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

Closing Remarks:
ACMHA Summit

March 17, 2007
Santa Fe, NM

PowerPoint Version

Good Morning and Thank You.

Over the past few days, you have explored, together, a number of interesting perspectives on integrating primary care and behavioral health care. As we close this meeting, I believe that we have reached a universal conclusion. Is integration necessary? Absolutely. What needs to change as we pursue an integrated system of care? We do.

We can no longer work as we once did…looking at each individual part of our health care system…isolating one thing that is broken…and then, trying to fix it. That approach works on machines…but not on living human systems. The consumers and families we serve are at the very center of our network of living systems, and the time has come for us to transform all of our support around them.

Right here, right now, we need to move forward with a new understanding. We need to begin viewing, treating, and funding mental and physical illnesses the same. We can no longer support any system that allows our mental and primary health care to remain separate. We must change any system that is not built on a universal presumption of treating the whole person.

Just how do we begin to do this? The answer lies in leadership. Through effective leadership, we will bring about a practical, quantifiable, informed, and accountable transformation of our national systems of care. The integration of mental health care and primary care will be a critical dimension of this transformation.

Many of you have heard me speak about leading transformation…from the federal perspective, as the Director of the Center for Mental Health Services, and a representative of SAMHSA. This morning, I would also like to share with you my personal perspective on leadership. I want to delve deeper into the dimensions of transformational leadership that will be required to bring about the profound systems change we seek. I want to talk about the kind of leadership that is necessary to move our systems to a new level of care.

Leading deep change…transforming how our systems work together…thinking about, planning, and doing things differently than we’ve ever done them before…that’s what today’s discussion is really about. Because, creating a system that will effectively integrate and coordinate primary care and mental health care will require us to move to another level of thinking and to demonstrate an entirely new kind of leadership in action.

Leadership in action is exactly how I would describe my approach to leading change. Throughout my career, and my life, I have worked to ensure that leadership is something that I do— it is a set of actions, not simply a title or a state of mind.

One of my early roles leading mental health issues was back in 1975 in Pennsylvania. As Chief of Victim Services at the Harrisburg Area Rape Crisis Center...the first Rape Crisis Center to be opened in the country…I was instrumental in establishing a model approach to rape crisis responding to the individual and collective assault and abuse of women. During my 10-year tenure as Director of the Rhode Island Department of Mental Health, Retardation, and Hospitals, we made some dramatic changes in mental health. We were the first state to eliminate our stand alone psychiatric institution…we were only the third state to close our institution for retardation…and we ranked in the top 5 mental health systems in the country. My success in transforming Rhode Island’s system of care was, in a large part, because of my approach to leading community mental health organizations and professionals. I encouraged them to take risks. They were unafraid to try new services…unafraid to engage with consumers in very different and creative ways…unafraid to reframe problems in different ways to surmount challenges. By demonstrating this fearlessness, and an action-oriented style of leadership, these individuals were able to engage many others to create systems that better served people in need. And the momentum that was created illustrates the tremendous effect a small group of people can have on a system.

While presiding over the National Association of State Mental Health Program Directors in 1997, I led this group on a quest to encourage every State to incorporate the principles of recovery and trauma-informed care into their systems. Today, I also hold another professional position, as a Captain in the U.S. Naval Reserve. I have proudly served as a member of our Armed Forces for 24 years. The Department of Defense was one of the first arms of government to undergo its own system-wide transformation, so I became very familiar with the principles of transformation early on.

Last summer, I attended a military executive training course on leading transformation. The course underscored what John Kotter, the author of Leading Change maintains─ “that new approaches are fragile and vulnerable to regression until change sinks down deeply into a system”─which may take years of effective leadership.

Kotter describes eight steps in leading positive change. You’ll notice that the steps are broken into three phases: creating a climate for change…engaging and enabling the whole organization…and implementing and sustaining change.

In the first phase, he says, leaders must create a climate for change that drives people out of their comfort zones. We do this by increasing the sense of urgency about the challenges we face so that people are compelled to contribute the extra effort that is essential to creating something new. The next step is to build a guiding team to begin work on possible solutions. The right vision is crucial to the process as well.

