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
Mental Health System Transformation:
Making It Possible! Making It Happen! Making It Known!
Washington, D.C.
March 14, 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]
Almost a year ago, I stood before many of you at your Annual Conference in New York City, and I made a pledge. I pledged to use every resource at my disposal to ensure that the transformation called for in Achieving the Promise is more than just a promise. I pledged to do my part to make certain that the kind of wholesale systems change you advocated for in your Vision for the Future of Mental Health is an achievable goal…within a set time frame.
I am here today to report on the progress we have made in the 20 months since the Commission released its final report.
Of course, measuring progress towards a goal that is not an end state…but rather, a continuous process along a continuum of change and innovation …is no simple task. As Jane Garvey , former Deputy Administrator of the Federal Highway Administration has said about the future, transformation “is not someplace we are going to, but a place we are creating.
[SLIDE 2/Transformation...]
In a paper, “Concepts of Transformation,” author Noel Mazade underscores that point. The paper describes transformation as a means to the ultimate goal of facilitating recovery and resilience in the lives of children and adults served by the mental health system. The report describes transformation as a process that is imbedded in the unpredictable…the process of creating something completely possible from the perceived impossible. To get there, the paper suggests, “We must suspend certainty and receive the impossible.”
Transformation is hard to measure. We aren’t sure exactly where we are on the continuum. But I can say with complete certainty: Transformation has begun. Transformation is real. Transformation is happening. We are doing the work—the hard, incremental, risk-taking work—of transforming our Nation’s mental health system.
Through direct and deliberate efforts to leverage Federal resources and programs…at CMHS…at SAMHSA….at HHS…and across the Federal government, we are facilitating the change in behaviors and attitudes needed for transformation. And, we are making headway. A Chinese proverb says, “Only step by step is the ladder ascended.” We are advancing transformation…slowly, steadily…rung by rung. We are in the infancy of this momentous movement, but we are laying the groundwork necessary to make transformation possible…to make it happen…and to make it known across this country!
Clearly, we cannot accomplish this task alone. A year ago, when I talked about how your Vision for the Future of Mental Health and Achieving the Promise reaffirmed each other, I proposed that our organizations would be most effective if we moved forward together. I am here today to re-emphasize the importance of our partnership.
Transformation is a collective endeavor. No one person or single institution can carry out transformation. It will require the involvement of every one of us. Each of us has a responsibility: to deliver the message of hope and recovery across this Nation.
Over these next few days, as you explore ways to approach policymakers…ways to persuade them to change their orientation…ways to educate them on how transformation benefits the people they serve…you will take on an extraordinary responsibility. You will become agents of transformation.
Today, I would also like to set the stage for how we can continue to work together to move these issues to action…to shape this transformation…to create the system we want…the system millions of Americans with mental illnesses deserve.
[SLIDE 3/MHST Phase 1]
In this first phase of transformation, SAMHSA/CMHS is working to—(1) advance the work of an internal Matrix Workgroup with oversight of transformation activities across SAMHSA; (2) develop strong partnerships and collaborative activities with other Federal partners; (3) release the first Federal Action Agenda; (4) increase Federal support to States for their formal transformation efforts; (5) capture and evaluate transformation strategies that work; and (6) continue to focus attention on emerging issues, practices, and trends.
[SLIDE 4/Federal Partners]
Our first priority has been to make a broad-based group of Federal agencies accountable for change. Together with senior staff members from 20 other federal organizations, we have created a Federal Action Agenda that describes how SAMHSA and its partners will respond to each of the goals and recommendations in Achieving the Promise.
One of the most exciting outcomes of this process has been the synergy that has resulted from having leaders of all of the Agencies that touch the lives of consumers—Labor …Housing…Education…Justice… Social Security—coming together…breaking down the barriers…the silos…that have existed for so long…to determine how we can cooperate and collaborate to better serve the whole consumer…mind and body.
These collaborations represent an unparalleled commitment on the part of the Federal government to work together toward a single vision: the day when all adults with serious mental illnesses and all children with serious emotional disturbances live, work, learn, and participate fully in their communities. The work already in progress at the Department of Labor, one of our Federal partner agencies, provides an excellent example of initiatives that are underway to facilitate transformation of multiple systems.
In response to the call of Achieving the Promise, The Department of Labor is developing an employer initiative to increase the recruitment, hiring, and retention of persons with psychiatric disabilities. Customized employment strategies, including self-employment and micro-enterprise development, are being explored. The Agency is also exploring workforce opportunities for ex-offenders with psychiatric disabilities who want to work in their communities…as well as promoting successful transitions for young adults with serious emotional disturbances from school to post secondary opportunities and/or employment. The Agency’s Employer Assistance Referral Network, or EARN, connects employers to employment service providers with direct access to candidates with disabilities and provides technical assistance to employers.
This is transformation in action!
Another Federal Partner, The Centers for Medicare & Medicaid Services (CMS), figures prominently in the transformation equation. Flexible, accountable financing that pays for treatments and services that work and that result in recovery is essential to mental health system transformation. As the largest single payer of mental health services in the United States, transformation simply will not happen without Medicaid on board. SAMHSA and 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.
