiple examples of state and local systems that work pretty well

7. Thresholds: Chicago Illinois An Example of a Recovery Services Organization

8. Thresholds…. Opened in 1959 and became a long time national leader in the psychiatric rehab/community support movement Their only mission for over 50 years: A good life in the community for those with most severe mental illnesses One of a small handful of places that can make some claim to having “invented” psychiatric rehabilitation Long history of innovation

9. Thresholds Mission Thresholds inspires people with severe mental illnesses to reclaim their lives by providing skills, support, and respectful encouragement to achieve successful and hopeful futures.

10. Thresholds’ Goals For Each Member Are Simple, Even If The Work Is Complicated A real home A real job A chance to learn and go to school Friends & family Good health services Less hospital and crisis time

11. Thresholds By The Numbers 850 staff Budget of ~$50,000,000 More than 25 program locations ~60 residential locations (more than 800 beds plus hundreds of vouchers) Serving ~7000 people a year Working in Cook, McHenry, & Kankakee, Counties More than 70% of services provided out of offices and day programs

12. Thresholds Pushes the Envelope • Founding member of USPRA • First urban replication in the world of ACT • First US program for mothers with severe MI who wanted to retain custody • First MH provider accredited by CARF • 33 year old research institute • Early adopter of evidence based integrated treatment • Writing new version of Illness Mgt. & Recovery with Dartmouth to include physical wellness • Writing shared decision making technology with Dartmouth for smoking cessation

13. Thresholds Builds Unique Capacity To Meet Individual Needs People with substance abuse disorders Deaf & hard of hearing Homeless individuals Pregnant & parenting teens Transitioning youth Individuals with extensive criminal justice histories People with diabetes & extensive health concerns People with histories of severe trauma Vets with serious mental illness Finds a solution for everyone

14. Thresholds Is Nationally Recognized: A Sample • 2011 Annapolis Coalition Pacesetter Award (IDDT) • 2006-10 Chicago's 101 Best & Brightest Places To Work • 2009 APA Gold Achievement Award (Sup. Emp.) • 2009 Belle Greve Memorial Award from National Rehabilitation Association (Peer Svcs.) • 2009 SAMASA Science to Service Award (IDDT) • 2009 NAMI Exemplary Psychiatrist Award • 2009 NAMI Heroes in the Fight (three awards) • 2008 SAMHSA Science to Service Award (Sup. Emp.) • 2008 Projects for Assistance in Transition from Homelessness (PATH) Award • 2008 NAMI Gordon Nash Award (Public Education) • 2006 Eli Lilly Reintegration Awards
 First Place • 2003 APA Silver Achievement Award (IDDT) • 2001 APA Gold Achievement Award (Jail Diversion)

15. What Makes Thresholds Special? • Unwavering commitment to recovery and real lives in the community • Smart implementation of evidence based practices • A very practical “we can find a way to do this” approach to problems • Long history of innovation and learning from practice • 33 years of translational research • Lots of partners and supporters

16. Most Of All, Thresholds Provides A Comprehensive, Robust, Flexible Recovery Services Platform • Deep community support that adjusts to the needs of clients. Can see people daily and more often when needed. • Fully mobile. Goes where clients are. • Housing supports • Supported employment services • Peer services • Rep payee services • Integrated health & wellness services • Integrated psychiatry and pharm services • Integrated treatment • 24/7 availability • Day services • Lots of friend and partners to help • And a genuine commitment to doing everything that it can to help a person succeed!

17. Thresholds & Olmstead Case in Illinois • Educated the plaintiffs’ legal team about the Illinois MH system • Helped find and support original plaintiffs • Provided technical assistance to the plaintiffs and advice to the state on the suit and settlement strategies • Provided testimony • Moved the first clients from their institutions after the settlement

18. And Illinois Is A Real Mess, A Pretty Tough Place to Do This Work • State budget is a disaster • MH funding is shrinking, Medicaid rates are low, grant dollars disappearing • Over-reliance on institutional care (3 Olmstead suits in process) • Weak MH leadership • Growing admin burden and Medicaid managed care • “Interesting” politics • Weak provider recovery and EBP expertise • Limited community support infrastructure • It is a tough place in which to do good work, but one can always find ways to do better

19. 10 Lessons From Thresholds • Recovery is real. People can have great lives in spite of the most severe mental illnesses • Symptoms, substance abuse, criminal history, etc. do not predict success. Recovery can be real for every person • Recovery is best operationalized through high fidelity, evidence based work & implementing EBPs takes persistence and dedicated resources • State reimbursement needs to support recovery. There is no substitute for cash being available for the RIGHT services.

20. More Lessons • ACT or ACT like services plus housing subsidies are the essential platform for success. • Providers need to live and breathe recovery. There is no substitute for mission. And not every provider is good at this kind of work. • Providers can do a lot with the hand that they are dealt… if they want to or are pushed to do it. • It takes a village… or a whole city… to make recovery real. This is our collective issue. • Humility is the openness to being taught. We can always learn and do better work.

21. Final Lesson: Start Where You Are & Keep Moving It’s not about waiting for the storm to pass, but about learning to dance in the rain