>>Welcome to my presentation on
some ideas for behavioral health and recovery services, to improve
services, and consideration of a new way to organize
our system of care. I’ve made this presentation
to over 15 groups, stakeholders from
around the county, talked to over 1,000 people, and we have received some really
valuable input on the ideas that I have in this Power Point. We will continue to look
at the feasibility of this and continue our dialogue with
our stakeholder community. This past year, in 2011, the
Affordable Care Act was passed by congress, signed
by the President. The Affordable Care Act, otherwise
known as Healthcare Reform, recognizes the importance
of behavioral health issues in the overall effort to improve
healthcare in this country. We were fortunate to have some
very strong federal advocates that put forth the connection between behavioral
health conditions, overall health conditions, and
how it can help control costs and improve quality. Therefore, behavioral health
services is well integrated into much of the Affordable
Care Act. After the passage
of the act, SAMHSA, the Substance Abuse Mental
Health Services Administration, released a paper, “Description
of a Good and Modern Addictions and Mental Health System,” that
foreshadowed what this good and modern system may need to
be in order to fully participate and respond to the requirements
of Affordable Care Act and to the needs of our
communities and individuals. In addition to the
significant impact that healthcare reform may
have on our delivery system, there are other important
changes that have been occurring at the state level that also raises
the opportunity for us to assess where we’re at as a system
of care and to really think about are we positioned to best
provide the highest quality of care for people seeking our services and
for the communities we work with. Those changes at the
state level are reflected in the governor’s proposal on
realignment of mental health and substance use services
on the mental health side. It’s really the culmination of
what started in 1991, realignment. And it’s a new proposition
for substance use treatment to be realigned to
counties, in a nut shell what that means is funding for those
services will flow directly to the county after receipt by
the state, of vehicle license fees and sales tax revenue, and that
the counties will have full responsibility for services. Which otherwise known as Risk,
to manage the overall population. It’s a good opportunity for us,
and also has some risk that we need to make sure we’re
positioned properly to manage. The other major change at the
state level is parole realignment, which shifts responsibility
for a subset of offenders who had previously been
incarcerated in state prison and supervised by parole will
now be the responsibility of the local jurisdictions
for supervision and treatment, and incarceration,
and we’ve been working with our criminal justice partners
to provide a plan and a response that can best meet the
needs of that population, which we all know has high
rates of substance use and mental health conditions. What I want to focus principally
on is the Affordable Care Act and how it reflects a potential
road map for our consideration. So the SAMHSA folks visioned
that this paper would help to identify some key elements
in this modern system of care that I’m going to go through. The good and modern
system would not only focus on effective treatment
and recovery services, but it’s a clear recognition, one
that we spend a lot of our time on and clearly recognize it here
locally is that for people to be in recovery and to lead a quality
life in the community they need to have access to healthcare and
connection, they need to have ways of being as self-sufficient
as possible, whether it’s through
employment or public benefits. They need to have housing that’s
safe and secure, and they need to promote their own education,
if that’s relevant to them. The other part of the good and
modern system, somewhat related to the first bullet, is that
there is this strong emphasis in the healthcare reform
legislation, in many instances, of how primary care and
behavioral healthcare needs to be far greater integrated
than it’s been historically. And that holistic approach to
one’s care should be delivered as much as possible. The good and modern system would
have these following elements in it. It would have a very high
degree of accountability, basically delivering what
it says it will deliver. The system needs to be
organized as much as possible, and in healthcare reform, there is
something called the three aims. Which relate to improving
individual health outcomes, improving the overall health
population and controlling cost. So this third bullet of the good and modern does control cost while
concurrently improving quality. That may seem like
counter intuitive, how do you control cost
and improve quality. I would flip the order
of this bullet and say by improving quality you
actually control costs, because you should be able to
prevent higher levels of care, emergency rooms, psychiatric
hospitalizations, which are the highest
cost in healthcare. The system also needs
to be accessible. People should be able to get
into the system in an easy way. They should be able to get to where
they need to be to get the services that are required for them. The system needs to be equitable. Meaning that the level
of services and the types of services should be
distributed across an area that makes it distributed in a way
that anybody can get what they need in the area that they live. And the second to last bullet
is the system needs to, again, be effective. Meaning it has to
