Transcript A Comparison of Two Approaches

Building a Recovery Focused
Mental Health System:
Reflections on Systems Change
and Growth in Community Mental
Health
November 7, 2008
Canadian Innovations in Recovery Conference
Kitchener, ON
Jason Newberry, Senior Researcher
Allan Strong, Recovery Education Coordinator
Outline of Presentation
1. History and background
2. Overview of the training
3. The evaluation process
4. Preliminary findings, learnings, next steps
5. Questions and discussion
Our Purpose Today
•
•
To provide an overview of how the mental health system
in our region is changing to be more recovery focused.
•
The background of our local context
•
The building of a multi-organizational partnership to
pursue a recovery focus.
•
The development of organizational & community
training.
To describe the evaluation of “recovery focused case
management” in the region.
•
How consumers contributed to defining outcomes
•
The evaluation design and approach
•
Findings so far



2005 - Ministry of Health and Long Term
care provided funding for the enhancement
of case management in the area ( 1.13
million dollars)
Decision about how the money should be
allocated must be made by consensus
Planning process involved 3 community
agencies, 3 hospitals and an alliance of
consumer - survivor groups
Waterloo Regional Homes for Mental Health
 Grand River Hospital
 Trellis Mental Health and Developmental
Services
 Homewood Health Centre
 Cambridge Memorial Hospital
 CMHA Grand River Branch
 The Self Help Alliance




Developed and agreed to a decision making
process
Adopted a statement of values and principles
to guide our work
Designed services that were “true” to guiding
principles and values
6
6

What does the word “recovery” mean to you
and how would you know when you have
recovered?
7
7
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
Statement was developed by the Self Help
Alliance
Statement addresses how the system will
look if values and principles of recovery put
in place
8
8
A recovery oriented mental health and
addiction system will :
Value
Empowerment – The system will
Value
and Instill Hope – Recovery can not
provide opportunities for individuals to
exercise control and power with respect to
their lives.
occur without hope. The system will
encourage hope and in doing so will focus
on skills and abilities.


Value Self Determination – The system will
recognize and accept that consumers will
make their own decisions about their life and
they will be in control of those decisions.
Work toward the Elimination of Prejudice and
Discrimination – The system will work toward
the elimination of prejudice and
discrimination toward people with mental
health issues.

Value Meaningful Choice – The system will
recognize and accept that individuals will
make their own decisions about their life
and they will be in control of those
decisions.
From these key values, principles were
developed - copies of the document are
available


Started from a shared set of values and
principles that were developed by
consumers. This has not been usually been
the case.
Values and principles provide not only a
common understanding but also something
to hold each other accountable.
12
12
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
Trip to Ohio - service providers went to Ohio
Self Help Alliance had been developing its
own programming based on recovery
(independent of service providers)
13
13
Consumer and Case Manager Training



A central part of system transformation.
Training of staff in recovery values and
principles, and practice.
Training of consumers about recovery and
their role in planning
14
14
Consumer and Case Manager Training




Since April 2006, 30 staff training sessions.
247 staff (case managers, housing staff,
ACTT, management).
Since January 2007, 85 consumer training
sessions.
Over 250 consumers participated.
15
15
Recovery Action Planning
Learning the planning process…
Six steps:
1. Ranking & selecting a component
2. Determining the status
3. The “MUSE”
4. Determining the goal(s)
5. Identifying skills & knowledge, developing
an action plan
6. Community Resources
16
16
We are a non-profit and independent
community-based research organization
located in Kitchener, Ontario, Canada.
 We engage in diverse streams of work,
including applied research and evaluation,
needs assessments, systems change
initiatives, training & education, facilitation
& planning.
 Our values emphasize community
participation, action, and relevance in the
work we do.

