Department of Human Services
Division of Mental Health
Nanette Larson, BA, CRSS, Director of Recovery Support Services
Jordan Litvak, LCSW, Regional Executive Director
Patricia Reedy, LCSW, Chief of Social Work Services
March 5, 2012
The purpose of this paper is to propose a context, rationale and a set of guiding principles for the provision of services that will be needed to restructure the community healthcare/mental health service system in Illinois. This document is intended as a centering guidepost for our sister agencies and governmental partners, as well as the service provider community. As the landscape of healthcare service delivery is dramatically changing, the Department of Human Services/Division of Mental Health (IDHS/DMH) is at a crucial juncture. The advent of healthcare reform provides new opportunities for transforming and rebalancing the landscape of our system of care into one that is more consumer-driven and recovery-focused. Therefore, rebalancing will become essential to traverse that landscape. As a result, innovation will be required.
Multiple contemporary realities shape the context in which rebalancing and innovation must occur:
- The planned closures of mental health hospitals and developmental centers
- Increased access to and the integration of behavioral health and primary care (P.A. 097-0166)
- Increase in the amount of local oversight over public mental health services (P.A. 097-0439)
- The development of the legislatively sponsored Mental Health and Strategic Planning Task Force (P.A. 097-0438)
- Community needs assessments and service gaps analyses (P.A. 097-0381).
- Maximization community-based services and reduction of reliance on nursing home care for persons with mental illnesses (Olmstead v. L.C. and E.W., Williams v. Quinn, Colbert v. Quinn)
Given the above dynamics of change, our challenge is to deliver quality care in the context of these realities, most likely with fewer resources. Although we have transitioned to a fee-for-service system to maximize federal Medicaid dollars, providers continue to be challenged to: 1) Find more efficient ways of doing business in an effort to improve outcomes, and 2) Generate sufficient revenues to sustain viability. The challenge of rebalancing and improving services with fewer resources provides an additional impetus for innovation and the increasing use of recovery oriented services in our system.
In the midst of these turbulent times, significant creativity and collaboration have emerged from our many community partners. We have a window of time in which we can give serious thought and consideration to the rebalancing of the community healthcare system. The time for optimizing innovation has arrived. IDHS/DMH encourages all system partners to embrace new program and service delivery models and to bring innovative ideas to the table to assist in our rebalancing.
For example, when an individual faces an urgent situation associated with a mental illness, hospitalization is not necessarily the best or most effective intervention. However, a broader array of services must be offered if people in urgent, non-emergent situations are to be served appropriately. With this in mind, this brief is meant to offer some guiding principles about the types of services, and the characteristics of services, that we believe will be helpful for individuals in these situations. It is the delivery of such innovative services which IDHS/DMH is most interested in investing.
B. Three Guiding Principles for Innovation in Rebalancing: Recovery-Oriented, Trauma-Informed and Outcome-Validated
The evidence is clear; the outcomes are validated. Recovery, while often perceived as a new concept in mental health, is actually not new at all. As the treatment centers that were available to persons with mental illnesses deteriorated in the late 19th and first half of the 20th century, perceptions about whether people could recover from these illnesses began to change. In the new millennia, we now know that recovery is, indeed, the expectation. Our service providers must fundamentally convey this.
Principles of Recovery:
- Recovery emerges from hope: The belief that recovery is real provides the essential and motivating message of a better future - that people can and do overcome the internal and external challenges, barriers, and obstacles that confront them.
- Recovery is person-driven: Self-determination and self-direction are the foundations for recovery. Individuals define their own life goals and design their unique paths.
- Recovery occurs via many pathways: Individuals are unique with distinct needs, strengths, preferences, goals, culture, and backgrounds, including trauma experiences. These trauma experiences that affect and determine their pathway to recovery.
- Recovery is holistic: Recovery encompasses an individual's whole life, including mind, body, spirit, and community. The array of services and supports available should be integrated and coordinated.
- Recovery is supported by peers and allies: Mutual support and mutual aid groups, including the sharing of experiential knowledge and skills, as well as social learning, play invaluable roles in recovery.
- Recovery is supported through relationship and social networks: An important factor in the recovery process is the presence and involvement of people who believe in the person's ability to recover; who offer hope, support, and encouragement; and who also suggest strategies and resources for change.
- Recovery is culturally-based and influenced: Culture and cultural background in all of its diverse representations, including values, traditions, and beliefs are keys in determining a person's journey and unique pathway to recovery.
