1. Presentation to Stakeholders Mercer County Community College
Summary of NJ DMHS Wellness and Recovery Transformation Stakeholder Input Process
Presentation to Stakeholders
Mercer County Community College
March 2, 2007

2. Sources of Recommendations
120 stakeholder committee and subcommittee participants including community practitioners, advocates, state employees, family members, consumers, and others
More than 200 consumer and families in focus groups

3. Five Broad Areas of the Stakeholder Summary
Consumer and Family Input
Evidence-Based and Promising Practices will Promote Recovery
System Enhancements
Workforce Development: Education, Training, Supervision, Retention
Data-Driven Decision Making and other Contractual/Regulatory Processes

4. I. Consumer and Family Input
The value of consumer and family input at every level of service development, provision, and monitoring was highlighted. All stakeholders believe that input from consumers and family members is integral to a system that emphasizes Wellness and Recovery principles.

5. Consumer Definitions of Wellness from Consumer Input Forums
In general, wellness was understood by consumers to be related to:
taking care of oneself and a state of physical and emotional health.
statements that defined wellness as, “a state of mind, attitude, staying drug free, keeping busy and getting enough nutrition, exercise and rest,”
“an overall condition of being healthy, not being emotional nor physically down.”

6. Consumer Definitions of Recovery
Traditionally oriented definitions of recovery related to becoming free of symptoms and illness. In these statements, recovery was large defined as an outcome of a process.
“symptoms to disappear,” and “medicine, stabilize, and get back to your life.”
Consumer-driven recovery was understood as a process and/or
Identified community supports as vital in this process, for example, having supports in the community to stay out of hospital,”
“ Learning about your illness, taking your time to get better, getting enough love,” “family support,” “and ,”recovery you have to work on. If you do not work on it, it will go away. “

7. Consumers’ Recommendations for Wellness and Recovery
Improving Community Supports, Linkages, and Services
Improving Staff/Consumer Interactions
Securing Physical and Emotional Safety
Creating Therapeutic Environments
Supporting Autonomy, Choices, and Personal Goals
Overcoming Personal Barriers – Self-management
Consumer forums identified several areas of recommendations including improving Community Supports, Linkages, and Services; Improving Staff/Consumer Interactions; securing Physical and Emotional Safety; developing a Therapeutic Environment; supporting Autonomy, Choices, and Personal Goals.

8. Improving Community Supports, Linkages, and Services
Better community services to prevent long-term hospital services
Upper management more accountable and accessible
Get patients out of the hospital faster
Having the necessary supports in the community to stay out of the hospital as well as the support of the community while in the hospital was important to consumers participating in the forums. Recommendations included large system changes, such as “Better community services to prevent long-term hospital services.” and making upper management more accountable and accessible, “upper staff such as complex administrators and other such upper staff should be accessible or reachable to patients to deal with problems and issues that might arise and please listen, hear and try to understand.” Consumers were also very concerned about “feelings of stagnation, feeling ready for discharge, but not being discharged.” “There needs to be a way to get patients out of the hospital faster.”

9. Improving Community Supports, Linkages, and Services
Improve linkage between inpatient and aftercare:
make sure each consumer has a doctor
schedule several community agency appointments in Advance
provide information on which community agencies to contact
assist with Section 8 and Social Security paperwork
Consumers identified the need for improved linkages between inpatient and community aftercare. They pointed to poor follow-up and a sense of “being lost in the system and the system’s lack of follow-up with you.”

10. Improving Community Supports, Linkages, and Services
connect consumers with addiction services and community twelve-step programs
strengthen ICMS and PACT
offering additional support groups, resources, general support, individual therapy, and personalized treatment plans
Some consumers were concerned about “too easy access to alcohol,” “friends that like to drink,” and “peer pressure”, so assistance with addiction services and connecting consumers with their community twelve-step programs was recommended. The forums also recommended strengthening ICMS and PACT, as well as offering additional support groups and resources, general support, individual therapy and personalized treatment plans.