Building an Evaluation Framework

CCBR was contracted by the community
partners to develop an evaluation
framework in reference to new system
changes.
The purpose of the evaluation is to….
“To understand how a recovery focus in the
Waterloo-Wellington-Dufferin mental health
system leads to positive changes for
individuals using case-management services”
Our Process



CCBR promotes the use of participatory
and collaborative research approaches.
In this project, we engaged with
consumers in two cities to help us define
what the outcomes of the recovery process
should be.
We also hired and trained consumer
researchers – almost all our data from
consumers was collected by our consumer
researchers.
The Logic Model Process



An important element of our evaluation
was the creation of “logic models” – visual
diagrams the depict the relationships
between CM services and expected
outcomes.
CCBR developed a set of logic models
through community forums with service
users and case managers (separately).
Synthesized the models and fed them back
to our steering committee.
The Logic Model Process


The logic models helped us gain an
understanding of recovery focused
outcomes from the perspective of different
stakeholders.
Helped us plan the evaluation – what to
measure, how, and when.
Recovery Outcomes – A Different Emphasis
Intensive Case Management Service
Standards (in Ontario) provide standards
and indicators of best practices. However,
they are not focused on outcomes – the
actual benefits experienced by consumers.
They are largely focused on service delivery.
Example:


Where possible, assertive outreach will be offered to
engage potential consumers in their place of choice,
considering the safety and security of the consumer
and the provider.
Service provision must be managed in a manner that
responds to fluctuations/variations in consumer
need.
Recovery Outcomes – A Different Emphasis
A few of the Standards (and their indicators)
approach and outcome orientation (e.g.,
consumer satisfaction, perceptions of
accessibility).
Our logic model sessions generated a greater
range of outcomes that:
 add to the Standards, giving a fuller picture of
consumer experience.
 help us think critically about why we think
recovery planning will lead to outcomes desired
by consumers.
 are recovery focused and quite different from
traditional outcomes (e.g., rehospitalization,
medication compliance, etc.).
Connecting
Linking to
formal
health
supports
Linking to
peer support
environment
s
Housing, Practical Support, Information, & Advocacy
*Creating
social
connections
with the
community
Involve &
educate family
& social
networks in
person’s health
Practical
assistance in
pursuing career,
employment;
finances
Work with
employers to
discuss health
issues,
accomm’s, etc
*
Providing
practical
support &
resources
Providing
support in
acquiring &
maintaining
adequate
housing
Planning
Provide
information
& advocacy
re: services,
benefits,
rights
Developing a
proactive &
personal plan
to prevent
crisis
Respectful relationships
Developing a
consumer-driven
& realistic
wellness plan
about future
goals
Ensure open &
transparent
reciprocal
communication -honesty in
relationship
*
Developing
interpersonal
skills &
relationship goals
Improved
overall
physical
health
*Increased choice
in accessing
different aspects
of system or
alternative
support
Increased
connections
& sense of
support in
community,
social &
family life
Increased
meaningful
work and
volunteering
Improved
housing
stability
Increased
financial
security &
stability
*Increased
resources &
support in
daily living
Feelings of
support in
crisis
*Increased sense
*Increased
skills &
knowledge
to pursue
goals
Minimal
disruption to
your life
when having
difficulty
Increased
knowledge
of the
concept &
process of
recovery
*
Sense of
renewal,
spirit, joy,
hope
Greater
participation
in regular,
day-to-day
community life
Greater
quality of
life
Willingness
to take risks,
to fail, & to
learn from it
Increased
confidence &
faith in own
decisions,
needs,
values
Increased self
esteem &
sense of
dignity &
respect
Greater selffufilment &
contentment
Increased selfawareness &
recognition of
reasons of
health
problems
of control & choice
regarding their
health, lives
Understanding
& believing in
your personal
goals &
dreams
Increased
stability in
employment
Sharing the
process &
success in
relationship
to others
Ongoing
listening
without an
agenda
Acting on
one’s own
plan for
recovery
(practicing
options)
Feelings of
personal
empowerment
Increased
*feelings
of hope
& ability to
dream about
recovery
People express
their identity
beyond the
mental health
system
Increased
confidence
in workers &
system
Providing
services that are
respectful
sensitive to
cultural diversity