SAMHSA has been working hard to create a climate for change across government by broadening the number of departments and agencies directly involved in transformation. Nine Federal departments, the Social Security Administration, and the Equal Employment Opportunity Commission now are members of our Federal Partners Workgroup for Transformation.

There’s a reason for such a broad representation. Each of these departments and agencies plays its own distinctive role in promoting and protecting the mental health of consumers. Each is essential for providing the variety of services that help people to achieve and sustain recovery…including a home, a job, and other reflections of social inclusion.

Our Federal Partners Workgroup reflects a genuine government-wide commitment to achieving real progress in integrated service delivery. The workgroup is also a perfect example of the critical collaboration that will be needed to develop and drive the systemic change in climate and culture needed for transformation.

We are finding that change of the magnitude we seek demands an entirely new kind of leadership within each partnering organization. We need leadership capable of changing the very language used to speak about behavioral health. Old language cannot convey new ideas. This tenet is behind many of the actions that SAMHSA has taken recently, such as our consensus statement on the meaning of consumer-driven recovery and our multimedia anti-stigma campaign.

The second phase Kotter identifies involves engaging and enabling the whole organization. He suggests that the following steps must take place to achieve this goal: Leaders must communicate so that all of those involved will buy into the process…they must empower action on the part of those around them…and they must create short-term wins to keep people motivated and spur them on.

Through our Federal Partner Workgroup, we are empowering action across the Federal government …embedding these new approaches...these new shared values...into the very fiber of how we work together. In doing so, we ensure that this work will continue...beyond the terms of the officials who are currently at these Departments and Agencies.

The last phase is implementing and sustaining change. There are huge considerations for mental health care transformation. How do we engage a sufficiently broad-based coalition to deliver coordinated, comprehensive services? How do we build an infrastructure that will support and sustain collaborative decisionmaking over time? Kotter puts it very succinctly: He says, don’t let up and make it stick.

SAMHSA is moving to implement and sustain change on a number of fronts. Our Federal Action Agenda identifies 70 different activities that we believe have the greatest potential to make an immediate impact…70 concrete, collaborative, and transformative activities we can do right now to make transformation happen…and make it stick. Through these activities, we are building bridges across and between levels of government. We are creating new partnerships with private sector industries and with advocacy groups. We are asking consumers and families to inform us at every turn.

To ensure that the resources needed to implement and sustain change will be available, our Federal Executive Steering Committee—comprised of twenty-one assistant secretaries and deputy commissioners representing the nine Federal partner departments and agencies—is working to promote access to effective services by identifying and eliminating regulatory and funding barriers within their organizations.

We have been working diligently, at the Federal level, to overcome the barriers that stand in the way of integration.

We formed a collaboration among SAMHSA, the Centers for Medicare and Medicaid Services (CMS), and the Health Resources and Service Administration (HRSA) to work together—with input from research experts and stakeholder groups like the National Association of State Mental Health Program Directors (NASMHPD) and the National Association of State Medicaid Directors—to clarify, collaborate and assist in education and technical assistance to promote the reimbursement of mental health services in primary care settings.

Last year, we convened an Expert Forum to identify barriers to reimbursement and strategies for overcoming these barriers. The Forum’s suggested actions to address these barriers include: reimbursement policy clarification; government and stakeholder collaboration; provision of education and technical assistance; and consideration of additional services.

To improve reimbursement of mental health services in primary care settings, the Forum’s most frequently suggested action was the need to clarify statements, policies, definitions, and services, and broadly disseminate the clarifications. They also emphasized the importance of targeted collaboration among the Department of Health and Human Services agencies and national stakeholder organizations to support the provision and reimbursement of mental health services in primary care settings.

The Expert Forum identified education and technical assistance recommendations that cross settings, payers, and practitioner and provider types. They stressed that consistent information must be shared among states, the federal government, national non-governmental organizations, practitioner associations, payers, and others to improve reimbursement of mental health services in primary care settings. By educating, encouraging, and providing technical assistance, aligned with clarified information on reimbursement policies and practices, payers and providers are in a stronger position to change behavior and improve the reimbursement of mental health services in primary care settings.