11. Improving Community Supports, Linkages, and Services
Address stigma and the relationships between various public service employees
better linkages between inpatient and outpatient providers
improved training for police and mental health screeners
more community staff
increase in emergency 911 cell phones
live contact support person 24 hrs a day
education on mental illness for general public and MH providers
Consumers were concerned about the stigma of their mental illness and the relationships between various public service employees when serving persons with mental illness. The forums recommended better linkages between inpatient and outpatient providers, improved training for police and mental health screeners, more community staff, an increase in emergency 911 cell phones, and having a 24-hour community agency live contact person that one can contact anytime for a ride, support, or just to “vent.” Additional education on mental illness was suggested for both the general public and persons working in the mental health field.

12. Improving Community Supports, Linkages, and Services
Barriers to remaining in the community
Lack of employment,
Lack of transportation,
Inadequate housing,
Few educational opportunities
Lack of employment, transportation, and housing were identified as barriers to remaining in the community. Some sought group homes while others were looking for a place to live on their own. Additionally, consumers noted a desire to complete their GED or other educational goals. Employment opportunities are needed for persons while they are in the hospital. Financial problems resulting from unemployment and a poverty of work opportunities were listed as barriers as was transportation (e.g., not having a car or driver’s license).

13. Improving Staff/Consumer Interactions
Hospital staff should be
more caring and understanding
offer hope through better communication
make the hospital a calmer place
be receptive to needs, respectful, and nurturing
The interactions between staff and consumers were an overwhelming concern in the forum comments. Consumers perceive that direct care and professional hospital staff do not have empathy, care, or respect for them.

14. Improving Staff/Consumer Interactions
Staff should understand that consumers still had to take care of personal business in the community while hospitalized
Create a business day – a day outside of the hospital to handle bills and other things
Another interesting finding was that many consumers expressed that staff had a lack of concern, failed to offer help with, and/or understand that consumers still had to take care of personal business in the community while hospitalized. Consumers cited, “make sure people don’t lose things in the community,” while they are in the hospital. They suggested, “Create a business day – a day out of the hospital to handle bills and other things.” Worries over children, rent, legal issues, bad credit, and families could be handled through effective community connections and support services.

15. Physical and Emotional Safety
A lack of physical and emotional safety from peers and staff was a concern identified by several consumers
Experiences ranged from bullying to physical attacks
Many recommendations that consumers be grouped by diagnosis/ functioning level
A lack of physical and emotional safety from peers and staff was a concern identified by several consumers in statements such as, “hustling, borrowing, gambling, trading, selling and buying.” Several comments were made about having “bullies on the unit.” In the varying contexts of this comment, some individuals were referring to fellow patients, and some were referring to staff. One person reported being given a black eye by a peer. Other people commented on peers not being motivated or being too negative. Another consumer’s concern was whether staff would be able to “Keep me from hurting myself.” Perhaps most strongly stated, “This is a f-----d up place. It’s very unstructured and unorganized.” Several consumers recommended that consumers be grouped by diagnosis/ functioning level.

16. Therapeutic Environment-Improved Treatment Activities
Recommendations:
1:1 therapy
employment activities
music/game rooms
outdoor activities,
more exercise
educational movies
topic specific groups
more relaxation time (less “forced” socialization)
Community transition activities
Attending church of their choice
Consumers were clear about their need for therapeutic activities while in the hospital. They noted isolation, noise, boredom, and a lack of appropriate activities as barriers to their recovery. Medications are the main focus of current interventions, while they noted that they need more psychological service/help. Recommendations from the forums included additional 1:1 therapy, employment activities, music/game rooms, outdoor activities, more exercise, and educational movies. While some consumers requested additional groups for specific issues (e.g., women’s groups, trauma groups), others advocated for more relaxation time (less “forced” socialization). Community transition, including activities like shopping, community bingo and bowling, was another area where some consumers thought additional groups would be helpful. Being able to attend the church of their choice as a “level three” to meet spiritual needs was

17. Therapeutic Environment-Improved Treatment Activities
Improving physical aspects of the environment
improved lighting and painting the walls in the bedrooms
Less noise
Individual interventions
ear plugs, dental floss, and hygiene products,
Improving physical aspects of the environment, such as improved lighting and painting the walls in the bedrooms was recommended. Consumers were interested in improvements that would make the environment feel calmer. Individual interventions that could help consumers accommodate to the environment, such as ear plugs, dental floss, and hygiene products, were also recommended in the forums.