Case
management
occurs where
desired
Increased
feelings of
comfort, trust, &
respect for lived
experiences
A sense of
diminished
professional
boundaries -more informal
relationship,
openness,
Outcomes for Service Users (synthesis)
Increased
opportunities,
resources &
connections
to work &
volunteering
Increased
awareness of
legal rights re:
discrimination
, employment,
etc.
Educating
Communicating
consumers
& exploring
about principles
options
of recovery
Use of
accessible,
plain
language
KEY RECOVERY-FOCUSED OUTCOMES
An emphasis on hope and dreaming, risktaking and action, confidence in the system,
and decision making leading to a cycle of
recovery.
*
Sharing the
process &
success in
relationship
to others
Greater
participation in
regular, dayto-day
community life
Understanding
& believing in
your personal
goals &
dreams
Willingness
to take risks,
to fail, & to
learn from it
Increased
confidence &
faith in own
decisions,
needs, values
Acting on
one’s own
plan for
recovery
(practicing
options)
Increased
*feelings
of hope
& ability to
dream about
recovery
Improved mental health & stability
Increased movement toward personal
goals
Sense of
renewal,
spirit, joy,
hope
Greater
quality of
life
Increased self
esteem &
sense of
dignity &
respect
Greater selffufilment &
contentment
Feelings of
personal
empowerment
People express
their identity
beyond the
mental health
system
Increased
confidence in
workers &
system
Planning
How do
Respectful relationships
we get there…?
Developing a
Developing a
consumer-driven
proactive &
& realistic
personal plan
wellness plan
to prevent
about future
crisis
goals
Developing
interpersonal
skills &
relationship goals
Educating
Communicating
consumers
& exploring
Feelings of
about principles
options
support in
of recovery
crisis
Ensure open &
transparent
reciprocal
communication -honesty in
relationship
*
Use of
accessible,
plain
language
Ongoing
listening without
an agenda
*Increased sense of
control & choice
regarding their
health, lives
*Increased
skills &
knowledge
to pursue
goals
Increased
knowledge
of the
concept &
process of
recovery
Increased selfawareness &
recognition of
reasons of
health
problems
Providing
services that are
respectful
sensitive to
cultural diversity
Case
management
occurs where
desired
Increased
feelings of
comfort, trust, &
respect for lived
experiences
A sense of
diminished
professional
boundaries -- more
informal
relationship,
openness,
Priority Outcomes and Questions
Service User Model
• How and to what extent is a recovery-focused
approach to case management helping people gain
the skills and knowledge they need to develop their
wellness plan and pursue their own goals?
• Are people beginning to understand the idea of
recovery and what it can mean for their own goals?
• How and to what extent is recovery focused
approach to case management helping to alter the
traditional relationships between case managers
and people they support?
• What is being done to ensure a reciprocal, honest
and open relationships between case management
and people?
• To what extent are people feeling an increased
sense of control and choice regarding their health
and lives?
• To what extent are people beginning to dream
about recovery and are hopeful that they will reach
their goals?
• To what extent are people active in their recovery
plan – taking risks, practicing options, and achieving
learning and confidence?
Priority Outcomes and Questions
Service/System Model
• What are the experiences, successes, &
challenges of the organizations within partnership in
building a collaborative, system wide approach to
recovery-focused case management?
• What is the impact of the training on the
knowledge and skills of case managers to promote
a recovery focus What are the successes and
challenges?
• Is a recovery focus apparent in the practice? Are
there attitudinal or organizational barriers?
Design & Methodology – Service Users
1. Service User Survey Interview
• A mix of demographics, existing & customized scales
focused on outcomes, and qualitative questions focused
on service use.
• This is our main “pre-post” to examine change.
• 86 participants
2. Service User Qualitative Interviews
• Qualitative interviews to explore ideas about recovery,
its relationship to case management, and expected
outcomes.
• 9 participants (4 Well.-Duff.; 5 Wat.Reg.)
Design & Methodology – Case Managers
3. Case Manager Online Survey
• A combination of custom scale items and openended questions to assess:
• the implementation of the recovery training
• use of the recovery action plan tool in practice
• perceptions and attitudes regarding recovery
values and practice.
• 57 case managers completed the survey
4. Case Manager Focus Group
• To gain a deeper understanding of the survey
