Summary of Meeting
Ramada Inn, Rockville, MD
September 26 – 27, 1996
DAY TWO: Sharing Information
CMHS Research, Training, and Technical Assistance Agenda for Fiscal Year 1997 and Beyond
Thomas Bornemann, Ed.D., CMHS Deputy Director and Acting Director of the Office of External Liaison, started the day by emphasizing the importance of the TA Centers as the "eyes and ears of the mental health field." CMHS and the TA Centers must be proactive rather than reactive, he said. We know there is a demographic bulge of both young people and those in retirement. As a result, "we need to be out front now to test models that include cultural diversity to serve these populations." A critical task of the TA Centers, he said, is to integrate, collaborate, and communicate, while retaining individual identity. Survival depends on working together, he added.
With Congressional funding for CMHS this year frozen at FY '96 levels, it is essential to maximize resources. Bornemann noted that CMHS is a latecomer to the "altar of evaluation and effectiveness." Not only must CMHS do a better job at disseminating information, it must apply that knowledge. In addition, research must lead to policy changes for systems of care.
Joe Rogers chided CMHS for focusing on high level professionals (e.g. - the associations, State planners). He asked how CMHS will move from this focus to a mass audience.
Bornemann responded that CMHS grew out of the National Institute of Mental Health with primary contact in the research and provider communities. It's important to maintain relationships with the guilds, he said, but CMHS looks to the TA Centers and consumers for ideas to broaden its focus.
Jim Ciarlo, Ph.D., Director and Research Professor with Frontier Mental Health Services Resource Network, addressed the need to go beyond the consumer and reach the masses through the media - radio, newspapers, the popular press, even television. He cited a recent National Public Radio story on Alzheimer's disease as an excellent example of how to get basic information to the public. Someone else also suggested distributing materials - such as brochures, pamphlets, and fact sheets - to recreation centers, schools, and places of worship.
Sharing Information
Michael English, J.D., Director of the CMHS Division of Knowledge Development and Systems Change, informed the group that part of SAMHSA's strategic plan is systems change. That is, the knowledge development and applications agenda must focus on outcomes that lead to systems change. In fact, English said, a measure of our success will be the systems change we create.
He also addressed the need to market CMHS. For example, folks on Capitol Hill - those who hold the purse strings - think CMHS and NIMH are the same. To remedy this broad lack of understanding about CMHS, we must understand who "we" are and what our agenda is. To that end, we must:
- Synthesize our knowledge,
- Convert the products into packages people can use, and
- Build consensus in the community to carry out projects that work and yield best practices.
Further, to maximize the return on our investments, CMHS - and the TA Centers - must "sell" their programs. We must get the word out about what we do and the value of our programs, English asserted. And preaching to the choir won't get the results we need. Instead, we must market to communities such as the health industry and primary care providers. We need to:
- Define our knowledge products and make them distinctive
- Target our customers; not everybody needs the same product.
- Release interim findings.
On this last issue, English cautioned that it's a delicate dance between releasing information prematurely and waiting years for final outcomes. One possible example for such a report would be a "slim jim" on findings from the 22 sites in the National Resource Network on Child and Family Mental Health.
The group discussion touched on many points, such as:
- We must mobilize people and tie in information at the county level - Joe Rogers.
- Policy folks are informers, makers, and implementers. All of them are part of the knowledge utilization chain. And we must do a better job of using the media to get information to the public - Steve Leff.
- We must listen to consumers. Doing so empowers them and guides us to provide the right services - Vicki Smith.
- What is systems change? It may be different for different populations. TA Centers need training. What are the guilds' agendas for systems change? We should bring in people whose success at systems change may shed light on how to effect similar change - Judith Cook, Ph.D., Director of the University of Illinois at Chicago National Research Training Center on Psychiatric Disability, and Barbara Friesen, Ph.D., Director of the Research and Training Center on Family Support and Children's Mental Health.
Applying CMHS Knowledge in the Field
Ellen Kagen, M.S.W.,Director of Special Programs with the National Resource Network on Child and Family Mental Health, and Trina Osher, Director of the Family Leadership Initiative for the Federation of Families, discussed ways to apply CMHS information to the field. Kagen noted the importance of distinguishing between knowledge and information. She added that "things can be important to the field - but are they relevant to the community?"
The goal of knowledge application is to close the gap between what people know and what people do. Kagen used adult learning theory to highlight the best way TA Centers can provide technical assistance. Adult learning is active, dynamic, and goal-directed, she said. Similarly, TA providers need to appreciate that their constituents have:
- Unique approaches and perspectives;
- Prior knowledge and experience; and
- Cultural competence/awareness.