have a high quality. Overall, the good and modern mental
health and addictions system needs to be seen by the public as
really a public health asset, that in its totality
helps improve lives and lengthens one’s life span. And we know how relevant that
last portion is to our population, given recent information
about length of life. The good and modern system
results in a number of things that not only are we treating
people once they are symptomatic or become ill, but there needs to
be a very strong and high emphasis on helping people avoid illnesses. Whether it’s behavioral
health illnesses or general health illnesses. And then once we work
with people it’s not just about helping them get well,
but what kinds of services and supports are available
to help them stay well. So those are two really key results that the system needs
to continuously pursue. The system also is one that emphasizes a number
of really key things. The system is about recovery and
resiliency, which really speaks to the long term trajectory of how somebody becomes
well and stays well. And that the system is not just
about treatment but to do things in primary prevention
and early intervention. I spoke about on the
previous slide the reasons and the needs for
cost effectiveness. And that the system needs to really
focus on historically unserved and underserved populations. We’re fortunate through the
mental health services act that there’s been such
attention to increasing access and providing culturally
relevant services to underserved populations. Additionally, the system,
as I mentioned earlier, not only is integrated,
but that the access to the system provides the right
therapeutic dose the system shouldn’t overprescribe
or under prescribe. We should be able to assess
the needs of an individual and to the best we can,
provide the right level of intervention and support. The system also discussed
the need to be organized. And that’s reflective in
having standards of care that are consistently
applied throughout the system. And that we utilize a number
of tools to help us make sure that the quality that we
deliver is always being assessed and that we have a
continuous quality approach. And that’s through the
data that’s collected. We historically, like most
governmental entities, collect lots of data. But unfortunately, lots of that
data doesn’t get transmitted into information that we use to
really assess how we’re doing and to find ways of
improving our care. That needs to be a focus. And the last bullet speaks to
the importance of the work force. Imagine that there are 46
million people in this country without health insurance, and that through the healthcare
reform legislation, 30 million are now ensured, and
let’s hypothetically say 15 million of them now feel like they
want to enroll in primary care. There certainly is not the
number of primary care physicians or nurse practitioners, to be
able to meet that level of demand, nor in the behavioral health
world is there enough clinicians and counsellors and peer
support and family partners to meet the need of the pent
up demand that we may see as a result of healthcare reform. So the work force development
piece that we’ve done through MHSA to a limited extent really will
be required to be a primary focus if we’re able to meet all
of the other requirements of a good and modern system. So in the review of this paper, and by the way the full paper is
available on our web site for you to read if you so choose. But our question once we read
through of the paper is to look at our current system
and ask is ours a good and modern system of care. And if there are some areas
that we’re lacking on, how do we move towards this
good and modern system of care. So I want to provide a
little history that may — that is relevant to our
development as an organization, as behavioral health
and recovery services. Before 2007, Alcohol and
Drug Services was part of the Human Services Agency
and Mental Health was part of the Health Department. Additionally, that is
not shown on this slide. The San Mateo County Hospital and medical clinics
was its own department. So there could be a third box here. And there was work done prior to
2007 in our co-occurring initiative between Alcohol and Drug
Services and Mental Health that really started to
move us along a continuum to work more collaboratively
together. In 2007, behavioral health and
recovery services was born, the board of supervisors accepted
a recommendation that was developed through a long series of
conversations with stakeholders and staff from both services, and the health system
was actually reconfigured that included the San Mateo
County medical system. And so they’re now a division
within the health system, overall. So this afforded us an
opportunity to accelerate the work that we were doing around providing
better services to individuals with co-occurring disorders. This slide shows our organizational
chart, and there’s the red box that highlights the alcohol
and drug services portion. Before the integration,
if you can imagine, you would extract the red rectangle and that would be the mental health
department organization chart at the time. When the integration occurred
we basically made some room in that larger original chart
and stuck AOD services in there. And we really didn’t attend to any
specific organizational changes that would be more reflective of a movement towards a
co-occurring integration. There were some responsibilities
that individuals took on that were more
around integration. For example, our medical
director at the time, Celia Moreno [Phonetic],
assumes medical responsibilities for alcohol and drug
services, where alcohol and drug services prior to the integration did not
