6 th Annual Organizational Change Forum

66thth Annual Organizational Annual Organizational Change ForumChange Forum

System Transformation to System Transformation to Recovery Focused ServicesRecovery Focused Services

Roy Starks-Mental Health Center Roy Starks-Mental Health Center of Denver of Denver

OverviewOverview

• Creating a Recovery Focused System

• Measuring Recovery

• Creating a Culture which Promotes Recovery Focused Work

What is Recovery?What is Recovery?

• “Recovery refers to the process in which people are able to live, work, learn and participate fully in their communities. For some individuals, recovery is the ability to live a fulfilling and productive life despite a disability. For others, recovery implies the reduction or complete remission of symptoms. Science has shown that having hope plays an integral role in an individuals recovery.” William Anthony

• Achieving the Promise—The President’s New Freedom Commission on Mental Health 2003

Vision StatementVision StatementNew Freedom CommissionNew Freedom Commission

• “We envision a future when everyone with a mental illness will recover, a future when mental illnesses can be prevented or cured, a future when mental illnesses are detected early, and a future when everyone with a mental illness at any stage of life has access to effective treatment and supports-essentials for living, working, learning, and participating fully in the community.”

Recovery focused System Recovery focused System componentscomponents

• 1989—MHCD formed by City of Denver in response to Robert Woods Johnson Foundation—Requirement for one mental health Authority

• Denver combined four existing mental health centers to form MHCD(small SE program, no consumer employment, no drop-in or clubhouse program, no strengths based case management, mission statement of quality mental health, no value of recovery—ie. Business as usual)

Recovery Focused System Recovery Focused System ComponentsComponents

• 1989-1993—Stabilize creation of new center• 1993-2000—Implementation of Lawsuit• 2000—Article on “Denver Approach” • 2000—New CEO with Recovery Commitment• 2001—Formation of Recovery Committee• 2001—Creation of RNL• 2003—Completion of Logic Model• 2003—Commitment to “Center of Excellence”• 2004—Adoption of new mission statement


• Enriching Lives and Minds by Focusing on Strengths and Recovery

• 2003 to 2007-Development of Markers and Measures

• 2007—Use of REE and conversion to PRO• 2006—MHCD receives award of Excellence

from National Council for 2005 for work in recovery focused system


• Outreach and engagement– Outreach workers in homeless shelters– Recovery Connections – Housing First project with CCH– Denver’s Road Home-1) Project for Homeless

Women 2) Project for Denver’s most difficult to house


• Housing with Appropriate Supports– Extensive system of Group homes,

congregate apartments, section 8 apartments• Partnerships with Colorado Coalition for the

Homeless, Denver Housing, Colorado Housing and Homeless program, REDI corporation, Senior Housing Options


• Intensive Case Management– Ratio of 1 to 12– Ratio of 1 to 25– Ratio of 1 to 40– Ratio of 1 to 80

Psychiatry only


• Integrated Treatment for Co-occurring Disorders– MHCD SURGE program High Fidelity use of

the Integrated Dual Diagnosis Treatment (IDDT) as developed by Kenneth Minkoff, M.D.

– Partnerships with Arapahoe House and CCH


• Involvement of Recovering Persons– On MHCD Board– Consumer/Staff Partnership Council– Peer Mentors– Extensive employment of recovering persons

• 40% in Rehabilitation program• CMA, vocational counselor, residential counselors,

mail room, administration, nurses, case managers• Survey teams; Office of Consumer Affairs


• Supported Employment– Use of IPS Evidence Based Practice—

Adherence to Fidelity Scale as developed by Drake and Bond—Serves 500 annually—Part of Mental Health Treatment Study

– In conjunction with Supported Education program—Modified from Clubhouse model—Part of Bridge to Community Integration

Why Evaluate Recovery?Why Evaluate Recovery?• The Surgeon General Report on Mental

Health (DHHS, 1999), and Presidents New Freedom Commission (DHHS, 2003) suggested mental health providers engage in system transformation to become more recovery oriented.

• At MHCD, we believe that evaluation is a critical component of system change. – We have a constant feedback loop about client’s

recovery for clinicians, managers and directors, thereby providing data to assist in system transformation.

Evaluating Recovery of the PersonEvaluating Recovery of the Person

• Development by MHCD of Multidimensional approach to evaluating recovery from different perspectives over time.

(1) Recovery Marker Inventory(RMI)

(Staff rating of member progress in recovery on eight dimensions. Used to inform clinical & program decisions - every 2 mo.)

(3) Recovery Measure by Consumer (RMC)

(Consumer’s rating of their own recovery on five dimensions – all members every 3 months)

(2) Promoting Recovery in Organizations (PRO)

(Consumer evaluation of how specific programs and staff are promoting recovery - random sample 1x per yr.)