18. Autonomy, Choices, and Personal Goals
Consumers have little choice over small things such as phone calls, wake up times, food choices, or when to meet with the team.
The forums recommended increases in choices.
“Constantly having people in charge of me, isolation and seclusion,” was a concern noted in the forums. Consumers have little choice over small things such as phone calls, wake up times, food choices, or when to meet with the team. The forums recommended increases in choices.

19. Overcome Personal Barriers – Self-management
Consumers acknowledged that taking responsibility for their behavior and illness is important for recovery
Consumers comments reflected a level of hopelessness and isolation in their experiences
Consumers identified building and maintaining relationships with others as barriers to their recovery.
Some consumers identified their own behavior or symptoms as barriers, both in the hospital and in the community. While these consumers implicitly or explicitly acknowledged that taking responsibility for their actions and illness is important for recovery to occur, these comments also reflect a level of hopelessness and isolation in their experiences. Building and maintaining relationships with others was another area where individuals noted barriers to their recovery. For some this was apparent in a “lack of friends” while for others it was manifested in family issues. “Family not understanding or desiring to be educated about mental illness being a life long process,” was reported by one consumer. Others had problems with information not being shared with family members or with stigma in the community.

20. Additional themes from Community-Based Consumer Family Forums
Treatment Planning and Support
Staffing
Resource Allocation
Data Driven Decision Making
Methods of Disseminating Information

21. Treatment Planning and Support
Involvement of family members in wellness and recovery planning and support of plans
Include the input of significant paid and unpaid supporters in all aspects of service planning, care, and evaluation.
Addressing perceived HIPAA and confidentiality concerns may be necessary

22. Input into Staffing Decisions
Mechanism for consumer input into
Hiring
Supervision, and
Firing decisions
Recruitment and retention
include consumers and family members as part of the interviewing process as well as supervision of evaluation plans

23. Resource Allocation
Include more consumers and families on county mental health boards and other committees
increase statewide input into the development and evaluation of programs and services
Evaluation of the adequacy of consumer/family representation on board and policy making groups

24. Data Driven Decision Making
Mechanisms be developed to assure consumers they can:
Rate the value the services that they receive and
have sufficient decision making input
Utilize surveys in which resulting feedback would be incorporated into operational decision making
consumers administer surveys to increase likelihood of genuine responses

25. Methods of Disseminating Information
Consumer advocacy educational forums
Consumer dedicated website
Informational newsletter
provide updates on the transformation including consumer written articles
Input solicited via written comment on specific issues
focus groups and consumer/family survey information

26. II. Evidence-Based and Promising Practices
“An ideal system is one that is wellness and recovery oriented and has access to a full array of evidence based practices as well as an array of programs that are promising models of exemplary practice.”

27. Evidence Based and Promising Practices: Recommendation Themes
Core Competencies for all EBPs
Training for Specific EBPs
New Promising Approaches
Monitoring of Implementation
Funding and Regulatory Issues

28. Core Competencies
Training for mental health clinicians in the following areas would support several EBPs:
Motivational Interviewing
Stages of Change/Recovery model of readiness
Cognitive-behavioral techniques

29. Core Competencies Illness Management and Recovery (IMR),
Those competencies outlined above are used in most of the following approaches
Illness Management and Recovery (IMR),
Assertive Community Treatment (ACT/PACT),
Integrated Dual Diagnosis Treatment (IDDT),
Supported Employment,
Family Psychoeducation,
Motivational Interviewing,
Peer Support and Self-Help,
Cognitive Behavioral Therapy (CBT),
Supported Education (SEd), Supported Housing (SH)
Wellness and Recovery Action Plans (WRAP).