findings. 10 case managers participated.
DRAFT copy – not to be used without permission
Design & Methodology – Managers
5. Management Key Informant Interviews
• Interviews with members of the committee to gain
insight regarding…
• building a multi-organizational partnership
• creating system wide service delivery policies
• Successes & challenges in translating policy into
practice
• Future initiatives of the system partnership
• 5 key informant interviews were conducted.
DRAFT copy – not to be used without permission
Feedback on the Case Manager Training
•Training has been well-received and
appreciated by most case managers.
• There was a desire for more training with
more practical dialogue, exchange and
discussion.
• Difficulties with the training, when cited,
would appear to linked more so to “difficulty
with the tool”.
Attitudes & Perceptions
• There was very strong support for the principles
and values of recovery (80%+ above the midpoint
of the scale).
• CMs tended to believe that their home
organization was doing a good job of
incorporating principles and values of recovery –
but the system had a long way to go.
Use of the Recovery Planning Tool
• 41% reported using the tool; 18% with some
modifications; 26% were not using the tool
• 66% were engaged in 1-5 plans; 23% in 6-10 plans;
11% in 10 or more plans
• Explanations for modifying the tool ranged from
simple changes to make it a bit easier to significant
changes (and abridged summary form).
From the focus group:
“For some clients the smallest amount of paperwork can be
intimidating. With 1 hour of flipping back and forth with this
cumbersome book, it’s pretty intimidating. Clients say; “I don’t
want to go there”. When in fact they have a vision of what
recovery is but the book and paperwork in front of them
prevents them from moving forward because they are frightened
by it.” – focus group participant
RE: the Recovery Planning Tool & Process
• The tool/process was viewed by CMs as difficult or
confusing for some service users and CMs alike.
• 44% of CM agreed that many service users are not
ready to go through the process; 37% believed the
process was not suitable for many service users.
• We also heard in some cases the tool wasn’t being
used with service users – information was being
gathered by CMs and then the tool was being filled out
later.
• This represents a lack of engagement with the
recovery plan process.
RE: the Recovery Planning Tool & Process
• A very positive finding was that case managers,
system-wide, have been truly engaging with the
tool to try to improve it and have initiated
processes to make it more user-friendly and
accessible.
• Case managers also reported feeling supported
by their supervisors and organizations in the area
of recovery planning.
Case Managers’ Perspectives on Outcomes
• At this point, there is little evidence that relationships
between CMs and services users (from CMs perspective)
has improved, although a majority of CMs cite “improved
communication”.
• Perceptions of service user outcomes were only
moderate (mean between 4 and 5.5 on a 7-point scale)
(see Table 12, p. 38)
• This is baseline data, and is expected. It could also be
a function of mental averaging of CMs.
• We will be following up on this data in the next phase.
Service User Evaluation – Demographics
• 86 service users participated
• 57% were male, 43% female
• CM service use ranged from .5 to 39 years,
• Average length was 11 years and 6 years for their
current agency
• 55% had completed H.S.; 21% had college/university;
24% had primary school.
Age category
Less than 30 years
30-39
40-49
50-59
60years or older
Total
Frequency
8
18
28
23
9
86
Percentage
9.3
20.9
32.6
26.7
10.5
100
Service User Evaluation – Baseline Outcomes
Our survey assessed:
• Community Integration
• Social Support
• Knowledge of Recovery Concept and Own Goals
• Hope and Dreaming
• Risk-taking, Action and Confidence
• Relationships with Staff
• Independence and Interdependence
• Control and Choice (empowerment)
Service User Evaluation – Baseline Outcomes
• This is baseline data. We do not expect “good outcomes”,
but a range of responses and moderate or low averages.
• We appear to have “good measures” – they were
internally consistent & reliable, there was lots of variation,
there were no “ceiling effects”.
• The measures intercorrelated in ways that made
theoretical sense:
• Better relationships with staff are associated with high
MHR scores.
• Sense of control is associated with MHR scores.
• Greater interdependence, community integration, and
social support are associated MHR scores.
STAFF
RELATIONSHIPS
CONTROL
Increased
skills &
knowledge
to pursue
goals
Increased
knowledge of
the concept
& process of
recovery
Increased sense of