To what degree is RECOVERY

happening?Multiple perspectives Multiple dimensions Change over time

Four Measures of Recovery

(4) Recovery Needs Level (RNL)

(Suggests best level of services for stage of recovery)

Recovery Marker Inventory (RMI)

Recovery Marker InventoryRecovery Marker Inventory

• Indicators usually associated with individual’s recovery– But they are not necessary for Recovery. For

example, a person may struggle to find a job because of their level of Recovery OR because the economy is bad

• Collected every other month on every consumer in high case management teams, according to a predetermined criterion on outpatient consumers

Recovery Marker Inventory Recovery Marker Inventory DimensionsDimensions

• Employment• Education/training, • Active/Growth orientation, • Symptom interference, • Engagement/role with service provider, • Housing, • Jail episodes/days, Hospital episodes/days due to

psychiatric reasons, Hospital episodes/days due to physical reasons,

• Substance abuse (level of use) • Substance abuse (stages of change).

Reliability of the RMI V2.1Reliability of the RMI V2.1• Reliability- how consistently we will get the

same score for individuals with the same level of indicators of recovery (we want high reliability, meaning high constancy in scoring).– Mathematically, it is hard to get a high reliability with only 6

items. – RM V1.0 has a CTT reliability of .67

• IRT reliability: Person = .75, Item = 1.00• CTT reliability = .78

Item difficulty for the Recovery Item difficulty for the Recovery Marker Inventory V2.1Marker Inventory V2.1

• The easiest marker is reduction in symptom interference. In traditional treatment this will be primary goal.

• As the markers increase in difficulty that means that the number of consumers that get a high score in this marker decreases,

•For example, if a consumer has a high score in engagement/participation, they will also have a high score in active growth and symptom interference because these markers are easier to achieve for our consumers.

• The hardest marker of recovery for our consumers to achieve is education. This means that most consumers who score high on education will score high on all other markers of recovery.

Promoting Recovery in Mental Health Organizations (PRO)

Recovery Enhancement Recovery Enhancement EnvironmentEnvironment

• Developed by Patricia Ridgeway• People rate the importance of several elements

(such as hope, sense of meaning, and wellness) to their personal recovery, and rate the performance of their mental health program on three activities associated with each of these elements.

• They also rate the program on factors in the program climate that promote resilience or rebound from adversity

PPromoting romoting RRecovery in MH ecovery in MH OOrganizations (PRO)rganizations (PRO)

• Developed by MHCD to address our special needs

• Sections for each type of staff that interacts with our consumers (front-desk clinical, medical, case managers, rehabilitation)

• Currently is being piloted at MHCD

The Reaching Recovery Program is the intellectual property of the Mental Health Center of Denver. By [viewing this presentation; receiving these materials, etc.] you agree not to infringe on or make any unauthorized use of the information you will receive.

Recovery Measure by Consumer (RMC)

Recovery Measure by ConsumerRecovery Measure by Consumer

• Intended to measure the consumer’s perception of their Recovery– Very useful to understand whether what we

observe matches how the consumer is feeling • For example, a person may stay at home because they

have an introverted personality, OR because they might have paranoia symptoms

– Sometimes, the consumer fills it out with the help of the clinician, thus sparking new areas to explore together

Recovery Measure by Recovery Measure by Consumer DimensionsConsumer Dimensions

• Active/growth orientation• Hope • Symptom’s interference• Safety • Social network

• The easiest domain of recovery is an increase in social networks and hope

• As the domains increase in difficulty that means that the number of consumers that get a high score in this domain decreases,

• For example, if a consumer has a high score in safety they will also have a high score in active growth, hope and social networks because these markers are easier to endorse for our consumers.

• The hardest recovery domain for our consumers to achieve is symptom interference. This means that most consumers who score high on symptom interference will score high on all other domains of recovery.

Recovery Needs Level (RNL)

Recovery Needs LevelRecovery Needs Level

• Helps to assign the right level of service to the consumers

• The basic assumption being that consumers recover and their needs change over time.

• Used at MHCD every 6 months in combination with their Individual Service Plan (ISP)


• Measures criteria for service needs in 17 areas such as:

• Hospitalizations• Lethality • Co-Occurring Substance Abuse• Case Management Needs


• Completed by Primary Clinician in Electronic Record

• Scored Electronically According to Algorithm • Five Levels of Service:

--ACT– High intensity case management – Medium intensity case management– Outpatient service– Psychiatry only

Lessons Lessons LearnedLearned

Lessons LearnedLessons Learned

• On average, individuals coming into MHCD who are homeless and have a severe mental illness, move from ACT to Intensive case management in 18 months

• In a five year period 21% moved to more intensive services and 64% moved to less intensive services


• As people move to less intensive services, they do not fall apart—In fact their recovery markers and measures both continue to increase.

• People at all five levels access supported employment services.

• As people move into employment, all of the recovery markers increase


• The first year the RNL was implemented, 25% of people in ACT moved to less intensive services

• Following the first year, 16% move from ACT to less intensive

• The cost for 400 openings to intensive services the first year would have cost the state an additional 5 million dollars.