For example, we know that 26% of Medicaid enrollees receive some form of mental health treatment—predominantly psychotropic medications. 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 partnership between Medicaid and mental health. At the same time, we are exploring ways to better integrate Medicare and other third party insurers in mental health systems transformation.
These kinds of cross agency collaborations are critical first steps. They represent a very exciting and productive beginning to a long-term process that will alter the face of mental health care in this country for generations to come. The most important outcome of this cross-agency collaboration at the Federal level is the model it provides for what States and communities can do. As you noted in your Vision for a Mental Health System, States must be the ultimate locus of accountability for the care that is available. It is at the State, County, and local levels where the real opportunities for change and the greatest chance to actually transform the lives of your patients exist.
In developing an Action Agenda for transforming the mental health system, we harnessed the power of collaboration with 20 different Federal partners. For transformation to take hold, we must replicate this level of collaboration across departments at the State and local levels. This is where knowledge about successful transformation strategies can best be shared…where shared leadership can be developed through new partnerships. This is where we will change the way the business of providing mental health care is done. This is where we will turn our ship and begin to do what we were unable to do before.
I am pleased to report: transformation is taking hold in the States. Some are further along than others. South Carolina , New Jersey, New Mexico, Wyoming, Connecticut, Kansas, and Hawaii already have cross-walked their plans with the goals of the New Freedom Commission.The Nevada legislature has passed a law that mandates the creation of the Nevada Mental Health Plan Implementation Commission, a group tasked with formulating strategies to move the State toward the goals laid out in the federal report. From California to the Carolinas, promising models of transformation in behavioral health are being developed. Transformative projects, seeded by the Commission Report, are being piloted. Tactics and strategies central to implementing and securing the funding for fundamental change are being put into practice.
[SLIDE 5/MHST SIGS]
The power and potential of the States to transform mental health care is the basis for our new Mental Health Transformation State Incentive Grants, or “Transformation SIGs.” Last week, we announced the availability of $18.8 million for these grants designed to support State efforts to focus on the systemic changes needed to meet the multiple needs of consumers and families and to foster recovery. These are foundational steps for developing the Comprehensive State Mental Health Plan called for in Achieving the Promise. Applications are due by June 1.
Eligibility for the grants is limited to the immediate office of the chief executive officer, such as the Governor, for States, territories, the District of Columbia, native tribes, and tribal organizations. We have limited eligibility for one very important reason: The depth and breadth of change that will be required across multiple systems can only be accomplished by the person ultimately responsible for all these systems and their operations.
[SLIDE 6/CMHS Budget Overview]
This $18.8 million represents a first step toward promoting change at the State level. As you well know, funding will dictate how quickly and broadly we can implement change. We are looking for ways to embed our vision for transformation into our allocation of grant and contract dollars.
One way we are embedding the transformation vision into our resource allocations is by increasing the accountability of our State block grant activities. Under this proposed structure, States will have greater flexibility in administering their block grant programs. In return, however, we will be asking for greater accountability related to the progress being made by States in serving consumers of mental health care.
Future block grant applications will ask States to respond to national outcome measures that will enable them to more effectively measure and manage positive outcomes for the people they serve. The New Freedom Commission advocated this approach in Goal 2 when it called for providing incentives to the States by granting increased flexibility in exchange for greater accountability and improved outcomes.
[SLIDE 7/National Outcome Measures]
These are the outcome measures used in the 2005 RFA.
(Refer to slide)
I like to think of this work as essential to “digging” the foundation for transformed mental health planning and services delivery. It is on these efforts that we will build a planning and service delivery system that is accountable to the millions of Americans seeking recovery from mental illnesses.
We have a number of other priorities for 2005…each designed to advance transformation. Before I briefly describe them, I should take a moment, here, to address a topic that has come up—SAMHSA’s reauthorization.
We should not wait...we are not waiting…for reauthorization to begin thinking about and acting on transformation. In fact, SAMHSA already has the authorities it needs to engage in transformation. So, the real benefit of reauthorization is to have a policy discussion with Congress on substance abuse and mental health and to have Congress pass legislation that may be needed to move ahead with the Department’s agenda. Reauthorization gives us the opportunity to talk about our priorities...your priorities...and the values that will drive these initiatives.
We are excited about these opportunities. We’re not expecting any surprises. We fully expect HHS Secretary Leavitt to vigorously support mental health transformation…and our plan of action for moving forward. And, our plan of action for 2005 is an ambitious one!
[SLIDE 8/Transformation Action Center]
One of our priorities—The Transformation Action Center, or TAC—will provide a cohesive, coordinated, and strategic structure for the provision of technical assistance within the Mental Health Transformation SIG program and for CMHS programs focused on assisting individuals in achieving recovery and promoting resilience. The TAC is a valuable resource for the entire behavioral health care community—one that you can and should make ample use of.
