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
The Balancing Act: Providing Quality Services
CARF Behavioral Health Conference
March 27, 2006
Tucson , AZ
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
Slide 2/Woman Doing Yoga
Yoga is the ultimate balancing act.
On the one hand, these b alancing poses and movements are some of the most rewarding…offering opportunities to increase flexibility and strength, develop coordination, and improve concentration. On the other hand, yoga’s balancing movements are also some of the most challenging.
What does yoga have to do with today’s discussion?
Slide 3/Woman Doing Yoga & Quote
Author Andrea Ferretti says, “balancing poses have a lot to teach us—about our willingness to be resilient, about our detachment from expectation and ego, about our ability to accept that we are not always in control. Pursuing balance, she says, on and off the mat, is truly worthwhile.”
We are here today on a truly worthwhile and rewarding pursuit…the pursuit of balance in behavioral health care. On the one hand, we’re being challenged to deliver quality services and demonstrate solid outcomes. On the other, we’re dealing with the realities of business processes and tightening fiscal pressure. We’re wrestling with how to “stay in the black” while doing a good job of serving the people we have a responsibility to serve.
Those of you on the front lines of the accreditation process know a thing or two about the challenges this balancing act creates…about being flexible in your approach...about the need for coordination and strength...about changing expectations and accepting that there are factors that are out of your control. It’s the nature of what you do.
And what you do is such noble work. You provide a blueprint for quality services...a “seal of satisfaction”...a safeguard that provides peace of mind for people who need it the most. Because of each of you, CARF is achieving great things. Because of you, referrals have increased significantly. Because of you, opioid treatment programs (OTPs)—which have free market choice—are choosing CARF. Just between January and March 2006, you have already done some 86 surveys of OTPs. I salute each of you for your commitment to this critically important mission.
SAMHSA Administrator, Charles Curie, sends his greetings and regrets that he could not be here today. But if he were here, I know he would echo my commendation. I assure you that he stands shoulder to shoulder with CARF and with each of you...the hardworking members...in your mission to improve the quality of care for those we serve.
We, at SAMHSA, know you are performing a precarious balancing act. And, as CARF celebrates its 40 th anniversary, we want to thank you for all you have accomplished over the last 4 decades...and for your continued efforts to meet this challenge. We couldn’t do what we do without you. We couldn’t pursue the vision of creating a quality-driven transformed behavioral healthcare system without the valuable services you provide.
This morning, I want to talk to you about a similar balancing act w e are facing at the federal level as we respond to increasing demands on one hand...and new fiscal realities on the other. I want to talk about steps we are taking to address this paradox at the federal level...and how these changes may be being felt in community-based services across this country. And I’d like to leave you with a few suggestions for preparing yourselves for the challenges ahead.
Slide 4/SAMHSA Centers
For those who are not acquainted with SAMHSA and the work we do, let me provide a little background. SAMHSA is an Agency of the U.S. Department of Health and Human Services. Our charge: to move the discoveries of research to community-based services to improve the lives of people with or at risk for mental illnesses and substance use disorders. Through its t hree Centers and supporting Offices, SAMHSA funds a rich portfolio of grant programs that support States’ efforts to enhance prevention programs and improve the quality, availability, and range of substance abuse treatment and mental health services.
When Administrator Curie came to SAMHSA four years ago, he focused the Agency’s vision to begin building systems of care around what people with mental illnesses and substance use disorders want and need...instead of what a government bureaucracy could offer. Our vision became “A Life in the Community for Everyone.” To achieve our Agency vision, we created a mission statement...to build resilience and facilitate recovery. And, to keep us focused on achieving our vision, we rely on our Matrix of priority programs and cross-cutting principles.
Slide 5/SAMHSA’s Matrix
Notice the blue axis is what we refer to as the Leadership Axis. We use this to make sure we are doing the right things. The red axis is what we call the Management Axis. We use this to make sure we are doing the right things, right.
