Remarks by
A. Kathryn Power, M.Ed.
Director
Center for Mental Health Services
Substance Abuse and Mental Health Services Administration
U.S. Department of Health and Human Services
Transforming Our Nation’s Mental Health System
Michigan Association of CMH Boards Conference
Lansing, Michigan
March 1, 2005
PowerPoint version
Attached is the text prepared for delivery; however, some material may have been added or omitted at the time of delivery.
[SLIDE 1. Cover]
Good morning and thank you, for that warm introduction. I am delighted to be with you this morning.
For the past year and a half, I have traveled from California to Connecticut…Maine to Mississippi…encouraging individuals, communities, organizations, and governments to push forward with the changes that will be needed to transform the Nation’s mental health care system. I must admit, this process of making transformation possible…making it happen…and making it known…has been at once rewarding, challenging and, quite frankly, a little exhausting. But I am always re-energized when I visit places like Michigan…a State that some of America’s greatest change makers have called home.
[SLIDE 2. Michigan change makers]
When I come to Michigan, I am inspired by the legacies of Michiganians like Henry Ford, who changed our lives by inventing “the people’s car,” the first practical, versatile automobile that ordinary people could afford. With the Model T, Henry Ford changed the world by making the rhetoric of American democracy real.
Rosa Parks is an honored resident of Michigan whose historic refusal to give up her seat on a Montgomery, Alabama, bus ignited the civil rights movement that spread across the nation and changed it…and all of us…forever.
Anna Howard Shaw, a Michigan minister and physician who was Susan B. Anthony’s “chief lieutenant,” worked towards the passage of the Nineteenth Amendment that granted women the right to vote and reshaped American politics. The efforts of these successful change agents touched vastly different aspects of American life. What do they have in common? They each transformed our world by daring to innovate. They each explored new territories without being absolutely sure where their quests would lead them. They each took risks in order to succeed.
I find the words of another Michigan innovator, the brilliant comic actress, Gilda Radner, surprisingly relevant to today’s discussion. She said, “Life is about not knowing…having to change…taking the moment and making the best of it… without knowing what's going to happen next.”
Those words could apply to each of you. You are involved in the same kind of uncertain journey, as you seek to improve and foster innovation in your State’s community mental health system. You know that your system needs to be reinvigorated…and reinvested in…to deliver on your promise to the individuals you serve. You know the results you want to achieve. You can’t know all of the obstacles you will face along the way. You have not always been certain of what direction to take. But you are seizing the moment…and making the most of it. Uncertainty has not stopped you from starting on the journey.
I am inspired by your efforts and I commend you for courage and your daring. While you may not know exactly what will happen next on this great quest to create the new world in mental health care here in Michigan, I am here to say definitively: you are on the right path. Transformation is the right course…the only course…that will lead you to your goal: a system that delivers the real hope of recovery to the citizens of this State with or at risk for mental illnesses. The progress you have already made is deserving of praise. In response to a call by Governor Granholm, the State’s Mental Health Commission made a comprehensive study of Michigan’s mental health system. Last fall the commission released a landmark report. It included specific goals and recommendations for transforming your State’s mental health system. Perhaps even more important, the Report sets out a “new vision” for the State that you can all be proud of—a vision of a future when all of Michigan’s children and adults will enjoy good mental health and will be served by a system that responds to their needs while promoting resilience and recovery.
By committing to this common vision, and adopting a set of shared values, you have created a picture of what is both expected and possible here in Michigan. This vision and these values will energize and mobilize your State. They will give purpose and meaning to your work. In an article called, “Overcoming Obstacles to a Recovery-Oriented System, Dr. William Anthony describes values as the “organizational Velcro that binds vision to operations.”
You have already begun to identify and address core issues that will tie your vision to operations. You’re already looking for ways to restructure to achieve administrative simplification. As you’re undergoing this wave of renewal, you’re asking…and answering…the tough questions about how to address stigma, parity and under-funding, and how to provide active roles for consumers in system planning and the implementation of evidence-based practices.
And you’re discovering that information is the key to achieving positive, measurable outcomes for the consumers and families you serve.
The theme you have chosen for this conference says a lot about your vision. It says you clearly understand that information is the foundation on which you will build a mental health system focused on recovery…a system that is accountable to people seeking recovery from mental illness. It suggests you understand and appreciate that good data are essential to identify gaps between service needs and service delivery…to set outcome goals…and to identify priorities for action.
