Section I: Introduction

History

Philadelphia has had a long history of innovation in the behavioral health field, beginning with the work of Dr. Benjamin Rush (1746-1813), the first to propose a disease concept of "chronic drunkenness" and to advocate specialized treatment services for this condition. The city's leadership role continued with the closing of the state hospitals in the late 1980s and the more recent formation of Community Behavioral Health (CBH), the nation's largest city-controlled managed behavioral healthcare organization. This document represents the next step in the evolution of Philadelphia's efforts to create a more effective and efficient system of care. This system is based on the latest thinking in the field, empirical evidence and another essential element: the preferences of the individuals and families receiving services.

These practice guidelines are framed by the notions of recovery and resilience. It is this framework, and an unwavering belief in recovery and resilience in behavioral health, that should be the basis for service delivery. The document is presented in three sections:

I. Introduction

II. Overview of the Framework

III. Strategies in the Four Domains

The guidelines presented in this report represent the collective vision of many people. Hundreds of stakeholders—including people in recovery, providers, family members, advocates and staff of the Philadelphia Department of Behavioral Health and Intellectual disAbility Services (DBHIDS)—participated in focus groups across the behavioral health system, contributing their ideas and perspectives about existing strengths, best and promising practices and opportunities for growth.

Their feedback has been blended with the lessons learned from Philadelphia's transformation efforts over the past 30 years, several exciting national trends and the empirically informed practices documented in the literature. Together they form the foundation for Philadelphia's new practice guidelines.

Momentum from National Trends

Several national trends are propelling the dramatic changes unfolding within the City of Philadelphia's behavioral health system. These trends include national health care reform efforts, mental health transformation processes, the recovery advocacy movement in the addiction field, the emphasis on resilience in children's behavioral health and findings published in the Institute of Medicine's Quality Chasm report.

Health Care Reform: Quality, Outcomes and Accountability

The historic health care reform legislation enacted on March 23, 2010 holds the potential to transform the landscape on which all healthcare services are delivered. In addition to extending health care coverage to an estimated 32 million more Americans, health care reform promises to improve the quality of care and increase the focus on outcomes and accountability.

Some of the implications of health care reform for behavioral health include:

• an increased focus on the coordination between and integration of specialty behavioral health services and primary care;

• a greater focus on comprehensive, "whole health" approaches that address the full range of needs of individuals receiving services;

• increased focus on supporting people in lower levels of care (e.g., services in community-based settings) rather than higher, more restrictive services (e.g., residential, inpatient, partial hospitalization programs);

• greater attention to treatment outcomes and provider accountability; and

• a focus on measures that will enhance the infrastructure (service systems and providers) to support the delivery of effective services (e.g., greater utilization of health information technology).

Mental Health Transformation: A Place in the Community

These substantive reforms in behavioral health policy and practice are not occurring in a vacuum. In recent years, behavioral health systems around the country have initiated efforts to transform their service systems by realigning their policies, services and structures to promote resilience and recovery. In the mental health arena, the work of the New Freedom Commission on Mental Health prompted much of this restructuring. Created in April of 2002, this Commission was charged with the task of examining the problems and gaps in mental health service delivery systems nationwide and recommending solutions to finally achieve the promise of "a life in the community" first made when the deinstitutionalization movement began half a century earlier. Following several years of study and input from thousands of people nationwide, the Commission concluded that existing mental health systems were not organized to reach the single most important goal for people receiving services, the goal of recovery. To address that challenge, the Commission articulated the following vision:

"We envision a future when everyone with a mental illness will recover, 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" (DHHS, 2003).

Neither the Commission's findings nor its vision was surprising to many people receiving mental health care. Over the previous two decades, the nation's mental health consumer movement had grown and advocated just these kinds of changes in the nature of service delivery. What was new was that their vision of recovery and community inclusion had now been adopted by the nation's mental health system.

New Recovery Advocacy Movement: Resources for a Lifetime Journey

While the transition from segregation and lifetime dependency to inclusion and capacity development took hold in the mental health field, a new recovery advocacy movement was unfolding within the addiction field. Champions of this movement have included people in recovery and their family members, addiction treatment providers and addiction researchers, all calling for sweeping changes in the way we envision, develop and deliver services to people with severe alcohol and other drug problems.

One of the most influential researchers and advocates in this new recovery advocacy movement has been William L. White. White maintains that, at its core, this movement represents a shift away from crisis-oriented, problem focused and professionally directed models of care to a proactive, solution focused approach directed by the person in recovery. It views addiction as a chronic illness and the recovery process as a lifetime journey that builds on people's strengths and resources, both internal and external. From this perspective, what is crucial is that people play active and central roles in choosing the services that will help them select and manage their own long term pathways and styles of recovery. The recovery management approach to addiction that White describes is one of the cornerstones of Philadelphia's system-transformation efforts.

Children's Behavioral Health: Focus on Resilience

In recent years there also has been a growing movement to change the nature of children's behavioral health care. Significant reports, including those of the Surgeon General, the New Freedom Commission on Mental Health, the Institute of Medicine and the World Health Organization, all reinforce the urgent need to foster behavioral health in children by embracing a public health approach that focuses on promoting resilience in children and families. According to the National TechnicalAssistance Center for Children's Mental Health, this type of approach is characterized by:

• a greater emphasis on building skills that enhance resilience and creating environments that promote and support optimal behavioral health;

• balancing the focus on children's behavioral health challenges with an equally strong focus on children's strengths;

• increasing the amount of collaboration across systems and sectors, including all settings and structures that affect children's well-being; and

• taking local needs and strengths into consideration in implementing services.