Using Recovery Using Recovery Information for Quality Information for Quality

ImprovementImprovementCreating a Culture Which Creating a Culture Which

Promotes Recovery Focused Promotes Recovery Focused WorkWork

MHCD ValuesMHCD ValuesWe, the staff, consumers, and governing board of MHCD, value:• Consumer recovery and resiliency fueled by hope and

encouragement toward consumer goals• Compassion and empathy• Service excellence, efficiency, and effectiveness to meet the

needs of consumers and the community• A wellness culture that recognizes, respects, and develops the

strengths of consumers, staff, and our partnerships in the community;

• Honesty, integrity, and ethical behavior in all our actions, communication, and relationships;

• Diversity in our workplace, relationships, and community; • Innovation, creativity, leadership, and flexibility• Green sustainability to protect the environment and reduce waste

in all our valued resources.

MHCD Wellness CultureMHCD Wellness Culture• We intentionally bring out the best in ourselves and others

by:• Seeing everyone’s strengths• Supporting and encouraging one another• Celebrating staff, accomplishments, and diversity• Respecting ourselves and others• Listening to each other• Creating an environment of healthy and positive

relationships and community partnerships• Believing everyone wants to be great• Being passionate about our mission and having fun in the

process• Believing anything is possible!

First Break All the RulesFirst Break All the RulesMarcus Buckingham & Curt Marcus Buckingham & Curt

CoffmanCoffman• “The Measuring Stick

– Do I know what is expected of me at work– Do I have the materials and equipment I need

to do my work right?– At work, do I have the opportunity to do what I

do best every day?– In the last seven days, have I received

recognition or praise for doing good work?– Does my supervisor, or someone at work,

seem to care about me as a person?

ContinuedContinued

– Is there someone at work who encourages my development?

– At work, do my opinions seem to count?– Does the mission/purpose of my company

make me feel my job is important?– Are my co-workers committed to doing quality

work?– Do I have a best friend at work?

ContinuedContinued

– Is there someone at work who encourages my development?

– At work, do my opinions seem to count?– Does the mission/purpose of my company

make me feel my job is important?– Are my co-workers committed to doing quality

work?– Do I have a best friend at work?

ContinuedContinued

– In the last six months, has someone at work talked to me about my progress?

– This last year, have I had opportunities at work to learn and grow?

These twelve questions are the simplest and most accurate way to measure the strength of the workplace.”

ContinuedContinued

– In the last six months, has someone at work talked to me about my progress?

– This last year, have I had opportunities at work to learn and grow?

These twelve questions are the simplest and most accurate way to measure the strength of the workplace.”

Go Put Your Strengths to WorkGo Put Your Strengths to WorkMarcus BuckinghamMarcus Buckingham

• Set out format for how to maximize the use of your strengths in the workplace

• Sets course for how to build on the strengths of others and to maximize their strengths in the workplace

Catalytic CoachingCatalytic CoachingGarold L. MarkleGarold L. Markle

• Provides detailed alternative to traditional performance evaluation which enables people to create a course to maximize strengths and accomplishments– Employee input sheet– Coaches perception– Employee creates plan

Client Driven Treatment PlanningClient Driven Treatment Planning• Individual Service Plan (ISP)• Asks consumers what they need and want• Elicits consumer’s strengths• Actively uses consumer strengths in

objectives and methods• Used and reviewed with the consumer• Included in Peer Review

Service PlanningService Planning• The Individual Service Plan asks consumers:

– What do you need and want? – What skills, interests, resources, and qualities do you have? – What cultural/ethnic/racial/spiritual strengths do you have? – What do you see as the areas you'd like to change?– Other input from consumer about priorities

• Clinician input about priorities • The Case Review is integrated with the ISP and involves consumers• Six Month Case Review

– Consumer Perception of Progress– Clinician Perception of Progress– Consumer-identified treatment focus for next six months

Role of the Role of the Electronic Medical RecordElectronic Medical Record

• STAR / eCET integrated platform• Helpful tool for Quality at the Source• Service integration

– Service delivery coordinated with service plan– Service integration among all staff– Actively includes Rehab and Residential

• Peer Review• Extensive staff training• Integration with recovery instruments

Data Collection: Integration and AutomationData Collection: Integration and Automation• Automated and integrated processes• Recovery Instruments:

Integrated with STAR electronic medical record• Show rate reports• Peer Review:

– Conducted electronically using STAR documentation– Input into an MS Access database for analysis

• Goebel UM Review:– All new admissions, identified in STAR database– Outliers identified in STAR services database– Services and documentation compared with RNL in

STAR• PRO Survey (Promoting Recovery in MH Organizations)

– Scannable forms eliminate manual data entry

Benefits of Our Integrated SystemsBenefits of Our Integrated Systems• Performance and process feedback to

clinicians, managers, administration– Peer review trend reports– Clinician utilization reporting– Consumer complaints data and reports

• Compliance with state and federal requirements– Billing– Due dates– Signatures– Formats

Benefits of Integrated SystemBenefits of Integrated System• Systems for collaboration,

cooperation, involvement– Accessible data– Efficiency through automatic data capture– Efficient and effective peer review– Information to provide quality care– Effective utilization of resources,

clinical and administrative• Mentor, Measure, Motivate

– Engage clinicians in using recovery data– Focus on what’s measured– Identify best practices– Watch trends for continuous improvement

Documents

6 th Annual Organizational Change Forum