I know these are issues of enormous magnitude, and the prospects of tackling them may seem daunting. But the fact that you have identified these challenges is a critical first step toward creating solutions. I congratulate you on the work you have done so far. I reiterate: you are on the right track.
[SLIDE 3. Achieving the Promise]
We, in the Federal Government, are traveling along the same path. As you know, about a year and a half ago, the President’s New Freedom Commission on Mental Health released the report, Achieving the Promise: Transforming Mental Health Care in America. Achieving the Promise confirmed that our society…our system…is not meeting the needs of millions of our citizens with mental illnesses. Achieving the Promise declared that our mental health system is disconnected and struggling to meet the needs of the consumers and families it serves…that the time has long passed for yet another piecemeal approach to reform. The report reached a conclusion that is echoed in your own State’s report: we must fundamentally transform our Nation’s approach to mental health care.
The task of transforming mental health across the entire United States is no less than monumental. But fortunately, Achieving the Promise provides us a vision of transformed mental health care along with 6 broad goals for achieving this vision.
I know that you have given a lot of thought to the goals of a transformed system. As I briefly describe the goals outlined in Achieving the Promise, I urge you to think carefully about what more you can do here in Michigan to make each of these goals a reality in this State.
[SLIDE 4. Goal 1, cont.]
In a transformed system—
- Americans will understand that mental health is essential to overall health. I know that you have plans to launch an anti-stigma initiative in Michigan. What else can you do to create a healing environment here in this State…an environment in which people can seek care—willingly, openly, and with hope in their recovery?
- Mental health care will be consumer and family driven. An individualized plan of care will be in integral part of the approach. You have set standards for your State plan. Have you carefully considered what constitutes a solid plan of care? Are these services adequate here?
- Disparities in mental health services will be eliminated. Our world is changing demographically and dramatically. I know you have been working on this issue. But, could more be done?
- Early mental health screening, assessment, and treatment will be common practice. Promoting and caring for the mental health of our children is extremely important to the future health and well being of our communities. What additional steps can you take at your community and State levels to protect your children’s mental health and to improve their access to appropriate and timely care?
- Excellent mental health care will be delivered and research will be accelerated. Michigan is already making great strides in this area—you are developing strategies for implementing several evidence based practices for recovery, including ACT, home-based care and supported employment. I urge you to ask and answer, “What other important practices need to be identified and widely disseminated to create the transformed system we envision?”
- Technology will be used to access mental health care and information. You have invested in technology to provide telehealth capacity and integrated health records. How can you make further use of technology to ensure access to quality mental health care for all Michiganians? Achieving the Promise also identified specific recommendations for achieving each of the six transformation goals. These goals and recommendations present the idea of transformation as a new paradigm for moving forward in the coming years.
[SLIDE 5. What is Transformation]
But what exactly do we mean when we say “transformation?” With a show of hands—would you say “transformation” is a synonym for change? (Pause) For reform? (Pause) For modernization? The truth is, you are all right. Even those of you who didn’t raise your hands are right…because “transformation” embodies all of these concepts…and yet, it entails so much more. The word transformation appears 11 times throughout the pages of Achieving the Promise. While the Report provided a clear vision of a transformed system, it did not clearly define transformation…or provide a specific blueprint for achieving it. The challenge for us, then, is to come to consensus on what we mean by transformation of the mental health care system…and then, to chart a course toward this vision.
Our first inclination might be to look across the field for examples of how this has been done. But, there simply are no examples of change of this magnitude…across whole systems and affecting every dimension of care…in all of healthcare. It becomes imperative for us to look to other fields for help with how to define…as well as how to bring about transformation.
In a recently-released report, Concepts of Transformation, author, Noel Mazade examines theories and operational definitions from other fields to conceptualize transformation. In the report, Mazade examined the National Aeronautics and Space Administration, NASA, and found that this Agency approached “transformation” as a way to “eliminate its stove pipes, promote synergy across the Agency, and support its long-term exploration vision in a way that is sustainable and affordable.”Mazade looked at the Department of Defense, a major proponent of transformation, and discovered an organization whose vision of transformation involved the “process of changing the form or structure of the military forces…and the nature of military culture.”