- Recovery is supported by addressing trauma: Services and supports should be trauma-informed to foster safety (physical and emotional) and trust, as well as promote choice, empowerment, and collaboration.
- Recovery involves individual, family, and community strengths and responsibilities: Individuals, families, and communities have strengths and resources that serve as a foundation for recovery.
- Recovery is based on respect: Community, systems, and societal acceptance and appreciation for people affected by mental health and substance use problems - including protecting their rights and eliminating discrimination - are crucial in achieving recovery.
Through the Recovery Support Strategic Initiative, SAMHSA has delineated four major dimensions that support a life in recovery:
- Health: vercoming or managing one's disease(s), as well as living in a physically and emotionally healthy way;
- Home: a stable and safe place to live;
- Purpose: meaningful daily activities, such as a job, school, volunteerism, family caretaking, or creative endeavors, and the independence, income and resources to participate in society; and,
- Community: relationships and social networks that provide support, friendship, love, and hope.
The percentage of people who have mental illnesses who have also been traumatized is staggering (Goodman et al, 1997). Moreover, repeated studies have documented that various samples of people with schizophrenia have rates of co-occurring PTSD from between 29% to 43%. This means that, for a sizeable percentage of the people we serve, we must be mindful of the likelihood that s/he has been traumatized, and that we must guard against the possibility of individuals being re-traumatized.
Psychological trauma is a pivotal force that shapes a person's mental, emotional, spiritual and physical well-being. Because trauma can stem from violence, abuse, neglect, disaster, terrorism and war, nearly every family is impacted in some way. Trauma-informed care provides a new perspec¬tive. Support personnel shift from asking "What is wrong with you?" to "What has happened to you?" This change reduces the blame and shame that some people experience when seeking treatment and being diagnosed. It also builds an understanding of how the past impacts the present. This can assist with connections that support progress toward healing and recovery.
Trauma-informed care takes a collaborative approach. Healing is led by the consumer, and supported by the service provider. Together, in a true partnership, people learn from each other. There is greater respect, progress toward healing, and greater effectiveness in services. Trauma-informed care in organizations impacts all aspects of service delivery-from how services are provided, to the environment or culture, to how the physical space is laid out. Trauma-informed care, if it is to be effective, also involves all members of the organization; from the receptionist at the front desk to the care provider and treatment team.
Ten Values of Trauma-Informed Care
- Understand the prevalence and impact of trauma
- Pursue the person's strength, choice and autonomy
- Providers must earn trust
- Healing happens in relationships
- Provide holistic care
- Share power
- Communicate with compassion
- Promote safety
- Respect human rights
Routine outcome assessment involves either clinician or patient monitoring, and the rating of changes in health status and indicators of social functioning (including quality of life) (Slade, 2002). Significantly, an important distinction exists between the rating by the person receiving services, and the rating by the clinician. Most rating scales in mental health are completed by clinicians. The patient voice is often ignored in the development of various instruments to rate health outcomes (Jacobs, 2009). However, partnership and shared decision-making are essential for effective service delivery. Therefore, it is essential to collaborate with persons receiving services in the choice and development of appropriate outcome measures.
The issue of validity raises the question of how a 'good outcome' is defined in mental health. As previously discussed, one of the first issues becomes whose perspective is relevant, i.e., the person receiving services, or the clinician, or significant others. A second issue is the content of the measure, which has traditionally been based on symptoms. Beyond symptoms, there is also an interest in other aspects of outcome, such as social functioning, satisfaction and recovery.
It is universally recognized as imperative that the services provided lead to measurable positive outcomes for persons receiving those services. To that end, the Substance Abuse and Mental Health Services Administration (SAMHSA) has developed a searchable online registry of more than 200 interventions supporting mental health promotion, substance abuse prevention, and mental health and substance abuse treatment (http://nrepp.samhsa.gov/ ) With such a treasury of outcome-validated interventions, it is no longer acceptable to provide services that are not informed by outcomes.
C. Innovation: A Working Definition
To satisfy the need for more integrated, recovery-oriented care as well as cost containment and efficiency requirements, public health care systems call for innovation. One simple definition of innovation is "the introduction of something new, a new idea, method or device" (Webster). Wikipedia defines Innovation as "the creation of better or more effective products, processes, services, technologies, or ideas that are accepted by markets, governments, and society. Innovation differs from invention in that innovation refers to the use of a new idea or method, whereas invention refers more directly to the creation of the idea or method itself." Thomas Edison, one of the world's greatest innovators said, "Innovation is 1% inspiration and 99% perspiration." Contemporary realities in public health care delivery systems call for innovation. Innovation is a concept that is almost universally relevant.