Over the years, the Matrix has undergone revisions to reflect current critical issues and to keep SAMHSA directing its resources to support programs that will have the most impact on improving lives. As a result, each of SAMHSA’s three Centers now focuses its efforts and funding on four priority programs …major, long-lived initiatives that can yield the greatest potential. We call these our “redwoods.”
Slide 6/SAMHSA’s Redwoods
SAMHSA’s four redwood initiatives focus on:
- Expanding the nation’s Substance Abuse Treatment Capacity in new and innovative ways;
- Strengthening our substance abuse prevention efforts and streamlining these efforts on a national scale;
- Addressing the needs of adults and youth with co-occurring mental and substance use disorders; and
- Implementing our action agenda to achieve a wholesale transformation of the nation’s mental health services delivery system.
Building treatment capacity, the first of the redwoods, is critical because we know substance abuse treatment works. We also know that evidence-based treatment can significantly reduce the burden of substance use on individuals, communities, and our Nation. SAMHSA is vigorously supporting States’ efforts to expand their capacity for substance abuse treatment, improve treatment systems, and respond to new and emerging trends.
Slide 7/Substance Abuse Treatment Capacity
One way, is through the President’s Access to Recovery initiative─a $100 million State-run voucher program administered by SAMHSA that expands treatment capacity and promotes consumer choice. Access to Recovery will allow thousands of Americans with substance use disorders the opportunity to choose treatment and recovery support services from a range of qualified organizations, including those that are faith-based.
Another way is through SAMHSA’s Block Grant and Targeted Capacity Expansion programs. SAMHSA is providing over $1.6 billion to States to address treatment gaps and provide rapid and strategic responses to consumer demand for substance abuse treatment services. SAMHSA’s Substance Abuse Treatment Capacity priority program area will help millions of Americans with substance use disorders get the treatment they need…treatment they truly deserve.
Slide 8/Strategic Prevention Framework
While treatment programs are promising, we must not lose sight of the importance of preventing substance use and mental illness…before it starts. Prevention is the foundation for SAMHSA’s vision of a life in the community for everyone. Through SAMHSA’s second redwood, the Strategic Prevention Framework (SPF), we are advancing a community-based public health approach that promotes mental health and prevents mental and substance use disorders.
The Strategic Prevention Framework empowers States, communities, and individuals to bring together multiple funding streams, service systems, and programs to promote a collective responsibility around prevention. Thus far, we have awarded 19 States and 2 territories 5-year Strategic Prevention Framework grants, with an emphasis on the prevention of underage drinking.
Slide 9/ Co-Occurring Disorders
Our third redwood is the Co-Occurring Disorders priority program area. Individuals with co-occurring mental and substance use disorders face multiple and complex challenges…with each disorder exacerbating the other. SAMHSA is guiding action at the local level by providing support and technical assistance to help States enhance their infrastructure and treatment systems for persons with co-occurring disorders.
SAMHSA’s Co-Occurring State Incentive Grants are helping States to increase their capacity to serve people with co-occurring mental and substance use disorders. Eleven States have received these grants with the goal to eventually have a Co-Occurring State Incentive Grant in every State. To further support State efforts, SAMHSA’s Center for Mental Health Services and its Center for Substance Abuse Treatment have jointly funded the Co-Occurring Center for Excellence, a technical assistance center and helpline designed to provide effective prevention and treatment services for persons with co-occurring mental and substance use disorders.
Slide 10/ Mental Health System Transformation-ATP&AA
The fourth and most distinctive of our redwoods is Mental Health System Transformation. Through this initiative, my colleagues and I at CMHS are leading the Federal government in a collaborative effort to transform our national mental health system into one that holds the promise of recovery for the millions of Americans we serve.
In 2003, the President’s New Freedom Commission on Mental Health released a report, Achieving the Promise: Transforming Mental Health Care in America, which recommended a profound change in behaviors and competencies…a fundamental transformation of the nation’s mental health system.
As part of an unparalleled commitment to collaborate to change the status quo, SAMHSA—along with agencies from nineFederal Departments—has released the Federal Action Agenda—the roadmap that will guide our steps as a nation toward this wholesale transformation. This document is our pledge to take action. This Action Agenda identifies the first, time-limited, realistic steps that the Federal partners—across all of the key health and human services agencies—can take during the next year to move transformation forward. I have copies of Achieving the Promise and the Federal Action Agenda available for you today.
