The New Freedom The New Freedom Commission Report: Commission Report: Creating a Consumer and Creating a Consumer and Family Driven Mental Family Driven Mental Health SystemHealth System

June 19, 2005June 19, 2005

King Davis, PhD, Executive DirectorKing Davis, PhD, Executive DirectorHogg Foundation for Mental Health Services, Research, Policy Hogg Foundation for Mental Health Services, Research, Policy

& Education& EducationRobert Lee Sutherland Chair in Mental Health & Social PolicyRobert Lee Sutherland Chair in Mental Health & Social Policy

School of Social WorkSchool of Social Work

The University of Texas at AustinThe University of Texas at AustinAustin, TexasAustin, Texas

Special DaySpecial Day

June 19, 2005

NAMI Charge: Take a NAMI Charge: Take a broad view.broad view.

Describe what a consumer and family Describe what a consumer and family driven system would look like and driven system would look like and how it would function;how it would function;

How to implement such a system;How to implement such a system; How to insure equal access to How to insure equal access to

treatment services;treatment services; How to incorporate the diverse needs How to incorporate the diverse needs

of our diverse populations in the of our diverse populations in the system.system.

The Challenge of The Challenge of Transformation:Transformation:

Help seeking - Myths

Status of Advocacy Organizations -Capacity

Disproportionate Poverty Rates

Capital Investments: Hospitals

State Planning: EBP

Human Resources

General Fund Pressure

Health Insurance Dilemmas

State Leadership – Governors, Commissioners & Boards

Private

Sector

System

Reform

State Legislative Interests

Societal Stigma – Impact

Federal Policy

States Rights – Decision Making

Federal Funding

King Davis, Hogg Foundation, 2004

Conceptual Clarity – Operational Definitions/Knowledge

Prior TransformationsPrior Transformations

1700s Local community and family based care1700s Local community and family based care 1763 Establishment of state hospitals1763 Establishment of state hospitals 1863 State hospitals for Africans in America1863 State hospitals for Africans in America 1942 Private health insurance linked to employment1942 Private health insurance linked to employment 1944 State systems of mental health – NIMH Created1944 State systems of mental health – NIMH Created 1955 Introduction of Psychotropic Medications1955 Introduction of Psychotropic Medications 1958 Deinstitutionalization1958 Deinstitutionalization 1963 Community Mental Health1963 Community Mental Health 1965 Medicaid financing for inpatient care1965 Medicaid financing for inpatient care 1973 HMOs as non-profit health care 1973 HMOs as non-profit health care 1980 End of federal support for community mental 1980 End of federal support for community mental

healthhealth 1995 Managed health care1995 Managed health care

Achieving the Promise:Achieving the Promise:

Transforming Mental Health Transforming Mental Health Care in AmericaCare in America

The President’s New The President’s New Freedom Commission on Freedom Commission on Mental HealthMental Health

First Step is to Look at the First Step is to Look at the Report:Report:

This report offers consumers, families, This report offers consumers, families, providers, and states an opportunity to providers, and states an opportunity to redesign their mental health systems, redesign their mental health systems, vision, goals, principles, services and vision, goals, principles, services and financing in ways that are significantly financing in ways that are significantly different than at any time in the past.different than at any time in the past.

But, critical questions must be asked!But, critical questions must be asked! Movement must proceed rapidly and Movement must proceed rapidly and

well!well! Timing is critically important!Timing is critically important!

What is significant?What is significant? 1. First report since Carter 1. First report since Carter

Administration.Administration. 2. First report by a republican president 2. First report by a republican president

since Eisenhower’s major effort.since Eisenhower’s major effort. 3. Focuses on changes at multiple levels.3. Focuses on changes at multiple levels. 4. Includes bold vision, mission and 4. Includes bold vision, mission and

goals.goals. 5. Seeks to equate physical and mental 5. Seeks to equate physical and mental

health – introduces important concepts.health – introduces important concepts. 6. Addresses issues of age, race, 6. Addresses issues of age, race,

ethnicity, families, consumers, & culture.ethnicity, families, consumers, & culture. 7. Builds on research & earlier reports:7. Builds on research & earlier reports:King Davis, Hogg Foundation, 2004

Six Critical Future GoalsSix Critical Future Goals Americans understand that mental health Americans understand that mental health

is essential to overall healthis essential to overall health Mental health is consumer and family Mental health is consumer and family

drivendriven Disparities in mental health are Disparities in mental health are

eliminatedeliminated Early intervention is commonEarly intervention is common Excellent care is delivered and research is Excellent care is delivered and research is

acceleratedaccelerated Technology is used to access mental Technology is used to access mental

health care and informationhealth care and information Source: New Freedom CommissionSource: New Freedom Commission