control & choice
regarding their
health, lives
Increased feelings
of trust, comfort,
and respect for
lived experience
A sense of diminished
professional boundaries,
informal relationships
Willingness to
take risks, to
fail, & to learn
from it
Increased
confidence &
faith in own
decisions,
needs, values
Increased confidence
in workers & the
system
Acting on
one’s own
plan for
recovery
(practicing
options)
Increased feelings
of hope & ability
to dream about
recovery
ELEMENTS OF
RECOVERY
Increased
connections & sense
of support in
community, social &
family life
Increased
skills &
knowledge
to pursue
goals
Greater
participation in
regular, day-today community
life
Increased s
control &
regarding
health,
Willingness to
take risks, to
fail, & to learn
from it
SOCIAL SUPPORT &
COMMUNITY INTEGRATION
Sharing the
process &
success in
relationship
to others
Increased
knowledge of
the concept
& process of
recovery
Increased
confidence &
faith in own
decisions,
needs, values
ELEMENTS OF
RECOVERY
Acting on
one’s own
plan for
recovery
(practicing
options)
Increased
of hope &
to dream
recov
Re: Community integration…
“…without the Recovery Plan I don’t think I would have
made it to go here or to go there. For example meeting,
coming out from the house, catching the bus, coming to
meet people is a very good thing for me. Talking to people
where I know that I can discuss about my problems.” –
service user interview
Re: Moving towards recovery...
“My case manager put me in a state of mind where I would
look forward to the future rather than “just sit on ODSP.”
She helps me with self esteem and problem solving. I have
confidence now that I can go back to work. My case
manager is very supportive and empathetic.” – from the
survey
Re: the “Cycle of Recovery” – risk, action, confidence
“Over time my case manager said: `why don’t you try
certain things to see if…go step-by step and see how you
might do’….I’m hopeful for achieving my goals considering
my past experience in the last 5 or 6 years. I went to
school and took 10 courses over 5 years and I did fairly well
in all of them. That gives me the motivation then to want
to continue to try and do something more if at all possible.”
- Service user interview
Re: Recovery planning...
“My case manager put me in a state of mind where I would
look forward to the future rather than “just sit on ODSP.”
She helps me with self esteem and problem solving. I have
confidence now that I can go back to work. My case
manager is very supportive and empathetic.” – from the
survey
Re: Relationships
“It's always very important to me in any relationship that it
be a good relationship. However, some of the workers I've
had in the past have not respected the fact that if they
constantly cancel appointments, if they say they're going to
do something and then they don't do it, that affects me.
That to me is very difficult….I'm available when I'm
supposed to be, and I'm doing that I'm supposed to do and
just like with anything I think that that needs to be mutual.”
VS.
“(In a good relationship) I feel more empowered. I feel like
I'm – I've had a good appointment, we've come up with
some really good solutions, I'm going to try this and I'm
more motivated to keep going during those really tough
times.” – service user interview
Participation in the Recovery Process
With recovery plan
(N= 56; 65%)
Without recovery
plan (N= 30; 35%)
Number
41
%
73.2%
Number
11
%
36.7%
39
69.6%
14
46.7%
38
67.9%
15
50.0%
Power and control
36
64.3%
10
33.3%
Clinical care
36
64.3%
14
46.7%
Family support
34
60.7%
14
46.7%
Peer
support/relations
Spirituality
30
53.6%
11
36.7%
27
48.2%
6
20.0%
Education
25
44.6%
9
30.0%
Stigma
21
37.5%
11
36.7%
Life Area
Community
integration
Work/meaningful
activity
Access to resources
Participation in the Recovery Process
Among those who had a plan in process:
• 56% had a copy of their plan, 44% did not
Of those with a copy:
• 12 (39%) had not consulted their plans
• 14 (45%) did so only “rarely” or “sometimes”
• 5 (16%) did so “often”
This finding is an area that deserves attention.
Future Evaluation – Phase II
• Re-administering the service user survey as a
time 2 follow up, to compare to baseline.
• Re-administering selected pieces of the case
manager survey to compare changes over time to
practices.
• Recommend collecting more qualitative data from
a more diverse cross-section of service users.
These three activities comprise the main
components of the next evaluation phase.
Questions, Comments?
Open Discussion…
Think about the Saskatchewan experience…


What are the greatest challenges to pursuing
a recovery-focused system in your region
(province, city, town, community)?
How can they be overcome?
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50