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

“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

Office of Mental Health

Coordinating Office of Drug and

Alcohol Abuse Programs

Community Behavioral

Health

Mental Retardation

Services

Michael J Covone Deputy Director

Margaret Minehart, M.D. Medical Director

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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

Mayor’s 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 HISTORICAL CONTEXTCONTEXT

andandBACKGROUNDBACKGROUND

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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

• Person’s 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-1950’s

– 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

 Condition

Mean Inpatient Service Use Mean Outpatient Participation after 3 Months

1 Year Prior after 3 Months

Group Treatment

Self-Help Groups

Engage + Standard Care

.54 admissions

3.3 days inpatient

.5 admissions4.4 days inpatient

44 hours .78

Standard Care Only

.33 admissions

4.4 days inpatient

.75 admissions

5.2 days inpatient

10 hours .30

 

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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 Hinders:Mental 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:What Helps:Mental Health Recovery Research Mental Health Recovery Research

by Steve Onken and Colleaguesby 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 people’s recovery

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VIEWPOINTS VIEWPOINTS ON RECOVERYON 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 PRINCIPLES and and

CORE VALUESCORE 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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• 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

Recovery Core ValuesDirection

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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 individual’s 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 one’s condition & a meaningful sense of belonging & then rebuilding a life despite or within the limitations imposed by that condition.”

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TRANSFORMING TRANSFORMING

PRACTICEPRACTICE

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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 don’t exclude people based on

prior treatment failure, etc.

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Practice Guidelines: Continuity of Care

• Persons in recovery aren’t 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 IMPLICATIONS andand

STRATEGIES STRATEGIES FOR CHANGEFOR CHANGE

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Recovery Practice Guidelines

Recovery-Oriented Value- Driven

Practitioner(Clinical)

Program(Provider)

System(Policy)

Culturally competent

Fidelity to model

Convey Hope and Respect

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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Create AwarenessCreate Awareness

And Increasing depth of content

Increasing numbers of people

Consumers, Families, Advocates

OBH Staff

Executive Directors

Medical Staff

General Public Program Directors

Boards of Directors

Line Staff

Legislators, Civic Leaders, Clergy

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Phase 2: Initiate ChangeFocus on Quality Provider self-assessment Agency Recovery plansPlan approval and implementationPerformance guidelinesPerformance measures and monitoring

Workforce developmentIntensive skill-based training

Consultation for providers

Service system re-design: New funding and realignment of existing resources

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Phase 3:Increase 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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Increased use of peer

support and self help

Identification of best

practices

Increased consumer

participation

Greater Vocational

participation

Independent functioning

Increased consumer satisfactio

n

Meaningful social roles

Improved treatment retention

Measuring Success

Reduction in stigma

Improved quality of

life

“Let no one ever come to you,without leaving

happier & better.”

Mother Teresa

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Questions?