February 26, 2012

An Ounce of Prevention…

by Richard Edwards

I’ve been reading Strategy for Sustainability, by Adam Werbach, about how to create sustainable efforts around environmental sustainability–reducing carbon footprint, reducing waste, reducing negative environmental impact in general–and doing so in a way that adds value to a business as well as the world. I recommend it, but not because I’m an environmentalist–I’m not, really. I recycle; I drive a fuel-efficient-but-plain-old-gas vehicle; and I try to watch my energy use, but that’s about it.  I recommend it because it clearly explains a construct for driving organizational change with the least amount of top-down energy possible.

I work mainly in quality improvement in the non-profit sector, specifically human services. It is a field that is heavily regulated by payor sources, licensing agents and state and local governments. Not for nothing, but there are a lot of rules. And in a process-oriented environment, it’s easy to mistake rule compliance–which is the foundation–for the mission–which is actually the target.  The floor becomes the ceiling.

For instance, let’s say you live under threat of audit every day, and understandably, you focus your efforts on 100% record compliance to withstand those audits. But, if 100% is your goal, what is acceptable? 99%? 95%? By most scales, 95% is an ‘A’–very good. And if you got 95% of the way towards a target goal, most people would say that’s pretty good, too. But remember, 100% isn’t the goal, it’s the starting point. If people believe 100% is the target, and targets are–by their very definition–aspirational, it’s not hard to understand how people come to accept slightly less than perfect as perfectly acceptable.

In small organizations, where a few people can drive and reinforce behavior and culture–and even do the quality assurance themselves–this can be corrected. But in larger organizations, this becomes increasingly difficult, and the tendency is to create systems whereby fraud and abuse and waste are eliminated through making the process fool-proof (but why would you want to hire fools in the first place?), or by making your quality assurance team the equivalent of the internal affairs cops (aka, the most hated officers in the building).

Werbach points to a different way, which is essentially to get all your employees involved, but what good is that if they are duped into 95% being acceptable? (Plus, eventually, 95% becomes the goal, and then what’s acceptable?) The trick is to come up with a transformational goal–something truly aspirational–that everyone can work towards in their own way. In this way, creating an ethical (or environmentally conscious) culture becomes sustainable, because everyone puts in at a level of energy they can maintain and reaches beyond simple compliance.

Similarly, when a martial artist breaks a board–or boards, or bricks, or cinder blocks–with their bare hand(s), they will tell you they are not aiming for the board. They will tell you to aim beyond the board. Otherwise, you will naturally pull up short of the contact point, making it less likely you will break the board, and more likely that you will break your hand.

So, what’s the aspirational goal when we’re talking about compliance? My angle is that the real target–the real outcome we’re seeking–is trust. Trust is not something you’re reimbursed for in healthcare, but without it, you can’t expect to survive. The great thing about it as a goal is that it’s something that all employees at all levels of the organization want, and that kind of common driver is essential to bringing an effort like this to scale.

But that’s just my angle. What are your thoughts?

February 26, 2012

A Pound of Cure…

by Richard Edwards

This morning, at my church, we did a small, share-the-plate fundraiser for a local non-profit service provider to persons with mental illness, specifically, a psychosocial rehabilitation setting.

Psychosocial Rehabilitation settings–PSRs (warning: pdf)–or clubhouses, as they are commonly called, provide a daytime setting in which individuals with significant mental health issues can find support. Typically, and in the case of this provider, they are provided in concert with other services, such as supported employment, or even supported residential apartment settings.

Sounds positive, right? In this case, it is–the people who work there are compassionate and committed, and they have undoubtedly had a positive impact in the lives of many, many people. But here’s where it goes wrong–in the words of one of its own board members (paraphrased, but not by much), “People with mental illness need clubhouses like this one because they do not feel comfortable in the community.”

That’s where the wheels come off the wagon, as far as I’m concerned, for PSR models. They are, essentially, congregate service settings. They are a place to go. And they are a workaround to the central problem, which is–that people with mental illness do not feel comfortable interacting with the community, because they are not welcome in the community. And because PSRs are congregate settings–they will never in a million years solve that problem.

Instead of talking about creating places in the community where people with mental health issues–and indeed, this could apply to all people with disabilities–feel welcome, my angle is that we should be creating communities where people are included. It is only when people have access and are expected to participate in the life of the community that they can truly be members of that community.  Location is not the same as membership.

But that’s just my angle…what are your thoughts?

September 12, 2011

NC Medicaid Gets What It Pays For…

by Richard Edwards

Last week, I attended a meeting of the Medical Care Advisory Committee, a federally-mandated group whose purpose is to advise the state on services it covers through Medicaid and Medicare.

