Promoting A Recovery Oriented System of Care

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Promoting A Recovery Oriented System of Care

• Arthur C. Evans, Ph.D.
• Director
• City of Philadelphia
• Division of Social Services
• Office of Behavioral Health/Mental Retardation
  Services

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The Guiding Principles of the Philadelphia System
of Care
RECOVERY and Resiliency
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The time is always right to do what is right.

• Martin Luther King, Jr.

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Overview

• Historical context and Background
• Various Viewpoints on Recovery
• Principles, Core Values of Definition
• Program and Practice Models
• Implications for the System
• System Change Strategies and Next Steps

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Philadelphia Office of Behavioral Health/Mental
Retardation Services
Arthur Evans, Ph.D. Director
Michael J Covone Deputy Director
Margaret Minehart, M.D. Medical Director
Office of Mental Health
Coordinating Office of Drug and Alcohol Abuse
Programs
Community Behavioral Health
Mental Retardation Services
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Division of Social Services
Division of Social Services Julia Danzy
Department of Health
Prisons Department
Department of Human Services
Behavioral Health and Mental Retardation
Recreation Department
Office of Adult Services
Mayors Office of Comm. Service
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CAVEATS

• Recovery is not throwing the baby out with the
  bath water. Reorientation
• Recovery is not panacea it will not solve
  larger societal problems (i.e. inadequate
  housing, poverty, stigma, budget problems, etc.)
• Reorientation is a process. It is not something
  that will happen overnight.
• Public Sector Challenges are Real
• It takes a consensus process to move the system
  in the direction of recovery.

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HISTORICAL CONTEXTandBACKGROUND
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Factors Influencing the New Recovery Movement

• Recovery-Oriented Providers
• Addiction self-help movement
• Mental Health consumer/survivor movement
• Family movement - NAMI
• Advances in treatment approaches
• Recovery oriented research
• Mental health and addiction advocates

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What has Been our Orientation?

• Focus primarily on symptom reduction or sobriety
• Client viewed passively as recipient of
  services
• Focus on fitting into a program
• Focus on client pathology and deficits
• Minimal individual and family voice or input in
  system
• Responsibility for change and control largely
  owned by programs
• Persons growth and sense of self is
  constrained by illness

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Relevant Mental Health Research

• Vermont Psychiatric Hospital Study
• Studied outcomes for 269 severely disabled
  patients discharged in mid-1950s
• 34 had achieved full recovery
• additional 34 had improved significantly in
  social functioning and psychiatric status
• findings replicated in WHO study where 45-65 of
  person w/ schizophrenia recovered and only 20-25
  showed classical deteriorating course

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Preliminary Outcomes from a Peer Outreach Program
Table 4. Inpatient and Outpatient Service
Utilization for Engage vs. Standard Care Only
 
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Relevant Substance Abuse Research

• 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
• New research concludes that the longer a person
  is in treatment for addiction, the better the
  odds that the patient will cut down on drug use
• (The study, entitled "Does Retention Matter?
  Treatment Duration and Improvement in Drug Use,"
  is being published in the May 2003 issue of the
  journal Addiction. )
• Researcher Bill White has documented spontaneous
  recovery of individuals who do not come into the
  formal Tx System

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What HindersMental Health Recovery Research by
Steve Onken and Colleagues

• The lack of helping factors and the resulting
  conditions e.g., poverty, apathy, isolation and
  hopelessness
• Stigma (internalized and external)
• Discrimination     
• Situations and structures which deny persons
  choices and control over their life      
• Tenaciousness of the disorder itself      
• Abuse and trauma.

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What Helps Mental Health Recovery Research by
Steve Onken and Colleagues

• Basic resources such as a livable income,
  affordable and safe housing and reliable
  transportation
• Positive attitudes, self-care and self advocacy
  where persons believe that recovery is possible
  for everyone
• A sense of meaning and purpose, for many hope or
  spiritual faith
• Choice in whether and what treatment to use and
  life options in general
• Relationships such as family and friends that
  sustain regular activities including fun
• Meaningful activities involving employment,
  education and/or volunteer and advocacy work
• Peer support in the form of groups, programs and
  role models
• Access to formal mental health services oriented
  toward the whole person where respectful staff
  partner with each person    in achieving agreed
  upon goals