have any medical directorship. And I was in the position
of director of Alcohol and Drug Services at
that time and took on some mental health
services act prevention and early intervention
responsibilities. But we really didn’t do any
other structural changes. Also during that transition
time we created a group of stakeholders called the
transition management advisory group, consisting of family
members, consumers, providers, and staff to consider what
were the important milestones that this organization, behavioral
health and recovery services, should achieve over the next year. And that group did identify
milestones which were very helpful. And they also helped draft
a new vision, mission, and values statements
that would serve as important guidance
for the organization. Additional work that was done
at the beginning in ’07 was to create these building blocks. Basically, important areas that
we wanted to maintain a focus on in order to continue to
strengthen this new organization. And you’ll recognize the boxes
as you read our newsletter, Wellness Matters, articles
have a box attached to them to help connect them back
to this ongoing effort in one or more of these areas. So in 2007 when we were coming
together as an organization, we held an off-site
retreat of management staff, from both Mental Dealth and
Alcohol and Drug Services to consider the new organization,
what were some of the things that the transitional advisory
group was recommending, and how we could make the
transition as smooth as possible. We discussed a number
of ideas at that time. One of the ideas that was
presented was consideration of organizing our services,
both county operated and contract, on a regional basis. And we had some conversation
at that time. But never did anything about that,
as we focused on other things. Last October, about five
months after I became director, we had another off site. The first one in that four-year
period, to look at the organization and also to look at the
paper, Good and Modern System that I was mentioning earlier,
to ask and answer that question, is ours a good and modern system. As the first retreat, we discussed
lots of ideas and this notion of providing a more organized, regional level system
of care came up again. So rather than just lay
— have it lay dormant, we decided to explore
what that might look like in a little bit more detail. And that’s what I want
to present at this time. The information on this slide is a
concept, and like any new concept, there really isn’t a level of
detail behind this that would get into the specific hows,
how this would happen, and the specific operations
and the specific of where these would be,
et cetera, et cetera. It’s a concept that we’ve
asked people to respond to. I’m going to go through
the concepts of what we’re calling
community service areas and the wellness diamond. Remember in the earlier slides on
the good and modern system I talked about being recovery
and resiliency-oriented, and that’s certainly what we
would propose in this concept, that the community service area and the wellness diamond
would be really recovery and resiliency focused, that’s
clearly connected and grounded into the specific communities in
which the services are provided, and with the individuals and family
members that receive our services. In the community service area,
and the wellness diamond, we would essentially serve
all of the populations that we currently
serve, and as you’ll see in the slide we attach
families to all the populations and describe families not
necessarily as blood lines, but essentially as anybody
who the person who’s seeking and receiving services feels is
an important person or persons for them as part of
their support system. That’s who we’re calling families. And those populations would
be our targeted population within the wellness diamond. Now over on the right-hand side
I want to focus on a number of parts of this diamond. The first is the outer part
where it says community. And you will notice on the
outer lines of the diamond, they’re broken, and
there’s a reciprocal arrow between the diamond
and the communities. And this is to convey two things. One is we know when we look
around San Mateo County that there are very distinct and very different
populations and communities. Their culture, their
norms, their values, the demographics are very unique. And what this is to depict is that
services are going to be delivered in a specific community that would
connect to the values, norms, and demographics of that community. And services could be
and should be tailored to the maximum extent possible so
that it’s a welcoming environment. And the system of care is
very accessible to the people that reside in that community, and
recall one of the important parts of the Good and Modern system is
that they’re seen by the community as a public health asset. And the concept here is that
the stronger its connected to the particular —
particulars of that community, the community itself will see the
services as a public health asset. The second part of the community
relationship is obviously individuals and family
members make up the community. And we would want that — there’s
easy entrance into the services and supports that BHRS has
to offer for individuals and family members living in the
community and that they can get to the place inside the diamond
to where they need to go. And there isn’t a linear path for
them go from service A to B to C, and maybe if they fail C they can
get to D. But that they can get to where they need to go. So if an individual in the
community may feel the need, short term, early
intervention, they could go right to early intervention
