1. 6 th Annual Organizational Change Forum System Transformation to Recovery Focused Services Roy Starks-Mental Health Center of Denver

2. Overview Creating a Recovery Focused System Measuring Recovery Creating a Culture which Promotes Recovery Focused Work

3. What is Recovery? “Recovery refers to the process in which people are able to live, work, learn and participate fully in their communities. For some individuals, recovery is the ability to live a fulfilling and productive life despite a disability. For others, recovery implies the reduction or complete remission of symptoms. Science has shown that having hope plays an integral role in an individuals recovery.” William Anthony Achieving the Promise—The President’s New Freedom Commission on Mental Health 2003

4. Vision Statement New Freedom Commission “We envision a future when everyone with a mental illness will recover, a future when mental illnesses can be prevented or cured, a future when mental illnesses are detected early, and a future when everyone with a mental illness at any stage of life has access to effective treatment and supports-essentials for living, working, learning, and participating fully in the community.”

5. Recovery focused System components 1989—MHCD formed by City of Denver in response to Robert Woods Johnson Foundation—Requirement for one mental health Authority Denver combined four existing mental health centers to form MHCD (small SE program, no consumer employment, no drop-in or clubhouse program, no strengths based case management, mission statement of quality mental health, no value of recovery—ie. Business as usual)

6. Recovery Focused System Components 1989-1993—Stabilize creation of new center 1993-2000—Implementation of Lawsuit 2000—Article on “Denver Approach” 2000—New CEO with Recovery Commitment 2001—Formation of Recovery Committee 2001—Creation of RNL 2003—Completion of Logic Model 2003—Commitment to “Center of Excellence” 2004—Adoption of new mission statement

7. Recovery Focused System Components Enriching Lives and Minds by Focusing on Strengths and Recovery 2003 to 2007-Development of Markers and Measures 2007—Use of REE and conversion to PRO 2006—MHCD receives award of Excellence from National Council for 2005 for work in recovery focused system

8. Recovery Focused System Components Outreach and engagement –Outreach workers in homeless shelters –Recovery Connections –Housing First project with CCH –Denver’s Road Home-1) Project for Homeless Women 2) Project for Denver’s most difficult to house

9. Recovery Focused System Components Housing with Appropriate Supports –Extensive system of Group homes, congregate apartments, section 8 apartments Partnerships with Colorado Coalition for the Homeless, Denver Housing, Colorado Housing and Homeless program, REDI corporation, Senior Housing Options

10. Recovery Focused System Components Intensive Case Management –Ratio of 1 to 12 –Ratio of 1 to 25 –Ratio of 1 to 40 –Ratio of 1 to 80 Psychiatry only

11. Recovery Focused System Components Integrated Treatment for Co-occurring Disorders –MHCD SURGE program High Fidelity use of the Integrated Dual Diagnosis Treatment (IDDT) as developed by Kenneth Minkoff, M.D. –Partnerships with Arapahoe House and CCH

12. Recovery Focused System Components Involvement of Recovering Persons –On MHCD Board –Consumer/Staff Partnership Council –Peer Mentors –Extensive employment of recovering persons 40% in Rehabilitation program CMA, vocational counselor, residential counselors, mail room, administration, nurses, case managers Survey teams; Office of Consumer Affairs

13. Recovery Focused System Components Supported Employment –Use of IPS Evidence Based Practice— Adherence to Fidelity Scale as developed by Drake and Bond—Serves 500 annually—Part of Mental Health Treatment Study –In conjunction with Supported Education program—Modified from Clubhouse model— Part of Bridge to Community Integration

14. Why Evaluate Recovery? The Surgeon General Report on Mental Health (DHHS, 1999), and Presidents New Freedom Commission (DHHS, 2003) suggested mental health providers engage in system transformation to become more recovery oriented. At MHCD, we believe that evaluation is a critical component of system change. –We have a constant feedback loop about client’s recovery for clinicians, managers and directors, thereby providing data to assist in system transformation.

15. Evaluating Recovery of the Person Development by MHCD of Multidimensional approach to evaluating recovery from different perspectives over time.