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Implications of Research

• People can and do get better with the right
  supports, some of which are outside of formal
  treatment
• We need to understand and incorporate those other
  factors that are important in peoples recovery

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VIEWPOINTS ON RECOVERY
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Current Recovery Perspectives

• Recovery as Rehabilitation (Deegan) recovery
  is the task of individual, rehab one aspect of
  recovery, extend rehab beyond treatment to all
  areas of life
• Recovery as Political Process the gaining of
  civil rights, self-determination, dignity and
  respect
• Recovery as Something Gained functions,
  external things, internal states, (Ragins), more
  than absence of symptoms
• Recovery Management (White) permanent addictions
  recovery is possible, focus on solutions, open up
  natural pathways to recovery
• Recovery as Philosophy state of mind, belief
  system,

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PRINCIPLES and CORE VALUES
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Recovery Core Values

• Participation
• Entry at any time
• No wrong door
• Choice is respected
• Right to participate
• Person defines goals
• Programming
• Individually tailored care
• Culturally competent care
• Staff know resources

• Funding and Operations
• Income is tied to Outcomes
• Person selects provider
• Protection from undue influence
• Providers compete for business

Participation
Funding-Operations
Programming
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Recovery Core Values
Direction

• Equal opportunity for wellness
• Recovery encompasses all phases of care
• Entire system supports recovery
• Input at every level
• Recovery-based outcome measures
• New nomenclature
• System wide training culturally diverse, relevant
  and competent services
• Consumers review funding

• Commitment to Peer Support and to
  Consumer-Operated services
• Participation on Boards, Committees, and other
  decision-making bodies
• Financial support for consumer involvement

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Objectives of a Recovery System of Care

• To the extent possible, individuals should have
  responsibility and control over their personal
  recovery process
• Increase individual/family participation in all
  aspects of service delivery
• Expand recovery efforts to all aspects of
  individuals lives- social, vocational, spiritual
  through direct services or linkage to natural
  helping networks
• Promote highest degree of independent functioning
  and quality of life for all individuals receiving
  care in our system

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Recovery Defined

• We endorse a broad vision of recovery that
  involves a process of restoring or developing a
  positive meaningful sense of identity apart
  from ones condition a meaningful sense of
  belonging then rebuilding a life despite or
  within the limitations imposed by that condition.

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TRANSFORMING PRACTICE
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Practice Guidelines Prevention/Health Promotion

• Persons in recovery will
• be able to access information re health promotion
  and treatment options
• promote their own health and build Recovery
  Capital (resources for recovery)
• Agencies will
• provide community and consumer education
• Utilize a range of community-based interventions
  to reduce risk factors and enhance resilience
• encourage access to resources or info, conduct
  anti-stigma campaigns

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Practice Guidelines Consumer Involvement

• Persons in recovery/Family
• participate on Boards
• participate in agency evaluations
• participate in planning structures
• know grievance procedures
• Agencies
• offer peer-run services
• hire peer staff
• routinely evaluate consumer satisfaction and
  solicit ideas on now to improve care

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Practice Guidelines Access and Engagement

• Persons in recovery
• can access services through any door
• are offered services where they live
• Agencies use
• a range of pre-engagement strategies
• peer engagement specialists
• specialized outreach strategies for difficult to
  engage populations
• specialized procedures to rapidly admit people
  who relapse
• admission criteria that dont exclude people
  based on prior treatment failure, etc.

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Practice Guidelines Continuity of Care

• Persons in recovery arent discharged just for
  being more symptomatic
• Agencies link people in recovery to
• appropriate aftercare services upon discharge
• self-help resources or natural supports
• Agencies have mechanisms for
• follow-up post-discharge
• people returning for services

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Practice Guidelines Individualized Recovery
Planning

• Persons in recovery
• actively participate in the development of their
  recovery plans
• sign all plans
• attend all planning meetings
• designate meeting participants
• receive their plans
• Providers
• develop holistic plans that include wishes,
  interests, goals, etc.
• regularly review plans with multi-disciplinary
  team (e.g., treatment, housing, work, natural
  supports)

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Practice Guidelines Recovery Support Staff