Similar to recovery-oriented services that build on the strengths of individuals, families and communities, resilience-promoting services are described as a departure from the field's traditional primary focus on the challenges and problems of children and families.

To provide the best services possible, prevention, treatment and community organizations must identify, nurture and develop the many internal and external conditions known as "protective factors." A concentration on these factors has greater potential for protection, healing and positive change than a narrow concentration on risks, adversities and stressors—factors which typically are much harder to change.

The Quality Chasm: A Fundamental Redesign

The paradigm shift that is underway in behavioral health was further cemented by recommendations articulated in a series of reports by the Institute of Medicine (IOM) on improving the quality of health care. The most recent report, released in 2006, focuses on "improving the quality of healthcare for mental health and substance use conditions" by identifying ten rules to guide the redesign of healthcare. According to the IOM report, following the ten rules will require "... a fundamental redesign of health care by health care organizations and delivery systems" (2006, p. 56). These rules are outlined in Table 1, on the following page, with more detailed information available at http://www.iom.edu/Activities/Quality/MHQualityChasm.aspx.

In the following practice guidelines, these ten rules will be interwoven with the principles and values of health care reform, mental health transformation, the new recovery advocacy movement in addiction and the promotion of resilience in children's behavioral health.

Local Momentum for Change

Along with the national trends that have informed this work, Philadelphia's efforts have unfolded against a backdrop of state-level support for and commitment to system transformation. In the 2005 report, A Call for Change, the Pennsylvania Department of Public Welfare, Office of Mental Health and SubstanceAbuse Services (OMHSAS) pledged to transform all service systems within the state to embrace a recovery orientation. The practice guidelines outlined in Transformation of Behavioral Health in Philadelphia are in keeping with the direction courageously laid out by OMHSAS in A Call for Change.

Finally, some of the most significant calls for change have come from both the people and families being served and the city's strong provider advocacy community. Philadelphia's providers have demonstrated their commitment to the idea that a true recovery- and resilience-oriented system of care does not simply add recovery support services to the existing treatment system. Rather, this transformation should have a profound impact on all the ways in which care is delivered, be it professional clinical care, rehabilitation or community-based support. The transformation process also extends beyond the behavioral health system to other people-serving systems, and to the broader community. Providers have also maintained that the radical and farreaching reorientation of care that is envisioned—and the dramatically different outcomes that individuals and families deserve—will require sweeping changes in the way the administrative system "does business."

DBHIDS recognizes that transformation will have a significant impact on all stakeholders and processes, including the administrative infrastructure, and has been committed to transparent, participatory processes in the development of these guidelines. This commitment will remain strong throughout the implementation process. All stakeholders are invited to join these efforts and to lend their passion and their expertise to this challenging, rewarding and vitally important next step in the evolution of Philadelphia's behavioral health system.

Section II: Overview of the Framework

Philadelphia's Approach to Transformation

Before examining the scope, purpose and framework of these guidelines, it is important to provide a brief overview of Philadelphia's approach to developing a system that promotes recovery and resilience, and to acknowledge the systemic challenges that exist.

Integrated Service Approach

The Philadelphia Department of Behavioral Health and Intellectual disAbility Services (DBHIDS) is taking a holistic approach to the transformation of behavioral health care. This approach uses the concepts of recovery and resilience to form a conceptual framework for service delivery and a bridge in the integration of mental health and addiction services for children, adolescents, transition-age youths, adults and families. (Please refer to Appendix B for further discussion of the concepts of recovery and resilience).

This aspect of transformation is particularly important. Although mental health and substance use conditions frequently co-occur within the same individual, the services for these two categories of conditions are often disconnected and/or delivered in parallel or sequential service models. In Philadelphia, however, services for mental health and substance-related conditions are funded and overseen by the same agency. This offers the city the opportunity to bring these services, not only under the same roof, but also under the same vision and goal: that of resilience, recovery and a meaningful and self-determined life in the community.

Transformative Approach

Three approaches to recovery-focused system transformation efforts have been identified: additive, selective and transformative approaches (Achara, Evans, & King, 2010). In an additive approach, systems focus on simply adding non-clinical recovery support services to the existing treatment system. As this approach focuses on adding new services, it perpetuates the belief that recovery-oriented systems of care can be created only with "new dollars."

Additive approaches to system transformation fail to recognize that all services, including treatment, should be delivered within a recovery framework. They overlook the essential role that treatment services must play in transformation processes. The primary focus in additive approaches is on recovery support services, rather than on re-examining all new and existing services through a new lens and values framework. As a result, important treatment variables such as assessment processes, service planning, the nature of service relationships and the focus of services remain unchanged.

This raises the risk that, even if non-clinical recovery support services are made available, they may be offered or designed in a manner that is not recovery oriented. They may be provided in ways that fail to reflect the values and principles of recovery-oriented care.

Another emerging approach to recovery-focused system transformation is the selective approach. In this approach, there is recognition that treatment practices must be changed and better aligned with principles of recovery and resilience, but the emphasis is on changing the treatment practices of select programs or in particular levels of care and incorporating recovery support services into the system.

Philadelphia's practice guidelines are based on a transformative approach to system change. In this approach, the entire system—including the context in which it operates—is aligned with principles of recovery and resilience. This includes treatment services and non-clinical recovery support services, as well as the fiscal, policy, community and social contexts within which the system operates.