This group–made up of physicians and healthcare professionals from across NC–has an unenviable task: making suggestions on where to cut some $350 million worth of Medicaid spending in North Carolina. But as Dr. Gray (Division Chief for DMA) pointed out, it was not the MCAC’s job to decide cuts, only to advise.

I’m sure that was a load off their shoulders, but it’s still obviously a task the group takes seriously, and not an easy one. DHHS Secretary Lanier Cansler explained at the outset that some $118 million of the total projected cuts could not be achieved because they were either duplicated elsewhere in legislation (and so, counted twice), or because they were tied to federally-mandated services (which can’t be cut).

As the DMA presentation points out, however (warning, pdf), NC isn’t exactly under-spending, but we are under-performing. Data from the Kaiser Foundation indicates that NC is actually on the high end in terms of per member spending, and in terms of spending on optional services. Despite this, NC ranks on the low end where health outcomes are concerned, according to another national study.

The group talked at length about why this is, and, what it suggests about where our spending priorities need to be. The final portion of the meeting was set aside for public comment. DMA is, I think, to be commended for this, because they certainly do not make their task–or the task of the committee–any easier by hearing from the public who will be negatively impacted by their decisions. But those stories–moving though they were–kept bringing me back to the original question…

If we’re spending more than average on services, but we’re getting less than average on health outcomes–what are we spending our money on? Certainly, we have an opportunity to learn from other states who are spending less and getting more (or spending the same and getting more), but I think it also points to a central issue in human services in general, and particularly in behavioral health. We are paying for the wrong thing.

Check out this article, by Robert Kaplan and Michael Porter, about how we establish cost for services in healthcare. Their focus is primarily medical, but it’s worth a read for social sectors, too. In the article, the authors point to poorly-measured outcomes as one of the main drivers of escalating healthcare costs in this country. Essentially, we have a system that perversely pays for services instead of outcomes. There is no incentive, the authors explain, to heal people quickly and effectively, because that’s not what we’re paid for…sound familiar?

This might seem horribly cynical, but ask yourself this question–if you, dear reader, as a human services provider, were paid based only upon the positive impact you helped create, as opposed to the amount of time you spend with people, how would you behave differently as an organizational leader?

I believe we’re still several years away from this, but when the day comes that Medicaid and other payer sources pay for outcomes instead of processes, my angle is that we will have a groundswell of evidence-based practices, instead of top-down (and unfunded) mandates; we will have a much more community-based system, instead of so much institutional bias; and we will be much more social capital-oriented, instead of paid support-driven.  And tumultuous as the transition will be, that will be a good day for all people.

But that’s just my angle. What are your thoughts?

 

August 18, 2011

Change Leadership in No Easy Steps

by Richard Edwards

This week I attended a conference–the Global Implementation Conference–sponsored by the National Implementation Research Network. It was fascinating, and I’ll write more about the conference itself and Implementation Science in coming posts. I wrote about it briefly in a previous post, “According to the Evidence…”, but it’s implications for the human services system in NC bears further exploration and discovery.

One of the things that surprised me about the conference was the emphasis on change leadership. It makes sense, if you think about it–implementation means change, and in human services, that means helping people to bridge the divide between where we are and where we want to be. Over the course of three days, I participated in several workshops and heard more than a few poster presentations on change and resistance to change. This model is simply my attempt at pulling together all that I heard, and what I’ve learned previously.  So, here it is…your feedback is much appreciated–

Now, I know this might not look very cheery, but hear me out.

First, credit where it’s due. Two of the folks who have really informed my thinking on this are Tony Bates at the Headstrong Foundation in Ireland, and Brian McNulty at the Leadership & Learning Center. Both are excellent speakers and thoughtful leaders in education and human services.

Okay, first principle–leaders are always leading change. Even though there’s an arrow from one side to the other, this is a continuous process. You are, as Tony said, ‘surfing on the edge of chaos’ as a leader. And if you try to stand still on a surfboard, something predictable happens, because the water you’re surfing on, and the environment and world we live in, is always changing. So, think of the arrow as directional only, not as Point A to Point B.

Leadership, someone once said, is about connecting memory and possibility. This is as eloquent a description of leadership as I’ve ever heard. Great leaders help us bridge the gap between that which grounds us and that to which we aspire. The most important tools for bridging that gap come from providing context–the why of what we’re doing, moreso than the how. People will figure out the ‘how’, if they really believe in and understand the ‘why’.