In the field of information technology, Mazade found that transformation is viewed as “a process of continuous evolutionary change driven by the dynamic needs of the enterprise.” In the energy field, he discovered that transformational activities typically focused on a process…a process in which energy efficiency innovations are introduced into the marketplace and, over time, they penetrate that market. This kind of market transformation is a complex and dynamic phenomenon that relies on ongoing change to ensure that innovations “stick”…that the market doesn’t regress to lower levels of efficiency over time.
What do these diverse industry views of transformation have in common? In every case, “transformation” involves a deep…and profound…and continuous process along a continuum of innovation—a process without end!
As these examples illustrate, transformation is not simply a fancy word for reform. It is far more encompassing than that. Transformation is not merely a synonym for modernization; it is much more than the process of improving current capabilities. Transformation certainly involves change; but change, alone, speaks to the predictable and possible.
Instead, Mazade’s report says, transformation is “imbedded in the unpredictable and the impossible Transformation is “life altering.” It is the way we “create something completely possible from the perceived impossible.”
One theory suggests that we learn about the world by navigating in three realms: what we know…what we don’t know…and what we don’t know we don’t know. Change occurs in the first two realms. Transformation occurs in the third. Mazade’s report offers this directive: to get to transformation, “we must suspend certainty and receive the impossible.”
[SLIDE 6. Defining Transformation]
Transformation, then, is revolutionary. It implies profound change—not at the margins of a system, but at it very core. Transformation assumes the need for a fundamental shift to another level of thought and action. In transformation, new sources of power emerge. New competencies develop. We look at opportunities and challenges, with the bright eyes of a child…as if we are seeing them and all of their possibilities for the first time. We look for what we can do now that we could not do before.
[SLIDE 7. Transformation Equation]
What will it take to transform our mental health system? This is what I call the transformation equation. Transformation equals vision, plus belief, plus action…multiplied by continuous quality improvement to the second power. Why is CQI squared? Because we must continuously ask ourselves if the resources and technical assistance we provide are effective and meeting the mark. We must continuously seek to improve. Without these elements, transformation cannot, will not, happen.
Achieving the Promise has given us the vision. Now, each of us must complete the equation through personal action. Each of you is critical to this undertaking. Transformation cannot happen without you. You are the true center of gravity for transformation!
Achieving the Promise gave enormous responsibility for transformation to the States. This is where we have the opportunity to impact the greatest number of lives. This is where Achieving the Promise will come to life.
The speed of transformation will be up to you. How much we can achieve within the short-term will depend largely on how much time and effort you are willing to invest in creating a transformed system of care that is consumer-driven…that embraces promotion and prevention…and that delivers on the promise that recovery is not only possible, it is the expectation! I’ve talked about the transformation vision. Now I want to spend a few moments on the concept of “recovery” because it is equally powerful. It is why your work to develop a new vision throughout Michigan is so imperative.
I know you are working very hard to develop a recovery vision, and I commend you for including consumers and family members in every aspect of crafting this vision.
And who better to direct the vision of recovery? Recovery is the vehicle through which consumers lives are transformed.
[SLIDE 8. Recovery Refers To]
Recovery does not necessarily mean, “cure.” Recovery is a process...a continuum of personal achievements as each person moves toward his or her greatest potential. 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. For many, it means finally being able to help make important decisions affecting their own lives.
The expectation of recovery for everyone changes our entire perspective on how we view and provide care, from birth to death. A recovery-focused system sees each individual as a unique human being—and not just as a person with a disability. It focuses on the overall health of the whole person, and accepts the mind and body as inseparable and integrated. It forces the dialog about care to revolve around the comprehensive services each person needs to promote his or her recovery and to lead a full life in the community.
Perhaps the most compelling element of a recovery-focused system is the belief that people with mental illnesses can take charge of their own lives, their own wellness, and their own care. This single belief has extraordinary implications for transforming mental health care. It demands change—from Federal and State agencies to the people we serve. Each of us must have the capacity, as well as the willingness, to become equal partners in determining care.
Transformation is a truly collective endeavor. Transformation of our behavioral health system is not a task that any organization…or State…or Federal Agency could accomplish on its own. I will support your efforts with every resource at my disposal!