The services TA Centers provide should be directed by the community itself. Cookie-cutter approaches simply do not work. The more a TA Center individualizes its program, Kagen said, the more it increases the possibilities for success.
In addition:
- The program's pace must match the community's desire to embrace it.
- It must be appropriate for the community. Kagen gave as an example a community in South Carolina where worker safety was the pressing issue - not wrap-around services as TA Center staff had thought.
- Cultural competence also must be tailored to fit the community.
In short, Kagen said that providers must know their community before they can offer the right services - that is, disseminate the knowledge the community can use.
Trina Osher discussed her experience creating a grassroots family support network in Rhode Island that eventually led to systems change. She suggested developing local-level or State-level TA Centers to provide targeted and relevant assistance. The challenge, she said, is for service providers to partner with - and learn from - the local community with the ultimate goal of putting TA Centers out of business.
A group discussion revolved around what role consumers and families should play in applying information. Someone noted that consumers/survivors employed in State mental health agencies are one way to promote this exchange.
Another person commented that a peer support mechanism seems to be the best way to encourage information exchange, that professionals can help families with the "business end" of treatment services, but peer support is critical for aspects of care.
Barbara Friesen noted that families are effective in getting information to Congress and to policymakers - that families are great advocates for change.
Someone pointed out the need to have families "at the table" as the service plan is being developed so the services delivered are, in fact, those that are needed. Gary DeCarolis illustrated this issue with an anecdote from Vermont. When providers answered a survey about what services should be funded, in-home services ranked number one. Families, on the other hand, placed respite care as their number one priority on the same survey. Providers ranked respite care 13th in importance.
In regard to Information Center products, Sylvia Caras requested that they be at least 51 percent consumer driven.
The question of evaluation came up. The Evaluation Center @HSRI is undergoing an external evaluation by Policy Research Associates, Inc. Others discussed how TA Centers, in general, evaluate themselves.
Michael English asserted the need for baseline data on best practices. Working from a consensus on what constitutes best practices, he said, communities must be allowed to adapt. The issue of involuntary treatment was raised. English replied that debate on this issue does not preclude work on other issues. Communities clearly need tools to help people with severe mental illness. In addition, providers need to be trained about best practices; such information must get into the professional curricula at educational institutions.
Targeting Technical Assistance and Improving Collaboration
Bruce Emery, M.S.W., Director of the National Technical Assistance Center for State Mental Health Planning, gave an overview of the kinds of sweeping changes to mental health systems States are facing. For example, 17 of 46 State Mental Health Authorities (SMHAs) have been reorganized within the last two years, in six States the SMHA was relocated within State Government, and in seven States services for other disabilities (such as substance abuse and mental retardation) have been moved into or out of the SMHA.
Thirty-five States report reorganizing or closing State hospitals, 19 are downsizing their systems, 17 are closing wards, 14 are reorganizing their systems, and only six are replacing an old State mental hospital with a new one. An additional nine States are planning to close 11 State hospitals, representing the loss of 871 beds over the next two years.
Similarly, funding has been shifting from State hospitals to community-based services. In FY81, States spent about 63% of their budgets for services on State mental hospital inpatient care and only 33% on community-based mental health services. By FY93 funding for each had equalized at 49%. And within that period, spending by State mental health agencies actually declined slightly from $6 billion to $5.8 billion after adjusting for inflation.
In regard to collaboration, Emery commented that to survive, the Centers need to be generous - they must be willing to share what they know with one another. "Concerns about territoriality," he said, "will affect our willingness to collaborate."
Expanding on this theme, Michael English noted that the TA Centers must articulate what it is they do, what they have in common - and what is important and different about their work. The answer to questions about the number of TA Centers, he said, is that their diversity is critical for meeting the many and distinct needs of Americans. Some TA Centers provide technical assistance in the same area - such as children's issues - but from a different perspective.
At the same time, English asserted, TA Centers must be marketed as a single effort. He suggested that the Centers consider forming a sort of "consortium" to gain the leverage of a collective. The Information Center could then market this consortium. The idea of a consortium of the CMHS Technical Assistance Center has its genesis, English said, in the need for CMHS to manage and portray its technical assistance activity as:
- Focused,
- Non-duplicative, and
- Strategic.