Important Important Concepts/IdeasConcepts/Ideas

TransformationTransformation TechnologyTechnology

RecoveryRecovery PreventionPrevention

ResilienceResilience Evidence BasedEvidence Based

ParityParity Practice BasedPractice Based

Family/ConsumerFamily/Consumer CollaborationCollaboration

EmpowermentEmpowerment Systems ChangeSystems Change

Knowledge TransferKnowledge Transfer Systems Systems PlanningPlanning

Cultural CompetenceCultural Competence Stigma Stigma ReductionReduction

King Davis, Hogg Foundation, 2004

CritiqueCritique Limited PublicityLimited Publicity ResponsibilityResponsibility No “Presidential” EventNo “Presidential” Event TimetableTimetable Tenure of CommissionersTenure of Commissioners StrategiesStrategies State Leadership State Leadership State HospitalState Hospital Background Reports Background Reports Jobs & PoliticsJobs & Politics Fiscal Status of StatesFiscal Status of States

IntegrationIntegration No Executive Orders No Executive Orders New MoneyNew Money Silo PotentialSilo Potential Parity BillParity Bill Focus on State PlansFocus on State Plans

ByproductsByproductsKing Davis, Hogg Foundation, 2004

The Second Step is to The Second Step is to Define: Key Terms and Define: Key Terms and

ConceptsConcepts

Consumer & Family Driven -KeyConsumer & Family Driven -Key TransformationTransformation RecoveryRecovery Cultural CompetenceCultural Competence Evidence BasedEvidence Based Mental HealthMental Health State PlanState Plan New FreedomNew Freedom

What Does it Mean to What Does it Mean to Drive?Drive?

Driven by the needs, values, Driven by the needs, values, interests of consumers and families?interests of consumers and families?

Driven by consumers and families?Driven by consumers and families? Driven by others based on Driven by others based on

perceptions of the needs of perceptions of the needs of consumers?consumers?

In the driver’s seat? In the In the driver’s seat? In the passenger’s seat? In the back seat?passenger’s seat? In the back seat?

Critical Internal Critical Internal Questions:Questions:

How does the family/consumer movement How does the family/consumer movement define “driven”?define “driven”?

What is the capacity of the family What is the capacity of the family movement to “drive mental health”?movement to “drive mental health”?

What is the capacity of the consumer What is the capacity of the consumer movement to “drive mental health”?movement to “drive mental health”?

Are consumers and families able to Are consumers and families able to collaborate to “drive mental health”?collaborate to “drive mental health”?

What are the risks in driving mental What are the risks in driving mental health?health?

What about families/consumers of color?What about families/consumers of color? Are we organized to “drive” mental Are we organized to “drive” mental

health?health?

Critical External Critical External QuestionsQuestions

Who will control the dollars?Who will control the dollars? Where has this worked before?Where has this worked before? How do we engage the professions?How do we engage the professions? How do we form coalitions?How do we form coalitions? How do we monitor the process?How do we monitor the process? Is this shifting of the burden?Is this shifting of the burden? Will state governors yield?Will state governors yield? What will be the role of legislators?What will be the role of legislators?

Summary Issues:Summary Issues: 1. Clear definition of “driven” and other key terms1. Clear definition of “driven” and other key terms 2. States rights issues – role of governors & federal govt.2. States rights issues – role of governors & federal govt. 3. What are the links between goals3. What are the links between goals 4. Involvement of professional groups in advocacy4. Involvement of professional groups in advocacy 5. Use of Medicaid/Medicare/state general funds -5. Use of Medicaid/Medicare/state general funds - 6. National plan on future of state hospitals/use of general 6. National plan on future of state hospitals/use of general

host.host. 7. Clear linkages between health & mental health & sa 7. Clear linkages between health & mental health & sa

systemssystems 8. Membership in consumer and family organizations8. Membership in consumer and family organizations 9. Elimination of federal contradictions in policy direction9. Elimination of federal contradictions in policy direction 10. Turn-over of state mental health commissioners10. Turn-over of state mental health commissioners 11. Low participation of families/consumers of color in 11. Low participation of families/consumers of color in

advocacyadvocacy 12. Capacity of advocacy organizations to “drive”12. Capacity of advocacy organizations to “drive” 13. Resolution of conflict between advocacy organizations13. Resolution of conflict between advocacy organizations 14. Involvement of business community14. Involvement of business community 15. Impact of stigma15. Impact of stigma

Defining Defining Transformation:Transformation:

Transformation is a complex goal Transformation is a complex goal that includes a series of processes that includes a series of processes that result in a fundamental change that result in a fundamental change in a system/structure from what it in a system/structure from what it was to what it has/will become. was to what it has/will become. Transformation is a meta-physical Transformation is a meta-physical event that encompasses values, event that encompasses values, principles, processes, outcomes, and principles, processes, outcomes, and a means of evaluation.a means of evaluation.