The best tools that leaders have at their disposal for providing this context are values, stories and focus. Values that help guide our decisions when they, our leaders, are not around. Stories that connect with us emotionally, and fill in the gaps in our cognitive understanding. And Focus to remind us of what’s important, and what’s just extra baggage.

But a single leader can’t do this alone, or at least not for very long, and many hands make light work. Effective change leadership requires alignment of those who are being led.

Q: What do you call a leader with no followers?

A: Someone out taking a walk.

To be aligned, or engaged, people need context of the very kind described, but they also need to provide feedback and be heard. Leaders need feedback, too, to be sure that the context they are setting is understood accurately. Rick Anicetti, former CEO for Food Lion, says his job was basically “Talking all day long, and then running to the other side of the organization to see if I can hear myself.”  Leaders provide context, and followers provide feedback on how things really are–it is this dialogue that keeps us moving towards our common vision.

Certainly, there are leaders who, through sheer force of will, can effect change, but when they leave, the ability to adapt and change leaves with them, because the changes have been all about them, and not about those who are being asked to change the most.

The consequences of not changing? Jack Welch, CEO at GE, said famously, “If the rate of change on the outside exceeds the rate of change on the inside, the end is near.” This can go one of two ways–both of which we are more naturally inclined to, I’m afraid, than successfully managing change.

The first is the violent death–chaos, when things spin out of control. Surfing on the edge of chaos, sometimes it’s tempting to let yourself (or your agency) slide into that chaos–this is the death wish at work. When human service agencies flame out, suddenly go bankrupt, or close their doors overnight, they’ve ignored the imperative of managing change, which means knowing how much you can tolerate at a given moment.

The second is the wasting death–atrophy, when organizations simply become less and less relevant over time, until someone says, “Whatever happened to…?” The entire universe moves towards a lower state of energy, towards stasis, and we would, too, given the choice. Safety is tempting, but for organizations in an ever-changing world, it is illusory. When organizations waste away, when they become irrelevant, when no one buys their products anymore, they’ve ignored the imperative of managing change, which also means embracing it.

So, while I think change leadership isn’t exactly natural–we’re all opposed to change on some level–given a vision, and the ability to connect people to that possibility through values and stories and focused goals, change leadership goes beyond just being about Point A to Point B, to being about a way of life. Because change is the way of life.

But that’s just my angle, what are your thoughts?

May 19, 2011

According to the Evidence: Implementing EBPs

by Richard Edwards

Today I sat in on a work session with the NC Practice Improvement Collaborative–a small group dedicated to the implementation and dissemination of evidence-based practices for human services in NC.

The main speaker for the morning was Dr. Dean Fixsen, from The National Implementation Research Network, a renowned speaker on practice implementation in organizations and state systems. He made several interesting points about change leadership and quality improvement, but I was especially interested in his research on the amount of time it takes to implement evidence based practices in an organization.

Two to four years, he said.

Admittedly, two to four years can go by in a flash (where have you gone, 2009?), but in the human service field, when new services go live with perhaps a 90-day hold harmless period, have we ever had two years to get something right? It seems to me that if we’re going to be about bringing science to service, we have to also be about the science of bringing science to service. And how do we fund that in a fee-for-service system?

Dr. Beth Melcher from DHHS was also present and spoke briefly about evidence based practices and their role within the new 1915b/c combo waivers, set to roll out in 2013. Her stance is that–in contrast to the opinion of some that the state is abandoning CABHAs (was she looking at me?)–the waiver environment will actually make EBP implementation easier, because of the flexible funding available through savings generated (if a 1915b/c waiver site or managed care organization saves money, it gets to put that money back into services at its discretion). That’s a fair point–and although I’m not convinced that’s really why NC is going down this road so quickly–it could make that 2 to 4 year start up period for a new EBP more manageable.

My angle is that this kind of flexible funding is essential to an innovative healthcare system that brings evidence-based practices to the people who will benefit most, in the shortest period of time. Otherwise, we run a substantial risk of just being another 2 to 4 years older, and perhaps not a day wiser.

But that’s just my angle. What are your thoughts?

May 12, 2011

Hey, Remember CABHAs? Nah, Me Neither…

by Richard Edwards

It was just January of this year, 2011, that DHHS Secretary Cansler made the announcement that “the era of mental health reform is over”. A new service model–Critical Access Behavioral Healthcare Agencies (CABHAs)–would put mental health and substance abuse services on a firm foundation, finally, after years of turmoil and substandard services for people in need.