• Providers
• offer people hope that recovery is possible for
  me.
• work collaboratively to develop
  relapse-prevention plans and advance directives
• assist persons in recovery with self-management
  strategies
• help engage and maximize use of natural supports
  such as friends, family, and neighbors
• promote autonomy and Recovery Capital
• aid in skill development as well as symptom
  management and treatment

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Practice Guidelines Community Inclusion

• People in recovery can be assisted to connect to
  community resources
• Agencies
• identify and regularly update traditional and
  non-traditional resource directories
• integrate program activities into community life
• utilize community social, recreational,
  educational, vocational, faith resources

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Practice Guidelines Housing and Work

• Agencies
• link people in recovery to safe affordable
  housing
• offer a range of work and educational
  opportunities to all persons in recovery
• eliminate work eligibility requirements
• strengthen linkages to vocational and educational
  providers

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Practice Guidelines Evidence-Based Practices

• People in recovery
• Provide information to help shape local
  adaptation of EBPs
• Participate in program evaluations
• Help interpret data
• Provide ideas about promising practices that need
  more research
• Agencies implement and sustain recovery-oriented
  EBPs

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Practice Guidelines Cultural Competency

• Agencies
• evaluate data to ensure that members of diverse
  cultural groups are receiving effective treatment
  
• provide services and materials that are
  linguistically and culturally appropriate
• establish and utilize relationships with local
  community institutions
• identify and eliminate health disparities
• conduct culturally competent assessments
• maintain staff composition that reflects
  diversity of population served

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Practice Guidelines Quality and Performance

• Agencies
• regularly administer opinion and satisfaction
  surveys
• collect recovery-oriented performance measures
• have a Continuous Quality Improvement (CQI)
  process that seeks to eliminate barriers to
  recovery
• Persons in recovery
• participate on CQI committees
• inform service needs assessment
• identify effective practices

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IMPLICATIONS and STRATEGIES FOR CHANGE
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System (Policy)
Program (Provider)
Practitioner (Clinical)
Convey Hope and Respect
Culturally competent
Fidelity to model
Person-Centered
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Phase 1 Determine Direction

• Develop Concepts Design Model
• Principles and core values
• Recovery definition
• Literature reviews, outside consultation
• Develop Consensus
• Consumers/people in recovery
• Family members
• Service providers
• Advocates
• Spread the Word - Create Awareness

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2
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Create Awareness
Increasing numbers of people
Consumers, Families, Advocates
Boards of Directors
OBH Staff
Line Staff
Executive Directors
Legislators, Civic Leaders, Clergy
Medical Staff
General Public
Program Directors
And Increasing depth of content
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Phase 2 Initiate Change

• Focus on Quality
• Provider self-assessment Agency Recovery
  plans
• Plan approval and implementation
• Performance guidelines
• Performance measures and monitoring
• Workforce development
• Intensive skill-based training
• Consultation for providers
• Service system re-design
• New funding and realignment of existing resources

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2
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Phase 3Increase Depth and Complexity

• Provide Advanced Training
• Continue Evolving Recovery-Oriented Performance
  Measures
• Re-align fiscal resources
• use contract language as change tool
• use incentives

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Upcoming Activities

• Community orientation sessions
• Reinvestment RFPs
• Release of Trilogy
• Provider technical assistance
• Building internal capacity
• System Transformation Groups

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Benefits for the Community

• Improved Recovery Outcomes
• Improved treatment retention
• Increased consumer/person in recovery
  satisfaction
• Broadened community supports
• Staff development through state-of-the-art
  training

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How Will This Affect Me?

• A recovery orientation will impact
• How we do our jobs
• Consumer/client outcomes
• Program models
• Career development opportunities
• Our communities

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Future Challenges

• Shifting the Culture of the System
• Reconciling client rights and best practices
• Ethical rules
• Risk Management
• Resource Allocation
• Changes in Administrative Infrastructure,
  Particularly the Policy of other State Agencies

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Improved quality of life
Measuring Success
Improved treatment retention
Meaningful social roles
Increased consumer satisfaction
Increased consumer participation
Greater Vocational participation
Independent functioning
Identification of best practices
Increased use of peer support and self help
Reduction in stigma
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Let no one ever come to you,without leaving
happier better.

• Mother Teresa

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Questions?