SAMHSA has a clear role to play. The Department of Health and Human Services has charged SAMHSA with leading Federal efforts to implement all of the Commission’s goals and recommendations—to make certain that we do, in fact, “achieve the promise.” I’m proud to say this process is well underway.
[SLIDE 9. Federal Partners]
During the past year, an executive team at SAMHSA has met with senior staff from 20 other Federal organizations to decide how we can respond jointly to the Commission’s Report. We began by conducting an exhaustive inventory of programs and funding that each agency already had in place. By organizing our inventories around the Report’s six goals, we were able to identify ongoing programs that already supported transformation. These are programs we will maintain and enhance. We also were able to determine where we could collaborate on new initiatives to support transformation or better align existing ones. This process has resulted in a Federal roadmap for change, which we call our Federal Action Agenda. This Agenda serves a purpose very similar to the implementation plan that is the next step in your transformation process.
Although not yet publicly released, our Action Agenda responds to each of the 6 goals and 19 recommendations proposed by the New Freedom Commission. Our agenda, however, is not a universal, all-encompassing document. SAMHSA and our Federal partners made a conscious effort to set time-limited, realistic priorities for year one of what we see as a 5-year arc for transformation. We will develop new agendas, addressing new issues, as we make progress.
One of our first steps is to invest additional resources in transformation. In fiscal year 2005, $20 million dollars are committed for State Incentive Grants to promote mental health transformation at the State level.
The Mental Health Transformation State Incentive Grants, or SIGs, will provide seed money for States to develop the infrastructure they need to transform their service systems. States, for example, can use funds to develop their policies and organizations, to train their workforce, or to implement quality assurance mechanisms. These grants will provide an unprecedented opportunity...one that will help States develop their own vision of a transformed mental health system.
[SLIDE 10. Key Transformation Activities]
The SIGs are a critical first step; however, many other transformation activities are underway across SAMHSA and our Nation. We are already—
- Conducting a comprehensive evaluation of the mental health workforce, including an inventory of how cultural competence is being addressed in behavioral healthcare training programs;
- Launching the National Action Alliance for Suicide Prevention to coordinate national efforts to prevent suicide;
- Developing a prototype of individualized plans of care that promote recovery and resilience;
- Expanding the science to service agenda. As part of this initiative, we are taking steps to identify evidence-based practices more rapidly and move them more quickly to the community level where we have the best opportunity to save lives. One important advance in the use of evidence based practices is the expansion of NREPP—¬SAMHSA’s National Registry of Effective Programs and Practices. NREPP has been conducting expert evaluations of programs to identify model and promising evidence-based programs. These programs are then included in an online national registry. Last year, NREPP was expanded to include mental health and co-occurring disorder treatment programs. We are now expanding NREPP to include mental health promotion and prevention programs.Just last month, we introduced six EBP implementation resource kits on our Web site: www.samhsa.gov. These kits contain a number of useful resources, such as implementation guidelines, manuals, and fidelity measures to help providers implement these practices at the community level.
[SLIDE 11. Key Transformation Activities, cont.]
As part of our continuing effort to motivate, facilitate and compel change, we are also—
- Initiating technical assistance on recovery and resilience;
- Providing technical assistance to help States develop Comprehensive State Mental Health Plans;
- Educating Medicaid and other public and private payers about the practicability of supporting evidence-based mental health services.
I want to take a moment, here, to focus on the critical role Medicaid has in the transformation process. As you know, few pieces of the mental health puzzle are as important to Michigan and, indeed, to every State…as how Medicaid’s role in mental health transformation is managed.
Medicaid is paying a major share of the cost of mental health care in America. In fact, Medicaid is currently the largest single payer of mental health services in the United States. Larger than private insurers! Larger than Medicare! Larger than all other State and local payers, combined!
As a result, Medicaid figures prominently in the transformation equation. Without Medicaid on board, transformation will not happen. I know that Michigan is facing tough issues around the appropriate use of Medicaid funding. Likewise,
SAMHSA and The Centers for Medicare & Medicaid Services, CMS, are working together closely to address more directly all the issues related to Medicaid’s support of mental health care¬: how policies are decided…how payment rates are determined…how payment can be more closely aligned with what we know works in mental health services.