30. Training Training Current training efforts will need to be expanded
Training packages used should be user- friendly
Sites determined to be “centers of exemplary practice” should pilot the materials
State should collaborate with professional societies and academic institutions for training and certification of the workforce

31. New Promising Practices
Development of funding for:
clubhouse models,
self-help centers, and
other consumer preferred models
Training for implementation of the shared decision making model
improve communication between providers and consumers

32. Integrated primary health and mental health services
New Promising Practices (cont.) Integration of Physical and Mental Health Services
Integrated primary health and mental health services
Education on physical illnesses
Regular assessment of health measures (BMI, BP, AIMS, etc.)
All programming should include exercise, fitness and nutrition and physical wellness
Alternative & complementary medicines

33. Monitoring
Advisory Committee to assist DMHS in efforts to implement, expand, and monitor practices
Utilization of scientifically derived fidelity scales, both existing and new scales
Fidelity of funded programs to wellness and recovery principles be evaluated
Data collection systems at the state level need to be developed

34. Funding and Regulatory Issues
DMHS
provide seed money and develop training and implementation plans
further support and expand EBPs and Promising Practices
Financial incentives and/or regulatory relief for agencies who adopt EBPs.

35. Inter-agency collaboration
Collaboration between:
Dept. of Human Services, and Dept. of Labor & Workforce Development in order to expand EBPs and Promising Practices
NJ Division of Medical Assistance to address Medicaid funding of EBPs
Practitioners and provider agencies to involve providers in the development of regulations

36. III. System Enhancements
“To complement new and expanded services, stakeholders felt that improvements to the current service systems would contribute to the development of a wellness and recovery-oriented system.”

37. Recommendation Themes
Pervasive Treatment Philosophy and Service Provision
Evaluation of the Current System
Documentation
Consumer/Family Provider
Advance Directives
Joint Protocols and Cross Training
Community and Staff Education
Access Issues: Point of Entry, Housing, Other

38. Evaluation of Current System
Systems Mapping
Compare the existing system with an ideal system designed by stakeholders
Service Duplication
Evaluate services for duplication and create regulations that clearly articulate in which multiple programs consumers can participate
Recovery Oriented System Indicator (ROSI)
Baseline of consumer satisfaction and a method for ongoing systems’ evaluation

39. Documentation
The Virtual Individualized Electronic Wellness/Recovery Action Plan (The VIEW)
Electronic record including Advance directives
Integrated Recovery Plan (IRP)
To replace the multiple treatment plans in multiple programs
Uniform Wellness and Recovery documentation requirements

40. Consumer/Family in New Roles
Navigator
Member of a community support team to help consumers navigate the system
Peer Educator
Provide self-help training and mentoring
Consumers provide training on mental health issues for members of the workforce (hospital and emergency personnel)

41. Advance Directives
Continued training and education on use of Advance Directives
Make sure Advance Directives are being honored in times of need
Navigator and Peer Educator positions can help with training and education

42. Joint Protocols and Cross Training
Shared responsibilities for multiple service users
Joint and cross training for providers of services for the shared populations

43. Public and Community Education
Anti-stigma, public information and education campaign
Particularly for the medical community, legislators, and developers of college curricula

44. Access: Point of Entry
Eligible for services without having been hospitalized
No Wrong Door
Single point of entry for all services needed: physical, social services, vocational, educational, etc.
No exclusionary criteria
Matching of consumers with needed services

45. Access: Housing
Develop and maintain information clearinghouse for housing
Wide spectrum of housing for all levels of the system
Emergency assistance and housing subsidies

46. IV. Staff Development: Recruitment, Retention, Education, & Supervision
Implementing EBPs and promising practices, as well as service system enhancements will require a highly competent workforce making recruitment, retention, and continued development of a qualified, competent, caring workforce as essential.