SAMHSA has begun two projects specifically related to the Institute of Medicine’s (IOM) recent report, Improving the Quality of Health Care for Mental and Substance Use Conditions. One project will address policy and transformation and the other is a direct service project. We are committed to the findings of the IOM’s report, and believe that it can help guide us in our mission to support transformation and improve the quality of care for people with mental illnesses.

Our policy project will examine how the current State transformation grants are being applied and how consistent they are with the IOM findings. This study will examine the role that the IOM report can play in supporting transformation and how well States are using this evidence based study to inform their strategic plans to support this transformation. We will also be looking to see if we can use the IOM report as a mechanism to measure transformation and change at a state level. We will use the results of this study to provide technical assistance to other states that are beginning to develop their transformation plans.

At the service level, we are working with mental health agencies to investigate how we can use the IOM’s report to guide service system level improvement and transformation. Through an agency-level community collaborative model, we will be using the recommendations outlined in the IOM report to inform system level change. Again, our intention is to build upon the findings of the IOM report to support change and transformation.

Our work with HRSA, CMS, the IOM and other stakeholders is an example of unprecedented collaboration, accountability, and leadership from all involved. It is clear: the Federal partners are taking action NOW to make transformation happen!

The signals are all positive. I have a strong belief that we are on the right road. We have a wonderful intuition that transformative change is happening…at the Federal level, in the States, and within individuals. We think that we are in the final phase of this profound change—the phase where we implement and sustain change.

But, when the stakes are this high, thoughts, beliefs, and intuition, alone, are not good enough. We must find a logical and systematic way to evaluate the impact of this large scale change. As Lord Kelvin, a Scottish mathematician and physicist during the late 1800s, said, "When you can measure what you are speaking about, then you know something about it; but when you cannot measure it, your knowledge is of a meager and unsatisfactory kind."

Without the ability to quantify our progress through the steps and phases of change, I am afraid that our true knowledge of the impact of transformation will be meager. I am afraid that the process of transformation will float. I believe we need to look, again, to the military and its transformation mission, for help with ways to monitor and measure the outcomes of our transformation strategy.

Slide: Dimensions of Transformation

The military executive training course that I participated in a few months ago included a discussion of the dimensions of transformation. In a nutshell, all six of these dimensions need to be aligned…and enabling capabilities need to be identified…to realize transformation.

We have recently begun to use these dimensions of transformation as a way to objectively examine the activities that are emanating from the States’ transformation efforts… and to document their impact on the overall transformation agenda. I believe that this focus on outcomes and accountability will be the most important work of transformational leaders going forward.

I’d like to share with you a few of the activities that our Transformation SIG States have reported to us as examples of the enabling capabilities…the dimensions of transformation…that are taking shape across the nation. I urge you to pay careful attention to how we are starting to organize and classify these transformative activities as a way to measure our progress toward transformation. One of your most urgent leadership tasks will be to engage your communities in thinking about ways to plan and measure your own progress toward transformation. This is a critical aspect of transformational leadership…and one that I urge you to take on with all of the resources at your disposal.

The first dimension of transformation involves changing the CULTURE…the understandings, beliefs, and practices that define and shape operational decisions, organizational responses, and the human reaction to change.

We’re seeing real progress toward effecting culture change from our SIG States. In Maryland, for example, the establishment of strong informal public/private partnerships has led to open lines of communication between stakeholders…allowing for a new level of coordination between groups.

The dimension of transformation that we call CONCEPTS refers to the ability to change our structured approaches to accomplishing a given course of action. Again, we are seeing real and meaningful progress here. Ohio is at the forefront of building infrastructure for transformation. This includes aligning and gaining commitments from major stakeholders, developing lasting structures for cross-agency collaboration, adoption of evidence-based practices, and workforce development. Ohio is also looking to use cost-savings realized in the transformation process to help continue to sustain this new approach over time.

AUTHORITIES—represented by changes in public laws or regulations that may be needed to provide permission or capabilities to implementation—are a critical dimension of transformation. Several States─Washington, Connecticut, New Mexico and Texas─have enacted new legislation in support of transformation. In fact, Texas has enacted 22 pieces of legislation into law that mandated transformation of the health and human service delivery system across the State. In this process, a new health and human service enterprise was created which streamlined a system of 12 separate agencies into four.