[SLIDE 12. Medicaid Activities]
For example, SAMHSA and CMS are collaborating on a series of technical assistance papers that highlight promising practices and unravel the complexities of specific mental health related Medicaid policies. The first of these papers, Psychotropic Medications: Addressing Costs without Restricting Access, has now been posted on the CMS Web site. Others will be available in the months ahead. We are working closely with CMS to identify those evidence-based practices that warrant further research, those that are ready for field implementation, and those that can and should be funded at the State and local level.
SAMHSA and CMS will also be working in close collaboration to provide technical assistance to the States and Territories in developing their Comprehensive State Mental Health Plans. Our goal is that every State plan will include a clear Medicaid component.
We are moving steadily and deliberately forward with transformation at the Federal level. I am happy to report that nearly every State has begun the work of transformation.
Michigan is making great strides on the road to transformation. The comprehensive document your Mental Health Commission has prepared that “crosswalks” your goals and activities with those of Achieving the Promise is very impressive. This crosswalk document, and the implementation plan that will follow, will be your roadmaps as you continue on the path to transformation. I urge you to follow these roadmaps closely.
Ultimately, transformation of the system here in Michigan is a process…one that will proceed in fits and starts. There will be bumps along the road. Change of this magnitude is inherently messy. But I want you to know I am impressed with your willingness to take on this task. I know you will not be deterred by the challenges.
[SLIDE 13. What States Can Do]
As you continue on this road to transformation, use your knowledge and background to help your mental health authorities, legislators, communities, and citizens at large understand what is involved in developing a comprehensive State mental health care system that is consumer-driven and focused on recovery.
Involve consumers to the greatest extent possible. There is no one more qualified than a consumer and his or her family to determine the kinds of care that are needed.
Build public support for transformation! Your commitment to building a comprehensive system is a start. But you will need to continue advocating for expanded services and funding. As advocates, you can help shape State and local priorities by generating the community feedback and data that can influence these priorities.
Provide a public forum to discuss which mental health services and supports focus on recovery. For example, help the citizens of Michigan understand that supported employment is far more effective (both clinically and economically) than day treatment for helping to build a person’s life in the community.
Encourage government officials to promote the use of evidence-based practices. We know that evidence-based practices help give to consumers genuine hope for optimal recovery and fulfilling lives beyond mental illnesses.[PAUSE]
Michigan has shown that it has the vision…and the resolve to advance transformation. What Michigan, and every State and territory stand most in need of today are leaders …transformational leaders who can come from any walk of life…from any sector…with any type of experience.
Leaders are our most valuable resource for a changing world. Equipment and processes become obsolete, but leaders supply new solutions. Leaders guide, direct, and influence others to bring about fundamental change.
Leaders are critical instruments for systems change…for transformation. I ascribe to Robert Greenleaf’s servant leadership model—a practical philosophy built around the concept that true leaders are those who lead by serving others. A deep desire to serve others…a desire to serve a higher purpose…lies at the heart of my approach to leadership.
You are also leaders. You can empower others to become leaders. But you must identify and articulate your own leadership philosophy before you can guide and encourage others to exercise their potential for leadership. Ask yourself, “What are the qualities of leadership that resonate with who I am?” Then begin to act on these qualities. Take action to achieve your mission and to take care of those you seek to lead.
Every woman and every man in this room has the power to take a leadership role in this great movement we are undertaking. You don’t necessarily have to be in a position of authority to be a leader. Henry Ford and Rosa Parks didn’t make a difference because of their authority. They made a difference because they dared to make changes in the way things were done. They were fearless. They did the very thing no one thought they could do.
Effecting systems change is much like blazing a trail. You start off in uncharted territory. You must have courage and boldness to make your way through…to realize your goal. I was struck by the sentiments expressed in a familiar quotation I saw again recently on a University of Michigan Web site designed to inspire students to realize their academic and post graduate goals.
[SLIDE 14. Quote]
The passage said—
Do not follow where the path may lead. Go instead where there is no path and leave a trail.
Each and every one of you in this room has the power to be a trailblazer…to lead the way…to ignite the flame of transformation across this State.
You , in the privileged positions you hold—positions of responsibility and influence—have the power to move the critical issues we have talked about today to action…to shape this transformation…to become part of the system we want, the system that thousands of Michiganians living with mental illnesses deserve. You are agents of transformation. Put your power to work to make this change happen…to help us Achieve the Promise…here…and across this Nation. Thank you.
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