[SLIDE 9/Transformational Leadership]
We must have people to drive the transformation process—transformational leaders who can blaze a trail…and inspire others to follow. One of the issues we are examining at SAMHSA is how we can invest in leadership. We recognize that we need to be smarter about how we train people to be leaders. Our goal for this priority is to stimulate and facilitate interest in leadership development.
By definition, transformation involves collaboration across systems...across populations. For strong transformational leadership to develop, every sector of the behavioral health care community must be represented—in leadership positions, and in thought leadership. You are leaders in your field. Transformation presents a tremendous opportunity for you to lead others in bringing about the changes we seek.
[SLIDE 10/Disparities Reduction/Elimination]
This priority is the same as Goal 3 in Achieving the Promise. Thus, our goals for this program strongly reflect recommendations described in the Report. Essentially, we intend to expand and educate the workforce so that it can respond adequately to the mental health needs of underserved populations. We have proposed an entire portfolio of activities to address issues such as cultural competence, public education, and the adaptation and evaluation of innovative and evidence-based practices that reflect and embrace cultural diversity. Our goal is to develop a National Strategic Plan to eliminate disparities entirely. I encourage you to avail yourselves of the programs and services we offer in this area.
[SLIDE 11/Science-to-Service]
We have a two-part goal for this priority. The first is to expand the number and distribution of evidence-based practices available through the National Registry of Effective Programs and Practices—NREPP. The second is to implement additional strategies to ensure that States and providers can implement and sustain more widespread use of the practices.
As part of our National Evidence-based Practices Project, we are funding development of a series of EBP Implementation Resource Kits. These kits are evaluation versions. You can become involved in this effort by assessing these EBPs for their relevance for consumers with the most severe and chronic conditions. Help us evaluate. Provide SAMHSA with the feedback we need to make the toolkits and practices successful from your important perspective.
[SLIDE 12/Individualized Plans of Care (IPC)]
Our goal here is to identify prototypes that will address the unique needs of individuals throughout the lifespan and that will create a foundation for coordinated services. NASMHPD is working with us to develop prototypes.
We also look to you to help with the development of these prototypes…and to encourage other providers in your communities to adopt these model plans.
[SLIDE
13/Model Comprehensive State Mental Health Plans]
Our goal is that we will have a model plan template available by the time we award the first mental health transformation grants. APA should be at the table when States are developing these plans.
[SLIDE
14/Workforce Development]
Our goal for this priority is to develop a workforce that has been trained and is supported through a competency-based approach. We also want the workforce to respond to and shape an environment that supports recovery. Similar to our science-to-service priority, we will be building on activities already underway, such as our collaboration with the Annapolis Coalition.
With your input, we can build a workforce that is also diverse in the types of issues addressed…we need you to point out the unmet needs you see…the gaps that must be filled to ensure we can effectively meet the needs of all consumers.
We need your help to move these priorities from ideas to action. We look to you for input on where we should focus our attention. We need your feedback on further changes that should be made. We need you as our partners. Transformation is no small task. It will take all of us.
What can you do?
[SLIDE 15/What You Can Do]
You can help to make the case that mental health system transformation must become a priority issue. Tomorrow, when you go up on the Hill, let Congress know how vital transformation is…inspire them to champion this cause and to implement the activities required to achieve the outcomes we desire. Help them understand and believe— …that recovery is a real possibility
…that we must use our fiscal resources to support proven, evidence-based treatments and services
…that cutting edge information technology and communications infrastructure is critical to transforming mental health care in America.
...that SAMHSA has a comprehensive, carefully constructed plan for advancing transformation...and that you are behind it!
One of the most important things you can do is help Congress understand and believe that we must effect a profound alteration in the status quo!
Rear Admiral Grace Hopper, a remarkable woman who rose to the challenges of programming the first computers, said, The most damaging phrase in the English language is, ‘It's always been done that way.’ During her lifetime as a leader in the field of software development, Rear Admiral Hopper contributed to the transformation from primitive programming techniques to the use of sophisticated compilers. She believed that "we've always done it that way" was not a good reason to continue to do so.
Today, I underscore her sentiment…and take it a step further. We must fundamentally alter the form and function of our Nation’s mental health system …and we must do it urgently and boldly. People living with mental illnesses deserve advocates driven by deeply felt passion.
The late actor and activist, Christopher Reeve, spoke with unparalleled passion and steadfast determination about the need to transform medical research.
[SLIDE 16/Reeve Quote]
Reeve said he “set out to change the way things are done in the clinic, the laboratory, and the government” by “causing a revolution in all three.”
We must be equally bold about what we have come here to do today. Our vision of a transformed mental health care system requires nothing short of a revolution in administrative policies, in funding mechanisms, and in the hearts and minds of every American. We have made real and measurable progress on the road to transformation. But there is much more to be done to make this revolution a reality.
This morning, I renew my pledge to use every resource at my disposal to transform our National mental health system and redirect it toward its primary goal—helping children, adults, and older adults achieve recovery to live, work, and learn in their communities. I ask you to renew your commitment to this great cause. If we dare, together, we can develop solutions that know no limitations. I urge you to use your power as catalysts for change…as agents of transformation…to do just that. Thank you.
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