Reforming Mental Health In the U.S.

Reforming the Mental Health System in the U.S.

NYAPRS Note: The following provocative piece about efforts to transform the nation's mental health system underscores the importance of providing "a support infrastructure that provides both advice and technical assistance for those providers who need it...(helping) "providers..(to be) convinced of the need for change and be able to communicate these benefits to their clients, communities and stakeholders." Over the past decade, the NYS Office of Mental Health has been a leader in this area, offering providers training and support to transform their attitudes, beliefs and practices via special OMH staff training programs and statewide projects like the NYAPRS Training Collective.

Does the Mental Health System Need Its Own "Apollo Program":

Necessary Steps for Mental Health Transformation

by Adrian Bishop and Richard Dougherty, Ph.D., Dougherty Management Associates

The goals and recommendations detailed by the President's New Freedom Commission on Mental Health are long overdue. Too long have Americans with mental illness had to cope with the stigma that surrounds mental illness, unfair treatment limitations and a fragmented delivery system. However, these goals and recommendations run the risk of never being implemented because they are so far-reaching. In fact, the Commission stated in the report: "To improve access to quality care and services, the Commission recommends fundamentally transforming how mental health is delivered in America."

These are broad outlines that provide an overall and rather philosophic strategy. How do we translate these overarching goals into something purchasers and providers can work on? Where are the rules, the guidelines, the methodology and the deliverables? How do we really transform the way mental health is delivered in America, especially with often confusing and inconsistent federal, state and local roles in the delivery system?

The scale of this transformation is enormous and will be the mental health equivalent for the Substance Abuse and Mental Health Services Administration (SAMHSA) to the Apollo program, which successfully took man to the moon. One key element in the original Apollo program was its leaders' ability to provide a vision (backed by scientific evidence and technological capability) and motivate a world-class team to translate the vision into actual practice, removing barriers to progress as they appeared.

The "Apollo program" for the mental health system must be designed and managed along similar lines, and must consist of enlightened and extremely focused leaders who clearly define a strategic vision for the mental health system that is fully aligned with the New Freedom Commission report and the Institute of Medicine's (IOMs) "Crossing the Quality Chasm."

These leaders must then work with the appropriate stakeholder groups to translate this vision into meaningful and achievable process-based goals and objectives. The recurring focus of Charles Curie and Kathryn Power at SAMHSA on the "transformation" agenda is an example of the leadership and motivation required to achieve this kind of system change.

While the federal role is significant, ultimately it is at the state level where the strategic vision must be translated into objectives and actions developed to bring the required transformation to providers and their clients. At the provider level, new client processes will likely have to be developed from the "ground up." At both of these levels, the change efforts must be guided by a clear vision and principles that focus staff decisions and actions.

To create the systemwide transformation at the federal, state and local level, we need to have new approaches to managing change. We need new content, project management tools and behavioral change in our workforce. Systems must be established to allow states to work closely together, sharing best practices, successes and even failures.

On a project of this size, work must be shared, not duplicated. Effective collaboration, carefully crafted incentives and frequent feedback are some of the most important tools and techniques needed to achieve the transformation.

Transforming the mental health system will be expensive, and much of this cost will be borne at the provider level, where many of the actual operational changes will be developed and implemented. For the transformation to be effective, providers must be convinced of the need for change and be able to communicate these benefits to their clients, communities and stakeholders.

The necessary resources must be identified, together with a support infrastructure that provides both advice and technical assistance for those providers that need it. One way to reduce the burden on states and providers will be to use a collaborative approach where small groups of providers work together to identify best-practice solutions to common issues and jointly implement those solutions within their respective organizations.

Similar approaches have increasingly been used by the Institute for Healthcare Improvement and others seeking to encourage large-scale system change. This will create best-practice methodologies and a pool of subject-matter experts that can, ultimately, provide the necessary guidance and assistance to the wider provider community.

Examples of potential collaborative projects would include improving retention in treatment, reducing the time to first appointment, reducing no-show rates, increasing employment of consumers, reducing readmissions and effectively implementing key technologies such as electronic patient records. Initial collaborator groups would be physical entities of local providers meeting in convenient common locations. However, as the collaborative approach developed, there would be no reason why collaborator groups could not be "virtual," in diverse locations using Internet-based technologies to communicate.

Proven improvement methodologies and tools should be used to drive the transformation and ensure the success of the individual improvement projects. Over the last few years, the tendency has been to move away from a business re-engineering approach, where large-scale projects were the norm, to a "lean" approach that advocates a larger number of integrated rapid cycle improvements that produce results in weeks rather than months or years. See, for example, the work being done by the Network for the Improvement of Addiction Treatment (www.niatx.net).

Through these smaller-scale improvement projects, managers and staff learn the techniques and can use the tools needed for change in other areas and on other projects. However, the number of projects, their rapid cycle times and the focus on real results require substantially higher levels of project management skills.

The success of the mental health transformation will ultimately depend on providers' willingness to develop best practices, embrace the necessary changes and share their successes and failures. An infrastructure of support must be established that can provide the key skills and technologies unlikely to be available now at the state or provider level. Providers must not be merely given (or perceive that they have been given) additional requirements to meet without the necessary resources or backing, but must see themselves as a critical element in a well-orchestrated and highly supportive "system of care."

Effective implementation of radically improved processes will require new or enhanced skills. Training for personnel at all levels will be needed. Feedback loops must be set up to monitor the effectiveness of the new processes, ongoing refinement will be needed, and provider and project leadership must be continually prepared to monitor results and remove roadblocks.

Historically, the most successful projects are those with a win-win outcome, and surely a mental health services transformation can and will produce lots of winners: consumers, providers and communities. If we can put a man on the moon in eight years from the time President Kennedy announced the goal, then we should be able to achieve the goals of mental health transformation.

Adrian Bishop specializes in quality improvement for the Lexington, Mass.- based behavioral health consulting firm Dougherty Management Associates. Richard Dougherty is the firm's president.

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Last Updated on 01/06/05 webmaster@namiscc.org

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