services and maybe it’s an 8 to 10 week group that’s very
skills-focused, and in the course of that group they feel like they
really would like to find a way to get engaged in longer
term recovery supports. And they would have an
easy way to do that. Focusing on the inner
diamond, you’ll see just for simplicity’s sake we’ve
divided the diamond into four parts with an overall description of
the services that would make up that particular area. And we also broke the diamond
in the middle to again reflect that there would be easy movement
between those areas of services for people so that they can get to
what they need, when they need it, and where they need it, and
that there would be a flow. And this reinforces many
of the things that the Good and Modern paper described in
terms of getting services to people in a way that they need
it, and when they need it. Kind of that right
therapeutic dose. The second part is what
would be the structure of this community service
area, and the wellness diamond. Imagine that this community service
area is a mini Behavioral Health and Recovery Services. Meaning that it would offer
for a particular community all of the range of services
for the most part, there will be exceptions, a core
set of services that were specific for that community, but would
basically be serving all the populations that we serve
in prevention, treatment, and recovery, as well as mental
health and substance use issues. So there are many behavioral
health organizations. We don’t know how many there
might be, that would be work that we would need to do later to determine how we would
actually develop criteria to determine a community and
a community service area. But that would be work subsequent
to this phase of our exploration. Suffice it to say that each one of these community service areas
would have a behavioral health and recovery services manager,
and they would be the single point of accountability for that CSA. They would have responsibilities
for all of the directly operated county
services that may reside there, as well as oversight for
the contract providers from that community,
including contract monitoring. A very important function of the
manager as well as other staff, but principally the manager, would be to develop the
community relationships necessary for this community service area
that he or she is responsible for to really have solid and broad
relationships with the community. They would need to really
spend time cultivating those relationships, whether it
be the faith community, the business community,
law enforcement or other key service
groups, et cetera. We’re also envisioning a
community planning committee. This would be not a policy group, because our policy group is
the board of supervisors. But basically providing advice,
input, and guidance in the delivery of services for that
community service area, working closely with the manager. We don’t know how big they may be, they may vary depending
on the community. But none the less, each community
planning committee would be comprised of 51%,
or a simple majority of consumer and family members. In addition, we would
have representation from contracted agencies,
other private agencies, key public agency partners and representatives
from advocacy groups. And what they would do is work
closely with the managers and staff around understanding the
particular needs of the community, developing services and supports
that are responsive to the nuances of that community, and also helping to evaluate how well the
services are functioning and what outcomes are being
delivered in that community. And then being involved in the continuous quality
improvement process. Each one of the community
service areas would have — operating under some
guiding principles. I’ve talked a lot about the
community and the importance of being connected to the
community in order to act — improve one’s health, and also the
overall health of the community. I’ve spoken about the
integration with primary care. But additional key principles that the community service areas
may help facilitate would be the further integration of mental
health and substance use services, and when possible, when feasible, actually provide more
co-location opportunities. Now we’re not proposing
at this point that every service
be fully integrated. That’s not realistic. But we do believe this
will create an opportunity that may create more
opportunities to make this happen. But it would be a guiding
principle that we would look for. Same day access would be a
guiding principle, again going back to how do we make a system of care — one, that’s easily accessible and removing unnecessary
administrative barriers. So that would be a principle. Increasing the opportunities
for peer and family supports to help support clients as they
work through our system of care. I have also spoke to the right
therapeutic dose and levels of care matching clients needs. In the last bullet I would like
to highlight, and that is looking at opportunities that
are hours of service and our entry points would
be much more flexible. Can we provide more evening hours, can we provide some weekend
services and supports. But those would be,
again, guiding principles that the community service area
and its partners in the community and the community planning
committee would continuously be looking at, as a community
service area was developing. In each one of the
community services — service areas, we would define what
would be a core set of services that would be common to each
CSA, but we would also look at what additional
services are important for that particular community
that may not be needed in all the other CSA’s,