Within IDHS/DMH, we find ourselves promoting innovation to improve services, increase efficiencies and meet the challenges of new paradigms and payment systems. It is, therefore, helpful to have a common understanding of what we mean by innovation so that this concept can be consistently applied to our vision and mission. Our common understanding can also serve as a guide in promoting, developing and evaluating innovative programs and services. The next section of this paper describes what we mean by innovation and gives examples of the types of innovations we believe will positively impact the persons we serve.
Useful innovation requires the ability to be creative as well as the ability to execute. Creative ideas poorly executed lead to poor and wasteful programs. In this section, we look at excellence in execution as well as excellence in mental health service delivery.
Excellence at executing program operations is required for quality innovation, as evidenced by:
- An agency's ability to execute its operations efficiently and effectively.
- Likelihood of program sustainability over time.
- The risks vs. benefits of a program must be assessed in order to use limited dollars wisely. Many innovative programs often require start up money in the form of capacity grants or advances. A key measure for IDHS/DMH is the degree of financial viability of a program without the necessity of grants or cash infusions over the long term. This is not to say that there will never be services delivered that can't be purchased by third party payers. More services will be available if we conserve taxpayer dollars by ensuring that everything possible is done to maximize financial viability of program services.
- Clear and specific deliverables coupled with measurable outcomes necessary for program evaluation.
- Program innovators must be clear about desired outcomes and develop credible and reliable systems for collecting and measuring supporting data.
- Ability to replicate such programs elsewhere in the state.
- While solutions to access and service are unique from community to community, the ability to replicate effective programs creates its own efficiencies and support systems, such as unified training programs, common quality indicators and Learning Collaborative programs.
- Improved continuity of care.
- Good continuity of care enhances recovery and reduces recidivism, thereby reducing costs. Improved service coordination among multidisciplinary providers supports contemporary trends toward integrated care.
- Use of best practices and/or evidence based practices.
- Applying best and evidenced based practices shows that service providers are operating within high quality practice standards and are more likely to achieve good outcomes.
- Excellent quality improvement plans.
- Continuous quality improvement requires relevant thresholds, timely incident report/review and the ability to adjust and refine programming based upon good data.
- Excellence in information systems.
- An agency's information system and billing infrastructure must be sufficiently capable of supporting expanded operations, data collection and effective claiming.
- Excellence in administrative systems.
- An agency's administrative structure must be able to support program development through effective hiring, training and provision of sufficient supervision for implementation of innovative programs.
- Commitment to a recovery orientation.
- Building upon individual strengths and addressing individual needs, agencies that provide recovery-oriented services are effective. Through a commitment to a recovery orientation, both staff and the healthcare environments inspire hope and empower individuals. This inspiration and empowerment supports skill acquisition that enables people to live, work, learn and participate fully in their communities.
D. Examples of Program Innovation
There are many sectors of mental health service delivery that provide the opportunity for program innovation. The examples below describe several such programs. The list below is not intended to be all-inclusive.
Publicly funded primary care/behavioral health integration is likely to be one of the most significant trends in health care delivery over the next ten years and beyond. Both federal and state initiatives are actively funding pilots; several initiatives in the state have also been funded through Title XX dollars. Seed dollars, when made available, are used to underwrite the initial costs of system redesign, training and administrative expense, with the expectation that these programs will become self-sustaining through innovative or traditional revenue generation models.
Recovery Support Specialist Services
Within Illinois and across the country, more programs are utilizing services delivered by peers. Proper recruitment, selection and training of peers, supported by the Certified Recovery Support Specialist (CRSS) credential, help to ensure service quality for innovative programming in a variety of service sectors, such as: Permanent Supportive Housing, Mental Health Courts, Crisis Respite Centers (e.g. Living Room models), services for individuals experiencing homelessness, and Individual Placement and Support programs (Supported Employment) - to name a few.
Use of Technology
The use of tele-pschiatry has expanded across Illinois. Psychiatric shortages, especially in rural areas, have made this service a pragmatic reality. Additional experimentation with use of technology for case management and primary care delivery show promising outcomes. Use of computers and other digital devices allow for improved communications across long distances providing improved continuity of care. Courses in Wellness Recovery Action Planning (WRAP) can now be found on line, making this invaluable service available across transportation barriers.
