Foundations for Building a Recovery Oriented Program

Chacku Mathai, CPRPAssociate Executive Director

New York Association of Psychiatric Rehabilitation Services

April 28, 2011

Backdrop: High Cost of Medicaid Care for New Yorkers w/ Multiple ‘Chronic’ Conditions

• New York’s Medicaid program serves over 4 million beneficiaries at a cost of over $47 billion annually (30% of all healthcare spending in NYS).

• 20% of Medicaid beneficiaries (1,029,621 ) account for 75% of the program’s expenditures: $31.1 million

• Average cost per year: $30,195 • These beneficiaries have “multiple co-morbidities, are

medically complicated and require services across multiple provider agencies. Due to their multiple and intensive needs, their care can often be fragmented, uncoordinated and at times duplicative. “

• 40% of these beneficiaries are diagnosed with mental illness and chemical dependency.

Backdrop: NYS Ranks 50th in Avoidable Hospital Readmissions

• NYS Department of Health estimated that $800 million was spent last year on ‘avoidable Medicaid hospital readmissions.’

• 70% of these involved beneficiaries with mental health, substance use and major medical conditions.

• 65% of admissions for this group were for medical reasons.

Vision for Recovery Outcomes • Believe that recovery is possible, even from

the most tragic circumstances or disabling conditions

• Uncover abandoned hopes and dreams• Discover our personhood through culture,

strengths, values, skills• Engage communities as life sustaining forces • Re-author the way we see ourselves • Reclaim a meaningful life and roles

Themes to Consider • Quality of life orientation as well as symptoms• Capacity to individualize interventions• Discharge planning with a focus on peer and

natural supports • Moving from diagnostically focused tracks to

fully integrated services• Supervision models to build hope and focus

on recovery• Increased visibility of people in recovery and

alumni as mentors and bridgers to community

Unemployment and poverty: A two-way street

Social Capital: Social connections

community organizations,support networks,

relationships/ connections “outside” mental health system, family supports, etc.

Human Capital:interviewing skills, job competencies,

education, training, certifications, etc.

Material Capital: work incentives, reliable transportation,

stable housing, work attire, savings, assets, etc.

EMPLOYMENT

Adapted from Potts’ definitions of: human, cultural and social capital (Potts, 2005)

Recovery Facilitation Capability Dimension Content of Items

I Program Design Program mission, outreach, services, community involvement, flexibility, crisis

II Physical Environment First contact/reception, publicly available resources, accessibility, non-segregated environment

III Staffing Recruitment, hiring, visibility of peer experience

IV Training Person-centered planning, connecting and coaching competencies, supervision, recognition systems

V Service Provision Relationship and hope-building engagement activities, assessment, recovery planning, focus on quality of life and life beyond services

VI Quality Improvement QI process reflects recovery indicators, QI team includes people receiving services

VII Program Evaluation Consumer needs, recovery outcomes, collection method, program design informed by data

Observable Correlates of Recovery

1. Level of Risk

2. Level of Engagement

3. Level of Skills and Supports

RECOVERY-BASED ACCOUNTABILITYQuality of Life Outcome Domains

•Housing/Home•Work/Career•Relational: Family/Friends/Romantic•Educational•Legal•Financial (Payee Status, e.g.)•Conservatorship• Incarceration•Hospitalization•Recreation/Leisure•Community/Citizenship•Health/Physical Wellbeing•Spiritual/Religion

Benefits of a New Workforce Culture

• Reflects most basic values of recovery-oriented systems of care– Belief in recovery– Community inclusion– Economic self-sufficiency– Workforce diversity

• Regular opportunities to see “recovery in action” for consumers and providers

General Workforce Roles for People in Recovery

• Peer-run organizations, e.g. recovery centers• Peer counseling positions, e.g. bridgers• Regular employee positions such as therapist,

practitioner, counselor, advocate, service coordinator, adminstrator…

• Volunteer peer roles • Community citizen volunteers

Developing Jobs for People in Recovery

• Review workforce needs throughout the agency (evaluate service needs and gaps)

• Include experience as a consumer of services in qualifications or preferences

• Create educational equivalencies to standard college requirements, e.g. work experience, related credentials, certificates

• Remove discriminatory or stigmatizing language from all written materials

Creating diverse teams

• Integrate peer positions in multi-disciplinary teams

• Create flexible schedules• Career ladders with opportunities for

advancement• Opportunities for recognized continuing

education• Performance reviews

Preparing the Work Environment

• Dual relationships, role definition, boundaries• Culture and standards for self-disclosure• Understanding reasonable accommodations• Will professional roles be diminished?• Will consumers require unreasonable amount of

support or lack necessary skills?• Role of consumer and non-consumer staff in staff

meetings and social events• Engaging people in recovery as colleagues

Preparing People in Recovery

• Impact of employment on benefits• Fears about ability to do the job• Fear of not being liked or accepted • Potential loss of friendships with other

consumers• Role of supervisor • Engaging other staff as colleagues

Education and Training

• Experience as a consumer does not equal capacity to serve in the workforce

• Review existing employee training programs for discriminatory or stigmatizing language

• Revise training programs to include recovery-oriented, person-centered, culturally competent content

• Recognize credentials, e.g. CASAC, Recovery Coaching, CPRP, etc.

NYAPRS Partnership with CEIC

• Building Recovery Facilitation Capability– Integrating peer support– Natural community supports

• Recovery Implementation Forums across NYS• Onsite Recovery Implementation Technical

Assistance • Case studies of local implementation• Dual Diagnosis Capability Assessments

References • Adams, Neal, & Grieder, Diane M. (2005). Treatment Planning for Person-Centered Care. Amsterdam, The

Netherlands: Academic Press.• Anthony, William A., Cohen, M., Farkas, M., & Gagne, C. (2002). Psychiatric Rehabilitation (2nd ed.). Center for

Psychiatric Rehabilitation, Boston University.• Davidson, Larry, Courtenay Harding, & LeRoy Spaniol (Eds.). (2005). Recovery from Severe Mental Illnesses:

Research Evidence and Implications for Practice. Boston, Mass.: Center for Psychiatric Rehabilitation, Boston University.

• Davidson, Larry, Michael Rowe, Janis Tondora, Maria J. O’Connell, Martha Staeheli Lawless. (2009). A Practical Guide to Recovery Oriented Practice: Tools for Transforming Mental Health Care. Oxford, England: Oxford University Press.

• Farkas, Marianne, Cheryl Gagne, William Anthony, & Judi Chamberlin. (2005). Implementing recovery oriented evidence vased programs: Identifying the critical dimensions. Community Mental Health Journal, 41(2), 141–58.

• Harding, C.M.; G.W. Brooks; T. Ashikaga; J.S. Strauss; and A Breier. (1987). The Vermont longitudinal study of persons with severe mental illness, I: Methodology, study sample, and overall status 32 years later. American Journal of Psychiatry, 144, 718–26.

• Mathai, Chacku. (2009). Building Integrated and Recovery Oriented Programs.• Ragins, Mark. (2007). Concrete Approaches to Recovery Based Transformation.• Ralph, Ruth, Kidder, Kathryn, Phillips, Dawna. (2000). Can We Measure Recovery? A Compendium of Recovery

and Recovery-Related Instruments. Cambridge, Mass.: The Evaluation Center at HSRI.• Spaniol, Leroy, Nancy J. Wewiorski, Cheryl Gagne, & William A. Anthony. (2002). The Process of recovery from

schizophrenia. International Review of Psychiatry, 14, 327–36.

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