or maybe not needed in any of the other CSA’s but specific
to that particular community. So it would be a combination
of a core set of services uniformly
applied through all the CSA’s, but flexibility to consider and offer additional services
specific to the community. I’ve mentioned that this is
about all levels of care, so in the core set of
services it would be provision of both substance use and
mental health services, and through the continuum
of prevention through treatment and recovery. The community service areas
would work on a strong connection to those other key elements
of the continuum that was in the very first slide on
the good and modern system. We know people need to have
proper safe and supporting housing in order to recover,
there needs to be a level of self sufficiency, et cetera. The community service areas
would also be an opportunity to further much of the great work
that’s been done in this county around connecting primary care
and behavioral healthcare. And it would also
provide more opportunities for peer-run support services
as an adjunct, and a support to the clinical services
that we current provide. This motivation for the community
service areas was first stimulated by our review of the Good and
Modern paper, and again trying to answer the question about is
ours a good and modern system. But it also was — is an attempt
to address some other problems that we have in need
of improvement. And they’re highlighted
on this slide. And they are how do we create
greater equity and the ability for people to access what we do. We know there’s variance in
how we apply standards of care, how policies and programs are
implemented, monitored, supervised. I believe that although there’s
examples of good connections to some communities and improving
relationships with communities in the county, I believe that
there’s still great opportunity to more fully optimize our
relationships with the communities in the interest of supporting our
clients and our family members and to work on issues
of stigma, et cetera. We’ve made some significant
progress in our co-occurring initiative
around substance use, mental health and trauma, but we have
a ways to go with that. It’s still an issue,
a challenge for us. We’ve also done a fairly good job
of using and working with consumer and family members, but we have
a ways to go with that as well, as we see the value of consumer
and family involvement in our care. And lastly, when there isn’t more
locally attached accountability and it — the accountability is
only at a broad county level, it really starts to breakdown the
relationship between the community and the overall delivery of
services and accountability. And we think that’s a problem
and that we need some work done on increasing accountability and
the transparency of what we do. So given that, that
list of challenges, we think that the CSA may
provide us an opportunity to address those and
make some progress. And these are some of the ways
we think we could do that. The core set of services would help with equitability
across the county. And it may improve
access, that standard — the application of standards
of care and the policy and program administration
under that single manager for the CSA could help
further greater integration. It will lower the level of
accountability and transparency to the specific community in
which these services are delivered and the specific community
would be engaged in assessing the delivery
of services. It’s certainly in my mind would
promote much stronger community involvement that could
really tap unused resources, currently in the benefit of our
consumers and family members. So that’s the crux
of the presentation, and what we’ve been asking
people is for their input. I want to stress a
couple of things. One is that there’s been no
decisions made as to whether or not we’ll actually
implement this. We’ve been very cautious
and deliberate in making sure we’re having
presentations and conversations with our relevant stakeholders. We understand how dramatic a change
this could be, and so we want to do it right and not fast,
and we only want to do it if it helps answer more
challenges than it creates. And that at the end of the day it
provides a higher quality of care. The other thing I want to
say is that the consideration of this proposal is
in no way a statement that what we do currently
is not of quality. In fact, I would argue that
we wouldn’t be in a position to consider this proposal if
in fact the current delivery of services was not
of a quality nature. That it’s only because
of that strong foundation that we can actually
think about these things. And finally, this is also
meant to stimulate conversation with our stakeholders, both
externally and internally, around how we can
continuously be a quality — an organization that’s focused on
continuous quality improvement. We do good work with many people,
but we can always do better. And this is the opportunity
to stimulate that. So I really want to
thank you for logging on, and hearing the presentation. We will take the input
that we have received and consider our next steps. If we decide to go forward,
our next steps will be to flesh out more of the details
of this redesign and then seek additional reaction to it before any other
decisions are made. As I mentioned, there’s
no time table. This is — this process is
all internally initiated, there’s no external pressure
or mandate from anybody that we need to do this. So we can put a stop
to it at any time. But at this point we’ll
continue the path of exploration. So thank you, again, and I
appreciate your interest.

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