16. (1)Recovery Marker Inventory (RMI) (Staff rating of member progress in recovery on eight dimensions. Used to inform clinical & program decisions - every 2 mo.) (3) Recovery Measure by Consumer (RMC) (Consumer’s rating of their own recovery on five dimensions – all members every 3 months) (2) Promoting Recovery in Organizations (PRO) (Consumer evaluation of how specific programs and staff are promoting recovery - random sample 1x per yr.) To what degree is RECOVERY happening?   Multiple perspectives  Multiple dimensions  Change over time Four Measures of Recovery (4) Recovery Needs Level (RNL) (Suggests best level of services for stage of recovery) (4) Recovery Needs Level (RNL) (Suggests best level of services for stage of recovery)

17. Recovery Marker Inventory (RMI)

18. Recovery Marker Inventory Indicators usually associated with individual’s recovery –But they are not necessary for Recovery. For example, a person may struggle to find a job because of their level of Recovery OR because the economy is bad Collected every other month on every consumer in high case management teams, according to a predetermined criterion on outpatient consumers

19. Recovery Marker Inventory Dimensions Employment Education/training, Active/Growth orientation, Symptom interference, Engagement/role with service provider, Housing, Jail episodes/days, Hospital episodes/days due to psychiatric reasons, Hospital episodes/days due to physical reasons, Substance abuse (level of use) Substance abuse (stages of change).

20. Reliability of the RMI V2.1 Reliability- how consistently we will get the same score for individuals with the same level of indicators of recovery (we want high reliability, meaning high constancy in scoring). –Mathematically, it is hard to get a high reliability with only 6 items. –RM V1.0 has a CTT reliability of.67 IRT reliability: Person =.75, Item = 1.00 CTT reliability =.78

21. Item difficulty for the Recovery Marker Inventory V2.1 Symptom Interference (.83) Active Growth (.63) Engagement/ Participation (-.10) Housing (-.22)Employment (-.35)Education (-.79) The easiest marker is reduction in symptom interference. In traditional treatment this will be primary goal. As the markers increase in difficulty that means that the number of consumers that get a high score in this marker decreases, For example, if a consumer has a high score in engagement/participation, they will also have a high score in active growth and symptom interference because these markers are easier to achieve for our consumers. The hardest marker of recovery for our consumers to achieve is education. This means that most consumers who score high on education will score high on all other markers of recovery.

22. Promoting Recovery in Mental Health Organizations (PRO)

23. Recovery Enhancement Environment Developed by Patricia Ridgeway People rate the importance of several elements (such as hope, sense of meaning, and wellness) to their personal recovery, and rate the performance of their mental health program on three activities associated with each of these elements. They also rate the program on factors in the program climate that promote resilience or rebound from adversity

24. Promoting Recovery in MH Organizations (PRO) Developed by MHCD to address our special needs Sections for each type of staff that interacts with our consumers (front-desk clinical, medical, case managers, rehabilitation) Currently is being piloted at MHCD

25. The Reaching Recovery Program is the intellectual property of the Mental Health Center of Denver. By [viewing this presentation; receiving these materials, etc.] you agree not to infringe on or make any unauthorized use of the information you will receive.

26. Recovery Measure by Consumer (RMC)

27. Recovery Measure by Consumer Intended to measure the consumer’s perception of their Recovery –Very useful to understand whether what we observe matches how the consumer is feeling For example, a person may stay at home because they have an introverted personality, OR because they might have paranoia symptoms –Sometimes, the consumer fills it out with the help of the clinician, thus sparking new areas to explore together

28. Recovery Measure by Consumer Dimensions Active/growth orientation Hope Symptom’s interference Safety Social network

29. Social Networks (-.48) Hope (-.32) Active Growth (.01)Safety (.08) Symptom Interference (.50) The easiest domain of recovery is an increase in social networks and hope As the domains increase in difficulty that means that the number of consumers that get a high score in this domain decreases, For example, if a consumer has a high score in safety they will also have a high score in active growth, hope and social networks because these markers are easier to endorse for our consumers. The hardest recovery domain for our consumers to achieve is symptom interference. This means that most consumers who score high on symptom interference will score high on all other domains of recovery.

30. Recovery Needs Level (RNL)

31. Recovery Needs Level Helps to assign the right level of service to the consumers The basic assumption being that consumers recover and their needs change over time. Used at MHCD every 6 months in combination with their Individual Service Plan (ISP)

32. Recovery Needs Level Measures criteria for service needs in 17 areas such as: Hospitalizations Lethality Co-Occurring Substance Abuse Case Management Needs

33. Recovery Needs Level Completed by Primary Clinician in Electronic Record Scored Electronically According to Algorithm Five Levels of Service: -- ACT –High intensity case management –Medium intensity case management –Outpatient service –Psychiatry only

34. Lessons Learned

35. On average, individuals coming into MHCD who are homeless and have a severe mental illness, move from ACT to Intensive case management in 18 months In a five year period 21% moved to more intensive services and 64% moved to less intensive services

36. Lessons Learned As people move to less intensive services, they do not fall apart—In fact their recovery markers and measures both continue to increase. People at all five levels access supported employment services. As people move into employment, all of the recovery markers increase

37. Lessons Learned The first year the RNL was implemented, 25% of people in ACT moved to less intensive services Following the first year, 16% move from ACT to less intensive The cost for 400 openings to intensive services the first year would have cost the state an additional 5 million dollars.