CMHS is under increasing scrutiny to justify its budget, improve management, and demonstrate a return on the investment of public resources. A consortium would create a forum for TA Centers to share and coordinate their individual activities, and to identify and execute opportunities for cross-TA Center collaborations on specific projects. In addition, these cross-TA Center collaborations would enable CMHS to more easily bring together a variety of talents and knowledge to accomplish its important work. For example, such collaborations would not require separate acquisitions of services - a process that often is stymied by bureaucratic obstacles.
Finally, a consortium would create unique capacity within the current TA Center structure that exceeds the sum of the individual parts. This gestalt would further CMHS efforts to expand knowledge application activities and to meet its customers' needs.
Jointly Supported Technical Assistance: Ensuring the Involvement of CMHS Cosponsors
Bonita Vesey, Ph.D., Associate Director of the National GAINS Center for People with Co-Occurring Disorders in the Justice System, presented an overview of the GAINS Center's first year of work, specifically in terms of accomplishing its goals when funded by three different Federal agencies - CMHS, the Center for Substance Abuse Treatment (CSAT), and the National Institute of Corrections (NIC). The GAINS Center's primary goal is to support systemic change to promote treatment services in jails and prisons for people with co-occurring disorders.
When the TA Center began its work, a great deal was known but little information had been documented. One of the initial hurdles was the fact that the players weren't talking to one another - mental health didn't talk to substance abuse and vice versa, and criminal justice didn't communicate with providers/planners outside its own purview.
The key to working with different Federal agencies has been to:
- Establish equal partnerships despite unequal funding;
- Agree on a common language;
- Develop shared goals;
- Administer the cooperative agreement through one agency (in this case the NIC); and
- Promote interdisciplinary agreement and cooperation.
Providing services in jails is difficult because of:
- Overcrowding;
- Management problems; and
- Budget deficiencies that lead to service gaps.
In addition, the criminal justice system was not designed to deal with homeless people with severe mental illness who are imprisoned or youthful offenders who receive long sentences.
Two focal points for the GAINS Center are front-end efforts to divert people from jail to appropriate services and discharge planning to ensure community linkages for ex-offenders.
Technical Assistance in a Managed Care Environment
Jeffrey Buck, Ph.D., Director of CMHS' Office of Organization and Financing (Managed Care), gave a presentation on the managed care activities underway at CMHS and SAMHSA. Two years ago SAMHSA recognized that the increase in managed care is an important issue. The Office of Organization and Financing is designed, in part, to reduce duplication of effort within CMHS and to keep pace with other managed care activities within SAMHSA.
Among its efforts, the Office is gathering information about the private sector to predict trends in the public sector - that is, Medicaid managed care - and is developing models of best practices.
James Ciarlo noted that the only leverage point States have is during contract negotiations. Trina Osher commented that no one yet understands publicly funded managed behavioral healthcare.
Identifying Agenda Items for Future Meetings
The meeting concluded with agreements to:
- Convene discussion groups on building consensus/defining collaboration (Division of Knowledge Development and Systems Change);
- Create a work group on managed care (Division of Knowledge Development and Systems Change);
- Develop additional links among the CMHS TA Centers and counterparts in other Federal agencies - prioritize child/adolescent TA Centers (Division of Knowledge Development and Systems Change);
- Work with TA Centers to figure out how to talk about CMHS and its functions (Division of Knowledge Development and Systems Change);
- Engage in conflict resolution;
- Make sure each TA Center is connected to the Information Center World Wide Web site (Information Center);
- Convene discussion groups on sharing information about technology (Information Center);
- Set up a forum for the TA Centers on the BBS (Information Center);
- Create a Listserv for TA Centers (Information Center);
- Give TA Centers hardcopy packets of Information Center literature for distribution at TA Center functions;
- Form a consortium;
- Link with the Information Center's Web page, check the TA Center description, and provide accurate information to the Information Center if needed (TA Centers);
- Send one or two current publications to the Information Center (TA Centers); and
- Form a workgroup on how TA Centers can involve consumers/survivors.
The group also recommended some topics for the next meeting's agenda. While no date is set, the third week in February (but not February 23-26) appears to be a time that works for most people.
Some suggestions for the meeting include:
- Effective communications/information dissemination;
- How to identify customers;
- Outreach to other Federal agencies;
- Systems change;
- Self-evaluation; and
- A separate workshop for TA Center "techies" on the Information Center.
Participants also suggested:
- An on-site Information Center training session;
- In-service for Information Center staff at TA sites; and
- At future meetings, each TA Center should bring one consumer to the table.
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