Use of Prevention Services
We have seen a number of communities make good use of prevention services (e.g., Mental Health First Aid) in conjunction with other forms of outreach. Utilization of this spectrum of services supports the general population as well as those in greater need. Knowing who to call for what service may prevent bigger problems down the road. Coordinated outreach and multiple communication strategies reduce isolation, especially across the many rural areas in Illinois.
Hospital Based Services
Hospital service innovation is emerging in many areas. More psychiatric inpatient units utilize -oriented programming, including Wellness Recovery Action Planning (WRAP). A number of community hospitals have created flexible unit capacity to accommodate changing needs. Multiple hospitals have created separate psychiatric emergency areas. These have the following advantages: 1) They help to minimize overcrowding in EDs for people with other medical conditions. 2) They can concentrate and develop staff with mental health expertise. 3) One important effect of the concentrated mental health expertise is an improved understanding of community options; this promotes suitable dispositions, when clinically appropriate, that avoid unnecessary hospitalizations.
Community Based Services
Some of the most impressive innovations we have seen in community agencies have been services experienced when people come to agencies for the first time. Warm and welcoming receiving facilities, coupled with minimal delays for service access, go a long way towards impacting consumers' recovery. Some agencies have deployed groups led by peers for orientation to services, while others have offered one on one peer support for consumers who may be ambivalent about getting involved in treatment.
Innovative Crisis Services
Alternatives to inpatient care need to effectively manage risk, ensure safety, and direct initial services on to a recovery oriented trajectory. In order to do so, each community needs to identify the right level of intensity of crisis services to meet the needs of its citizens. Crisis services can range from residential to mobile, with enhancements such as use of technology, peer supports or clinically managed detoxification. The effective crisis program will be embedded into its community and take into account complementary services and resources.
These examples are not intended to be an all-inclusive list of innovations. However, changing service delivery trends and requirements for increased efficiency strongly suggest that some of the best opportunities for innovation will involve many of the elements described above.
E. Meeting the Challenge
Agencies that can collaborate and partner to combine purpose and mission will be those who develop the critical mass to meet the many fiscal and operational challenges of the future. Competency in weaving braided funding approaches will become a necessity to remain viable and sufficiently fluid during these times of rapid change. Contingency planning met by budgetary discipline, combined with focus on mission and vision, will be the challenge of the day.
The informed reader will realize that the parameters listed above are not mutually exclusive. Indeed, many of the concepts presented overlap quite naturally. We hope that these guiding principles and examples of program innovation provoke, motivate, and lead to increased innovation. The resulting restructured delivery system may well be characterized by enhanced outcomes, and progress toward our goal of a truly facilitative, recovery-oriented system of care.
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Goodman, Rosenberg, Mueser, Drake. Physical and Sexual Assault History in Women with Serious Mental Illness: Prevalence, Correlates, Treatment, and Future Research Directions. Schizophrenia Bulletin, Vol. 23, No. 4, 1997
Jacobs, Rowena. 2009. Investigating Patient Outcome Measures in Mental Health. Centre for Health Economics, University of York.
Keilman, John. 'Living Room' offers ER alternative for mental illnesses. Chicago Tribune, December 1, 2011.
Lysaker, Outcalt, & Ringer, 2010. Clinical and psychosocial significance of trauma history in schizophrenia spectrum disorders. Expert Review of Neurotherapeutics, 10(7), 1143-51.
Mueser, et al., 2004. Interpersonal Trauma and Posttraumatic Stress Disorder in Patients With Severe Mental Illness: Demographic, Clinical, and Health Correlates.
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SAMHSA Recovery Support Strategic Initiative; Guiding Principles of Recovery
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Public Act 097-0166 adds a new Community Behavioral Health Care section that tasks IDHS to strive to guarantee persons suffering mental illness, substance abuse, and other behavioral disorders access to locally accessible behavioral health care providers who have the ability to treat these conditions in a cost effective, outcome-based manner. IDHS is to designate essential community behavioral health care providers as essential providers for 5 year terms, to ensure continuity and quality of care that is integrated with the person's overall medical care through the following:
- Promote the co-location of primary and behavioral health care services centers.
- Promote access to necessary behavioral health care services in the State's Health Insurance Exchange policies.
- Promote continuity of care for persons moving between Medicaid, SCHIP, and programs administered by the Department that provide behavioral health care services.
- Promote continuity of care for persons not yet eligible for Medicaid or who are without insurance coverage for their conditions.
- Work toward improving access in Illinois' underserved and health professional shortage areas.