Slide 11/ MHSIGs
To help States jumpstart transformation, we awarded the first Mental Health Transformation State Incentive Grants (SIGs) — a $2.7 to 3 million dollar per year investment over the next five years — to seven States who will begin to make the systemic changes needed to meet multiple consumer needs and foster recovery. We are asking these States to do something truly revolutionary—to unite all of their State agencies involved with adults and children behind a common vision of mental health care as it should be! These States have an unprecedented opportunity to lead by example. What these States learn can help speed the pace and extent of transformation by others.
SAMHSA’s redwood programs are not stand alone trees...instead, they are a small forest with intertwined branches. The success we achieve in any of these programs will promote growing success in the other three. Through these four programs, we can serve more people…we can give people what they need most... and we can make tremendous impact. Like the magnificent redwood, these programs will grow strong...they will make an impact that will endure for generations to come.
Why so much emphasis on making an impact? It’s really very simple. Congress is looking at SAMHSA’s work as a business. Therefore, like any other business, we must operate efficiently and effectively...while providing all of the services needed and desired by our consumers. We must demonstrate that we are delivering real, measurable, concrete improvements and outcomes for those we serve.
Today, we’re hearing this call for accountability louder and more clearly than ever before. The President’s call for restraints in federal spending and a new government-wide focus on performance measurement and management exemplify what we are talking about today...the balancing act. Across the Federal government, we are working hard to keep the promise of vital programs while addressing their growing costs...to strike a balance between compassion and responsibility. Departments across the Federal Government are heeding the call to set priorities and make sure tax dollars are being spent wisely.
What does this mean for SAMHSA? It means we’ve had to get real about accountability. We’re moving past providing funding for treatment and services to providing funding for the most effective, evidence based treatment and recovery support services that move consumers and families along the path to recovery. One way we have accomplished this is through the use of National Outcome Measures, or NOMs.
Slide 12/NOMs
NOMs is a strategy to use data to help Federal and State substance abuse and mental health managers determine program effectiveness and ultimately improve services in the communities they serve.
Developed in collaboration with States, the NOMs initiative looks at ten domains which embody meaningful, real life outcomes for people who are striving to attain and sustain recovery, build resilience, and work, learn, live, and participate fully in their communities. The first area is abstinence from drug use and alcohol abuse or decreasing symptoms of mental illness and improved functioning. Four domains focus on resilience and sustaining recovery. These include getting and keeping a job or enrolling and staying in school; decreased involvement with the criminal justice system; securing a safe, decent, and stable place to live; and social connectedness to and support from others in the community such as family, friends, co-workers, and classmates.
Two domains look directly at 1) increased access to services for both mental health and substance abuse and 2) retention in services for substance abuse or decreased inpatient hospitalizations for mental health treatment.
The final three domains examine the quality of services provided. These include client perception of care, cost-effectiveness, and use of evidenced-based practices in treatment.
Data for reporting on the NOMs will come primarily from the States. States will be supported in their efforts by SAMHSA with infrastructure and technical assistance through a new State Outcomes Measurement and Management System (SOMMS), an umbrella activity in SAMHSA to implement NOMs.
Currently, each State is at a different stage of readiness and some of the measures themselves are still in development. However, ultimately we will be able to report State-level, consistent, cross-year data which will allow us to examine the impact of programs and changes over time.
NOMS are really about putting people’s needs first. It is about reporting on our performance in helping people attain and sustain what they say they need to achieve a life in the community. The tighter our measurements become, the more we can show our effectiveness…the greater the number of people served…and, the greater the hope for recovery and a life in the community for everyone.
A focus on outcomes that foster recovery and resilience is the foundation of everything we do at SAMHSA. Recovery is not only an outcome...it is also a process. Recovery is the journey of hope through which lives can be transformed. At SAMHSA/CMHS, we have been working hard to define the process of recovery and to determine ways to measure how we are moving the prevention and treatment systems of care forward to advance that process.