Another dimension of transformation—PROCESSES—refers to changes in the steps, tasks, or procedures needed to implement concepts or apply capabilities. New Mexico has been extremely innovative in changing the processes involved in financing a transformation-driven mental health services. They enacted legislation to implement a purchasing collaborative to streamline what was a fragmented and uncoordinated array of services into a single entity. This new process allows New Mexico State agencies to work together to provide and pay for comprehensive services in a coordinated way.

New CAPABILITIES, or the techniques, tools, and systems that may be required to execute a specified course of action, go to the very heart of transformation. We are seeing measurable progress in this dimension. For example, Oklahoma has launched a major transformation initiative with the introduction of its “Innovation Center.” The Innovation Center provides technical assistance for the 10 partnering agencies on the Governor’s Transformation Advisory Board. It helps establish and support project partnerships, develops leadership, identifies research-based practices, develops rapid prototype programs, and plans large-scale implementation. The Center demonstrates Oklahoma’s strong commitment to build a solid yet flexible infrastructure to transform its mental health systems.

A transformed ORGANIZATIONAL DESIGN—expressed by a change in the division of labor that may be needed to bring about desired results—is the final dimension of transformation that must be aligned before we can realize the transformed system that we envision. I am happy to report that we are seeing movement in this aspect of transformation, as well. The State of Washington has developed a new organizational structure for their Mental Health Transformation Incentive Grant that is separate from the Mental Health division— placing responsibility for the grant in the office of the Governor. Its goal: to facilitate more efficient cross-agency collaboration. Washington wants to ensure that no one agency or department has full responsibility for transformation, but rather, that it is seen as a State-wide effort with support from leadership at the highest levels. Through this collaborative, led by the Governor’s office, each agency will leverage its strengths, expertise and knowledge.

The real and measurable progress toward transformation that the nine TSIG States have reported is just the tip of the iceberg. This is the progress that we know about. I believe that these kinds of success stories are unfolding in States and communities from California to the Carolinas. I urge you to go back to your communities and take stock…and then, take action. Outcomes are the bottom-line for mental health and primary care services, just like profit is the bottom line in businesses. While we typically measure our gains and losses in very human terms, we must also find ways to quantify our successes.

Stories of individuals who have successfully moved systems are all around us. Just a few weeks ago, in a segment entitled, The American Spirit, anchor Katie Couric interviewed Dr. Donald Berwick, a physician on a personal mission…a crusade to make hospitals safer for patients. Berwick launched the “100,000 Lives Campaign”…a campaign designed to encourage hospitals to adopt standardized practices in the way they care for patients. The goal: to reduce complications and build excellence into the system.

Berwick has dedicated his life to moving what might seem like an unmovable system. Having successfully recruited hospital after hospital to join him in his mission, this one committed physician is taking small, yet important steps forward. In describing his progress toward the goal, he said, “It’s in reach. It’s a matter of will…and, a matter of leadership.”

This morning, I want to echo Dr. Berwick’s sentiments. A transformed system of mental health care integrated with primary care is within in our reach. And, from the progress we are seeing taking place in the States, we know that it won’t take a legion of foot solders or an equally impressive budget to successfully implement the large-scale systems change we have described.

As Dr. Berwick explained, our ability to realize this goal is a matter of will…and, of leadership. Not ordinary, garden-variety leadership…but transformational leadership.

Our leadership roles assign a tremendous responsibility to each of us. As transformational leaders, it is part of our charge to take our quest for change to the core of systems…and create something where there was nothing before. We have to take risks…and be resilient and resolute in pursuing our vision. And, as the late Admiral Arthur Cebrowski—former head of the Pentagon's Office of Force Transformation—said, we have to “Be bold…and pick up the things that look really hard. Other people will have done everything else.”

We must also measure how well our transformative strategies work…and how well we are doing at putting these strategies into practice. Armed with what we learn from this assessment, we can change lives. And, this is knowledge of a very satisfactory kind. This is what transformation is all about. This is how we must change. This is how we can…and must…exercise transformational leadership. Thank you very much.