A Designated Essential Provider must be not for profit or a governmental entity that:
- Demonstrates a commitment to serving low-income and underserved populations.
- Provides outcome-based community behavioral health care treatment or services.
- Does not restrict access or services because of a client's financial limitation.
- Is a community behavioral health care provider certified by the Department or a licensed community behavioral health care provider holding a purchase of care contract with the State under the State's Medicaid program.
Public Act 097-0438 adds a new 23 member Mental Health Services Strategic Planning Task Force composed of a broad range of legislative, provider, consumer, advocacy, union and academic behavioral health stakeholders to: 1) Develop, within 18 months, a 5-year comprehensive strategic plan for the State's mental health services. 2) To monitor progress during the plan implementation quarterly and make recommendations to the Governor and General Assembly to determine if the recommendations will become law.
The plan shall address the following topics:
- Provide sufficient home and community-based services to give consumers real options in care settings.
- Improve access to care.
- Reduce regulatory redundancy.
- Maintain financial viability for providers in a cost-effective manner to the State.
- Ensure care is effective, efficient, and appropriate regardless of the setting in which it is provided.
- Ensure quality of care in all care settings via the use of appropriate clinical outcomes.
- Ensure hospitalizations and institutional care, when necessary, are available to meet demand now and in the future.
Public Act 097-0439 for counties with a population of less than 3 million amends The Counties Code, adding a new 7 member volunteer mental health advisory committee if the county has a health department but no approved mental health program. The advisory committee shall identify and assess current mental health services in its respective jurisdiction, monitor any expansion or contraction and report to the county board.
Also, for counties with populations of less than 3 million, amends The Community Mental Health Act adding a new 7 member volunteer mental health advisory committee if no community mental health board has been established- unless mental health services are provided. The advisory committee shall identify and assess current mental health services in its jurisdiction, monitor any expansion or contraction, and report to the county board.
The committees shall have no taxing authority and the sections are repealed December 31, 2018.
Public Act 097-0381 - Legislative Findings
By recognizing in Legislative Findings an already deteriorating mental and behavioral health treatment system, exacerbated by the recent fiscal crisis, and characterized by fragmentation, geographic disparities, inadequate funding, workforce shortages, lack of transportation, and overuse of acute and emergency care, where many of an estimated 25% of Illinoisans with serious mental illness go without treatment because it is not available or accessible, an organized and integrated system of care is needed.
Regional Integrated Behavioral Health Networks
The Act requires IDHS to facilitate the creation of Regional Integrated Behavioral Health Networks to:
- Provide a platform for the organization of all relevant health, mental health, substance abuse, and other community entities.
- Provide a mechanism to channel financial and other resources efficiently and effectively.
The goals are:
- Particularly in rural areas, access to appropriate evidence-based services
- To improve access to behavioral health services throughout Illinois, but especially in rural Illinois communities, by fostering innovative financing and collaboration among a variety of service providers
- To support the development of region-specific planning and strategies
- To facilitate the integration of behavioral health, and primary, and other medical services.
- To advance opportunities under federal health reform initiatives
- Ensure actual or technologically-assisted access to the entire continuum of integrated care
- Identify funding for persons without insurance or who do not qualify for governmental programs; and
- Improve access to transportation in rural areas
Regional Integrated Behavioral Health Networks Steering Committee
To achieve the Act's goals the IDHS shall convene a Regional Integrated Behavioral Health Networks Steering Committee composed of responsible State agencies, including a member of each Network to
- Work collaboratively providing consultation, advice, and leadership to the Networks
- Facilitate communication within and across multiple agencies
- Remove regulatory barriers that may prevent Networks from accomplishing the goals
- Collectively or through one of its member agencies provide technical assistance to the Networks
Regional Networks Councils
In each of IDHS's regions Regional Networks Councils shall be convened comprised of community stakeholders.
Each Network shall, within 6 months, develop a comprehensive Regional Plan to address
- An inventory of services
- Identification of unmet needs
- Identification of opportunities to improve access through integrated care
- Development of a comprehensive plan to address community needs
- Development of a specific timeline to implement specific objectives and evaluation measures
- Include the complete continuum of services
Annual Report to the Governor and General Assembly
Report status of each Regional Plan including recommendations of the Regional Networks Councils to accomplish their goals and improve access to services.
- Include performance measures
- Changes to services capacity
- Waiting lists
- Volume and wait times in emergency departments
- Development of care integration partnerships or barriers to their formation
- Funding challenges and opportunities