A transformed system: A transformed system: RecoveryRecovery

To achieve the promise of To achieve the promise of community living for everyone, community living for everyone, newnew service delivery patterns and service delivery patterns and incentives must ensure that incentives must ensure that everyevery American has American has easyeasy and continuous and continuous accessaccess to the most to the most currentcurrent treatments and best support servicestreatments and best support services

Source: New Freedom CommissionSource: New Freedom Commission

Factors That Drove Prior Factors That Drove Prior TransformationsTransformations

Increased Cost of Care – Born by StatesIncreased Cost of Care – Born by States Critical EventsCritical Events: Preparation for War; : Preparation for War;

Crises; Elections; Critical ReportsCrises; Elections; Critical Reports Scientific Discovery: Scientific Discovery: Thorazine, Thorazine,

StelazineStelazine Federal Policy:Federal Policy: Medicaid, CMHC, HMOs Medicaid, CMHC, HMOs Changes in Private Changes in Private Health InsuranceHealth Insurance

Coverage – Coverage – Potential for profitsPotential for profits AdvocacyAdvocacy by Interest Groups by Interest Groups State State PlanningPlanning Efforts Efforts

What did we learn?What did we learn?

Transformations are complex processesTransformations are complex processes Transformations are subject to Transformations are subject to

interpretation by interest groupsinterpretation by interest groups Transformations are expensiveTransformations are expensive Transformations require oversightTransformations require oversight Transformation is controversialTransformation is controversial Transformations are powerful toolsTransformations are powerful tools Transformation requires new policiesTransformation requires new policies Transformation requires a value baseTransformation requires a value base

The Third Step is to The Third Step is to Outline The Future Outline The Future System: System: PrinciplesPrinciples Consumer choiceConsumer choice Knowledge basedKnowledge based

Family choiceFamily choice Locally basedLocally based Cultural competence Cultural competence InsurableInsurable Integrated services:Integrated services: Health/MH/JusticeHealth/MH/Justice CollaborationCollaboration Health basedHealth based Shared power/governanceShared power/governance Child centeredChild centered Flexible use of dollarsFlexible use of dollars Recovery focusedRecovery focused ParityParity Prevention orientedPrevention oriented AccountabilityAccountability Evaluation centeredEvaluation centered InclusivenessInclusiveness Long term careLong term care

The Future System: The Future System: ImplementationImplementation

Collective statement of vision & Collective statement of vision & missionmission

Clear definition of terms & conceptsClear definition of terms & concepts Participation in state planning effortsParticipation in state planning efforts Participation in federal operational Participation in federal operational

planplan Realistic timetable for changeRealistic timetable for change Set-aside of federal and state dollarsSet-aside of federal and state dollars Mechanisms for evaluation of resultsMechanisms for evaluation of results Leadership training and developmentLeadership training and development Capacity building & trainingCapacity building & training

The Fourth Step is to The Fourth Step is to Identify the Barriers:Identify the Barriers:

Aging members within advocacy groupsAging members within advocacy groups Conflicting direction within advocatesConflicting direction within advocates Absence of planning models: businessAbsence of planning models: business Shrinking mental health dollarsShrinking mental health dollars Limited federal control of mental healthLimited federal control of mental health Unorganized advocacy efforts - nationalUnorganized advocacy efforts - national Degree of societal stigmaDegree of societal stigma Complexity of the taskComplexity of the task Resistance to changeResistance to change

ConclusionsConclusions Transformation cannot occur fully without addressing the Transformation cannot occur fully without addressing the

complex issues of disparities, knowledge, evidence, research, complex issues of disparities, knowledge, evidence, research, participation, help seeking;participation, help seeking;

Clear definitions and strategies are needed for meaningful Clear definitions and strategies are needed for meaningful transformation;transformation;

Transformation comes at a time of significant reductions in Transformation comes at a time of significant reductions in state budgets for human services; local and state disputes over state budgets for human services; local and state disputes over direction; state legislators maintain control of systems; dollars direction; state legislators maintain control of systems; dollars have driven prior transformations;have driven prior transformations;

Families and consumer advocates must increase the capacity of Families and consumer advocates must increase the capacity of their organizations to lead;their organizations to lead;

States must develop long-term plans for their state hospitals States must develop long-term plans for their state hospitals and the long-term availability of inpatient care;and the long-term availability of inpatient care;

Evidence based approaches must be expanded to include the 4 Evidence based approaches must be expanded to include the 4 populations of color;populations of color;

Cultural competence offers promise but requires national field Cultural competence offers promise but requires national field testing, cost estimation, educational trials, linkages to testing, cost estimation, educational trials, linkages to licensure, accreditation, and further development;licensure, accreditation, and further development;

Poverty and related socio-economic issues will affect the Poverty and related socio-economic issues will affect the application of evidence based approaches;application of evidence based approaches;

Proposal: Now is the Proposal: Now is the TimeTime National Televised Acceptance of the National Televised Acceptance of the

Report by the Report by the President/Governors/Consumers and President/Governors/Consumers and Families - TogetherFamilies - Together

National Summit of Consumers and National Summit of Consumers and Family Organizations – National and Family Organizations – National and StateState

Maintain the Freedom Commission - Maintain the Freedom Commission - Outlining of the Future System - VisionOutlining of the Future System - Vision Developing the Implementation PlanDeveloping the Implementation Plan Developing the Monitoring ApproachDeveloping the Monitoring Approach Interface with State/Federal OfficialsInterface with State/Federal Officials