47. Recommendation Themes
Recruitment and Retention
Methods for Increasing Staff Competency
Standardized curricula
Training for Evidence Based Practices (EBPs) & Promising Practices
Supervision
Consumers as Providers
Policy Changes
Hospital-Specific Recommendations

48. Recruitment & Retention
Salary and benefit parity with state employees for Community Staff
Annual true Cost of Living Adjustments
Salary differentials for additional credentials
Career ladders

49. Recruitment & Retention: Credentialing
Certified Psychiatric Rehabilitation Practitioner (CPRP) as preferred credential
Recovery-oriented
Open to all educational levels/experience
Upward mobility for those earn CPRP’s and specified credentials

50. Some educational programming ideas
Pre-paid tuition program
Expand existing academic programs to all state psychiatric hospitals
Expand existing academic programs to all regions of state
Use flex-time to attend classes
Time off for work-related educational programs

51. Recruitment of Like-Minded Individuals
Involve consumers in hiring, supervision, firing
Liaison with colleges for recruitment and influencing of curricula
Support consumer employment in field
Centralized website for job listings
Market loan forgiveness program
Use exit interviews in QA initiative

52. Increasing Staff Competency: Standardized Curricula
Developed & delivered by academic entity, SME, or national experts
Core content identified by Workgroups
Centralized and coordinated training vs. On-site and customized
Follow-up with TA, consultation, and monitoring
Core courses approved for state licenses and national certifications
Establish incentives for attending training

53. Increasing Staff Competency: Standardized Curricula
Cross Training
Infuse Wellness & Recovery in all state funded training
Cross train staff in DD, Aging In, Jail, DAS, Elderly
Cross train and co-train hospital and community staff

54. Methods for Increasing Staff Competency: EBPs
Academic entity develop and deliver standardized, replicable training
Develop Centers of Excellence and Centers of Exemplary Practice as training and consultation sites
Develop agency leadership coalition to promote EBPs
Ongoing evaluation

55. Methods for Increasing Staff Competency: Supervision
Individual and group supervision
Skills based, non-punitive
Individual learning plans
Performance appraisals, evaluations, PAR/PES based on W&R principles and competency development
W&R survey tool for measuring staff application of W&R principles

56. Consumers as Providers
Receive training for administration of ROSI
Deliver training to general community workers, e.g., police, EMTs, screeners
Deliver training on Advance Directives
Navigator

57. Policy & Procedure Changes
New policies & procedures will require training for implementation
Data collection and reporting
Electronic records, e.g., VIEW
Service access based on need

58. Community: Standardized Curriculum – 12 Domains
Person–oriented attitudes, values, knowledge and behavior
Engaging families and significant paid and unpaid supporters in all aspects of service planning, care and evaluation
Knowledge of clinical and biological aspects of mental and physical illness and developmental disabilities
Knowledge of addictions and mental illness as co-occurring disorders
Assessment, recovery planning and documentation
Intervention and support strategies

59. Community Competencies 12 Domains (Continued)
Community resource development and acquisition
Legal issues and civil rights
Systems collaboration
Ethics and Professional Behavior
Cultural competence
Methods of evaluation

60. Hospitals: Standardized Curricula
Contract with academic entity to develop standardized curricula for Core Competencies and EBPs
Conduct train-the-trainer sessions for training coordinators
Training coordinators will offer ongoing access to training for existing and new employees
Ongoing support and TA available to training coordinators through academic entity

61. Hospitals: Curricula Content
Echoed community recommendations
Additional recommendations for hospital settings
Basic therapeutic skills
Accountability
Communication
Supervisory training
Staff safety and security during W&R introduction
Hands on training to “ease the transformation process”

62. Hospitals:Additional Recommendations
Hospital Workforce Subcommittee continue to meet for competency development and implementation monitoring
Allocate FY2008 resources to assure equivalent training resources throughout the hospital system
Consistent staff development plan
Monitor and re-evaluate after one year

63. V. Data-Driven Decision Making: Contracts, Regulations, and Outcomes
“Critical to all the recommendations outlined above will be the appropriate administrative structures and processes to support the wellness and recovery transformation effort and sustain this new orientation.”
Recommendations for changes in contracting, regulations, and outcome measures were addressed by the relevant subcommittees as well as other sub-committees.