Slide 13/ Recovery Consensus
Last month, SAMHSA unveiled a consensus statement outlining the principles necessary to achieve mental health recovery. The statement was developed through the deliberations of more than 110 expert panelists representing mental health consumers, families, providers, advocates, researchers, managed care organizations, State and local public officials, and others. The panel determined:
“Mental health recovery is a journey of healing and transformation enabling a person with a mental health problem to live a meaningful life in a community of his or her choice while striving to achieve his or her full potential.”
The consensus statement offers these 10 fundamental components of consumer-driven recovery.
- Self-Direction
- Individualized and Person-Centered
- Empowerment
- Holistic
- Non-Linear
- Strengths-Based
- Peer Support
- Respect: their lives
- Responsibility
- Hope
Another key to recovery is person/family-centered planning. Person/family centered planning is a full process that engages consumers and their families as respected partners in every step of a path toward recovery and a meaningful life in the community. Since these plans are an integral focus of your accreditation surveys, you will be interested in knowing that SAMHSA recently convened a consensus conference of more than 70 participants nationwide to identify necessary elements of person/family-centered planning and best practices for mental health services. SAMHSA will soon release a person/family-centered consensus statement. We are also working to identify promising approaches and publish four training guides for consumers, families, providers and mental health administrators on person/family-centered plans of care.
One of the most direct routes to building a recovery focus in both the substance abuse and mental health services systems is to strengthen the workforce that delivers the care. This will not be an easy path to forge. Mental health care is a very labor-intensive field, with the workforce absorbing nearly 80 percent of our expenditures. In both the substance abuse and mental health systems, there is a wide range of providers with separate schools of training that apply numerous theories and therapies without standardized core competencies.
As we know, there are several gaps that plague our country’s mental health care workforce:
- Shortages of workers, especially in rural areas,
- Lack of ethnic diversity and cultural expertise among providers,
- Outdated education and training methods and content
- State-to-State variations in licensing requirements, credentialing, the scope of practice and competency measures.
One way we can overcome these roadblocks is by building partnerships. We must partner with licensing boards and accrediting bodies to improve and expand the workforce in many different ways. For over a decade, we have worked hard to develop and institute core competencies for all clinicians providing mental health services and substance abuse treatment. We have worked to move these competencies into education programs where they can then be incorporated into licensing standards or certification requirements. And the work continues.
SAMHSA is currently developing a National Human Resources Strategy and will be hosting a summit later this year. The focus of this strategy and the summit will be competency-based training and assessment.
These are some of the issues and challenges we are wrestling with on the federal level as we pursue our balancing act…as we strive to leverage diminishing funds to do the most good...as we work earnestly to demonstrate to Congress, to our partners, and to the people we serve that we are using the resources that have been entrusted to us to really deliver on our promise.
What does all of this mean to you?
In a word…accountability. In these times of growing demands and tightening budgets, each of us is being asked to demonstrate that what we do is value added. Each of us is being asked to answer the tough questions...to prove to those who support us that they are getting their money’s worth...that their investment in our work is a good, solid investment. SAMHSA has to demonstrate the value of its programs and services to Congress. Likewise, there are those who question spending money to accredit behavioral health and opioid treatment programs. We have to continue to work together to demonstrate that the benefits of accreditation are worth the investment.
CARF has already made great strides in demonstrating the value of the services it provides and the results it achieves. In a recent survey, 86% of programs surveyed indicated that they realized some benefit in accreditation. In 2005, an independent review of CARF and other SAMHSA-approved organizations has found agreement with the accreditation bodies’ findings nearly 95% of the time. Over the last 40 years, you have moved from simple program evaluations to outcome evaluations that measure effectiveness, efficiency, cost benefits, access, and satisfaction.
You have been very responsive in creating separate standards that are tailored to the unique needs of opioid treatment programs...behavioral health facilities...and most recently to services for children and youth. Yes, you are doing your job...and doing it well. But in these times, when everyone is being asked to do more...with less...there are steps CARF can begin to take right now to move its efforts to the next level.