41. Using Recovery Information for Quality Improvement Creating a Culture Which Promotes Recovery Focused Work

42. MHCD Values We, the staff, consumers, and governing board of MHCD, value: Consumer recovery and resiliency fueled by hope and encouragement toward consumer goals Compassion and empathy Service excellence, efficiency, and effectiveness to meet the needs of consumers and the community A wellness culture that recognizes, respects, and develops the strengths of consumers, staff, and our partnerships in the community; Honesty, integrity, and ethical behavior in all our actions, communication, and relationships; Diversity in our workplace, relationships, and community; Innovation, creativity, leadership, and flexibility Green sustainability to protect the environment and reduce waste in all our valued resources.

43. MHCD Wellness Culture We intentionally bring out the best in ourselves and others by: Seeing everyone’s strengths Supporting and encouraging one another Celebrating staff, accomplishments, and diversity Respecting ourselves and others Listening to each other Creating an environment of healthy and positive relationships and community partnerships Believing everyone wants to be great Being passionate about our mission and having fun in the process Believing anything is possible!

44. First Break All the Rules Marcus Buckingham & Curt Coffman “The Measuring Stick –Do I know what is expected of me at work –Do I have the materials and equipment I need to do my work right? –At work, do I have the opportunity to do what I do best every day? –In the last seven days, have I received recognition or praise for doing good work? –Does my supervisor, or someone at work, seem to care about me as a person?

45. Continued –Is there someone at work who encourages my development? –At work, do my opinions seem to count? –Does the mission/purpose of my company make me feel my job is important? –Are my co-workers committed to doing quality work? –Do I have a best friend at work?

46. Continued –Is there someone at work who encourages my development? –At work, do my opinions seem to count? –Does the mission/purpose of my company make me feel my job is important? –Are my co-workers committed to doing quality work? –Do I have a best friend at work?

47. Continued –In the last six months, has someone at work talked to me about my progress? –This last year, have I had opportunities at work to learn and grow? These twelve questions are the simplest and most accurate way to measure the strength of the workplace.”

48. Continued –In the last six months, has someone at work talked to me about my progress? –This last year, have I had opportunities at work to learn and grow? These twelve questions are the simplest and most accurate way to measure the strength of the workplace.”

49. Go Put Your Strengths to Work Marcus Buckingham Set out format for how to maximize the use of your strengths in the workplace Sets course for how to build on the strengths of others and to maximize their strengths in the workplace

50. Catalytic Coaching Garold L. Markle Provides detailed alternative to traditional performance evaluation which enables people to create a course to maximize strengths and accomplishments –Employee input sheet –Coaches perception –Employee creates plan

51. Client Driven Treatment Planning Individual Service Plan (ISP) Asks consumers what they need and want Elicits consumer’s strengths Actively uses consumer strengths in objectives and methods Used and reviewed with the consumer Included in Peer Review

52. Service Planning The Individual Service Plan asks consumers: –What do you need and want? –What skills, interests, resources, and qualities do you have? –What cultural/ethnic/racial/spiritual strengths do you have? –What do you see as the areas you'd like to change? –Other input from consumer about priorities Clinician input about priorities The Case Review is integrated with the ISP and involves consumers Six Month Case Review –Consumer Perception of Progress –Clinician Perception of Progress –Consumer-identified treatment focus for next six months

53. Role of the Electronic Medical Record STAR / eCET integrated platform Helpful tool for Quality at the Source Service integration –Service delivery coordinated with service plan –Service integration among all staff –Actively includes Rehab and Residential Peer Review Extensive staff training Integration with recovery instruments

54. Data Collection: Integration and Automation Automated and integrated processes Recovery Instruments: Integrated with STAR electronic medical record Show rate reports Peer Review: –Conducted electronically using STAR documentation –Input into an MS Access database for analysis Goebel UM Review: –All new admissions, identified in STAR database –Outliers identified in STAR services database –Services and documentation compared with RNL in STAR PRO Survey (Promoting Recovery in MH Organizations) –Scannable forms eliminate manual data entry

55. Benefits of Our Integrated Systems Performance and process feedback to clinicians, managers, administration –Peer review trend reports –Clinician utilization reporting –Consumer complaints data and reports Compliance with state and federal requirements –Billing –Due dates –Signatures –Formats

56. Benefits of Integrated System Systems for collaboration, cooperation, involvement –Accessible data –Efficiency through automatic data capture –Efficient and effective peer review –Information to provide quality care –Effective utilization of resources, clinical and administrative Mentor, Measure, Motivate –Engage clinicians in using recovery data –Focus on what’s measured –Identify best practices –Watch trends for continuous improvement