64. Recommendation Themes
Establishing measurable outcomes
Developing a data collection system
Removing systemic obstacles
Evaluating service outcomes and basing funding on performance
Providing service performance information to consumers
Ensuring consumer input
The recommendations across subcommittees consistently reflected the themes of 1)establishing measurable outcomes that are consistent with wellness and recovery, 2) developing an accurate data collection system, 3) removing systemic obstacles to achieving wellness and recovery outcomes, 4) evaluating service outcomes and basing funding on performance, 5) providing service performance information to people with psychiatric disabilities and family members, and 6) ensuring consumer input into the development of a wellness and recovery system and into funding decisions.

65. Establish Measurable Outcomes
Operationalize NJ’s transformed system
Identify system goals
Create associated outcome measures
Identify and/or create fidelity measures relevant to each modality or service.
It was recommended that DMHS operationalize a model of New Jersey’s transformed system including an articulation of the role of DMHS. It is thought that this process could be informed by consultation from other states that have successfully made such a transformation. It is necessary for DMHS, in consultation with providers, participants and experts, to identify system goals and create associated outcome measures that are client/consumer specific; program specific, and system specific. It is also recommended that DMHS in consultation with these same groups identify and/or create fidelity measures.

66. Develop Data Collection System
Develop capacity, infrastructure, and funding
Establish baseline data
Provide initial and ongoing training
It is recommended that DMHS develop the capacity, infrastructure, and funding to support statewide data collection and analysis that is consistent with program modality. This should include the establishment of a baseline of data to support outcomes evaluation and system transformation. Further, DMHS should provide initial and ongoing training for data collection and reporting for all Division funded agencies and hospitals.

67. Remove Systemic Obstacles Promote Cross System Collaboration
System-wide needs assessment
Data sharing
Include “physical” health data
Hospitalization data
Employment data
Recommendations reflect obstacles in many aspects of the system. A system-wide needs assessment should be conducted to identify service gaps and provide a statewide report card. It was recommended that providers serving the same individual be required to share data. This should include physical health care data as well. Data related to physical health and wellness service needs, availability, and effectiveness should be collected and tracked. There should be a review of requirements from regulatory agencies to reduce duplication of data submission. DMHS should advocate with NJ Medicaid for changes that remove obstacles to wellness and recovery services (e.g., changing from clinic to rehabilitative).

68. Evaluate Service Outcomes Performance Based Funding
W & R outcome measures in all contracts
Tie service outcomes first to monitoring and later to reimbursement and contracting decisions
Establish consequences and incentives
Redirect resources from lesser-valued/lower priority to higher priority services
It was recommended that DMHS embed wellness and recovery outcome measures in all inpatient treatment services and community contracts including partially funded agencies. Service outcomes should be tied to continued funding and the contract award and monitoring processes. Some suggested a continuum of compliance levels (e.g., minimal, recommended, and ideal) with associated financial consequences and incentives. DMHS should planfully redirect resources from lesser-valued/lower priority to higher priority services. Funding should be available for pilot studies.

69. Ensure Consumer Input In transformation and resource allocation
gather input
provide support for participation
include reticent groups
Support consumer being well-informed
informational newsletter
educational forums
interactive website
Several recommendations addressed the need to ensure consumer input in the transformation process as well as ongoing resource allocation and funding decisions. DMHS should identify ways of gathering input (e.g., county MH boards, policy groups focus groups, distributing surveys), provide adequate support for participation (e.g., travel reimbursement), and include groups of consumers who tend to be reticent (e.g., those rejecting services, those who have left services, and those who have yet to feel empowered enough to provide input). Further, it was recommended that DMHS support the consumer community to be well informed by creating an informational newsletter, providing educational forums, and creating an interactive website.

70. Provide performance information to consumers and family members
Performance report card
Specify outcome data
Publish on the Division’s website
It was recommended that DMHS create a reader-friendly performance report card on programs, agencies, and hospitals. This report card should specify outcome data and should be published on the Division’s website.

71. Other Regulatory Issues
Work with Medicaid
Share data on “physiological measures’, other illness/diagnoses, and hospitalization
With DMAHS review and if needed revise regulations to support wellness and recovery approaches within federal guidelines
Working with DHS Licensing & Inspections
Engage Office of Licensing staff
Review and revise regulations