Right now, it is critical for CARF to measure meaningful outcomes that demonstrate success. I know that CARF has focused on outcomes-related effectiveness for some time. Now is the time to look at developing and implementing nationally standardized outcome measures...and using the data to create a national database that will allow this valuable information to become more widespread.
Now is the time to think about how to make the monitoring of outcome measures an integral part of screening, assessment, treatment planning and providing treatment. Now is the time to redouble our efforts toward ongoing continuous quality monitoring. N ow is the time to work toward a model that ensures consumers that the care they receive is the highest possible care...every day...in every program. I urge you to look at the SAMHSA NOMS as a model of the kinds of quality measures CARF can integrate into its approach.
Right now, it is more important than ever for CARF to sharpen its focus on recovery. I know that a focus on recovery, wellness, and resilience has been one of the foci in CARF’s accreditation surveys for more than a decade. With SAMHSA’s Consensus Statement as a guide, now is the time to amplify the call for individualized plans of care and person centered planning.
I would like to take a moment here to recognize your work in rights protection as a key component of recovery. CARF’s efforts to reduce and eliminate the use of seclusion and restraint and CARF’s oversight of these practices is worthy of praise.
Reducing and eliminating the use of S&R is a mental health system transformation imperative! SAMHSA is undertaking a number of related initiatives. We awarded grants to eight States to explore and evaluate best-practice alternatives to seclusion and restraint. Our Seclusion and Restraint Matrix Workgroup has led the development of a consumer-based staff training manual on the alternatives of seclusion and restraint, which will be published shortly. We are in the process of developing a training video and regulations that will be sent out to the field. Our goal is to find ways to reduce and ultimately eliminate these practices and mandate the use of safer, more humane alternatives.
{Pause}
This will not be easy work. Many will say that it can’t be done...that we just can’t do any more than we are already doing. I say: together, we can. And we must.
SAMHSA’s work in partnership with CARF and other accreditation bodies on the national accreditation of Opioid Treatment Programs is proof of that. Even though many said it couldn’t be done, as of May 2004, almost all of the nation’s 1140 OTPs were accredited for the first time. To date, CARF has surveyed and accredited approximately 624 of these programs. A significant number of these have now maintained accreditation for more than 3 years and have received more than one accreditation site visit. CARF was instrumental in helping SAMHSA develop the original accreditation program for OTPs and recently participated in helping to revise the CSAT guidelines for accreditation of OTPs. The revised guidelines will be available for review in late April.
Each of these accomplishments is a step on the road to the wholescale transformation of our behavioral health care system that SAMHSA is undertaking. There are no quick fixes. And it will take all of us.
Slide 14/IOM Report
The recent IOM Report, Improving the Quality of Health Care for Mental and Substance-Use Conditions echoes the importance of organizations like CARF in the transformation agenda. The report concludes that clinicians and health care organizations “will not be able to fully achieve coordination of patient care without complimentary and supporting activities on the part of Federal and state governments, health care purchasers, quality oversight organizations, and other organizations that shape the environment in which clinical care is delivered.”
None of the suggestions I have made today will offer immediate relief for the balancing act. They are however, the platforms for long-term, systemic change that will increase the ability of consumers and families who are living with addiction and mental illnesses to participate fully in their communities while, at the same time, enabling each of us to measure and demonstrate the value of these services.
It will be a journey...a process. In yoga, mastering the difficult balancing poses requires constant practice. You have to work up to “perfect balance.” Likewise, our pursuit of balance in behavioral health care will require ongoing and continuous effort.
Slide 15/Quote
Aristotle says, “Quality is not an act. It is a habit.” I urge each of you to make a commitment today to make the pursuit of quality...balanced by accountability...a habit in every aspect of your work. I urge you to make it your mission.
Reach down deep inside of yourself, and ask, “What more can I do? What am I already doing that I can do better? ” Then, listen to your response and act on it. Stay focused…don’t give up...be relentless. And, ultimately, the people we serve will reap the rewards of our balancing act. The end result will be a more hopeful and healthy America.
Thank you.
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