CABHAs would, through the substantial investments they make through the addition of key personnel–a Medical Director and a Clinical Director, as well as a Quality Improvement/Training Director–provide a clinically sound provider community to NC’s citizens. Of course, this would cost money, so CABHAs would be the only providers allowed to bill the new Targeted Case Management service.  TCM would offset the costs encumbered by the CABHAs and provide stability to a fragile provider community that has been hit by repeated service rate reductions in the past two years. As of this writing, there are just over 200 CABHAs operating in NC, and while that’s a much larger number than was anticipated, it also represents a significant winnowing of the provider field. Becoming a CABHA clearly had raised the bar beyond what many were able to achieve.

CABHAs were the future. Until they weren’t.

In April of 2011, the state announced the rollout of statewide 1915b/c Medicaid waivers similar to the Cardinal Innovations plan being operated by Piedmont Behavioral Healthcare since 2005. A 1915b/c waiver, in Medicaid language, means essentially that the managed care organization has much greater control over the services in its array and the providers in its array. Waiver operations, unlike the current NC state plan for Medicaid services, are closed networks–they do not have to admit any willing provider, and they manage the network more closely.

The state has been moving towards a waiver-based system for a while. PBH began its pilot operation in 2005, and two additional Local Management Entities–Mecklenburg County and Western Highlands Network–have also been approved. There are several others that are in the cue, but according to the release by the DHHS, all services will be overseen by Managed Care Organizations (nee LMEs; nee Area Programs) by July, 2013.

Why is this relevant? Remember all those CABHAs who hired their medical directors and clinical directors and QI/training directors and provide outpatient therapy and psychiatric services…remember how we thought they were the future? Under the waivers, there is no guarantee that any of them, anywhere, will be part of the contracted provider community. Of course, many of them will, because one of the primary responsibilities of the MCO is to provide access to services, but many of them won’t–perhaps as many as half–and if you’re a CABHA, there’s simply not a thing you can do about it.

A bill on the statewide rollout of the waivers has been introduced–you can read about it here.

My angle is that public systems should not be set up to protect anyone but the people receiving services and the public at large. CABHAs, any more than LMEs, or DHHS staff, or state operated services, or the Adult Care Home industry, do not have guarantees they’ll be here tomorrow.  But my great concern in all of this is that it seriously calls into question the long-term vision for the mental health and substance abuse system in North Carolina–what is the ultimate plan? Is there an ultimate plan? And does it really include undermining what was until recently the underpinning of the whole system?

Further underscoring this concern is the announcement–made in a flyer (warning: pdf) posted on the Division of MH/DD/SAS website for people with intellectual and/or developmental disabilities–that Targeted Case Management (remember that service?) would not exist as it does today under the waivers. (There have been subsequent communications, but this was the first official statement.) So, if you’re a CABHA…and if you survive the next two years…and if you make it into the provider network of the MCOs for the communities you serve…you will lose the ability to provide the one service that it supposed to help you cover the costs of being a CABHA in the first place.

What a difference a year makes.

Oh, wait, it hasn’t been a year, yet. It hasn’t even been six months.

But that’s just my angle–what are your thoughts?

May 4, 2011

North Carolina ranks 8th in…Institutional Bias??

by Richard Edwards

Recently, United Cerebral Palsy issued its national report card on inclusion, ranking the fifty states on their attempts to serve individuals with intellectual and/or developmental disabilities in community and family settings.

North Carolina ranked 43rd over all. You can read the press release here, and the complete report here. (Warning: pdf) Most notable to me is that NC continues to rank in the top 10 states nationally in terms of the number of people–over two thousand–housed in large institutional settings (16+ residents).

And while several states have closed their institutions entirely (Go, “Bama!), North Carolina is rebuilding ours.

Just this year, Governor Perdue participated in the ground breaking of a replacement for Cherry Hospital in Goldsboro, NC. And recently, the NC Department of Health & Human Services began seeking bids for the reconstruction of Broughton Hospital in Morganton, NC–a project with a total budget of $154,772,802.

Why, in the face of data that supports downsizing institutions as good policy, and the clear example of our neighbor states, do we continue to invest in these types of large congregate settings? Even with a federal DOJ investigation pending against NC regarding our failure to provide community-based living options for people with disabilities as required by the ADA and the Olmstead Decision?

I am not saying that hospitals are not an important part of the continuum–they are. But consider this–for what we are spending to build a hospital in Morganton, we could invest in community hospital beds in Charlotte and Asheville and serve the vast majority of people who are displaced to that state hospital.

My angle is that we do it, not because it’s truly needed, but because jobs are truly needed. Communities–like Goldsboro, and Morganton, and Butner–depend upon the institutions in their community for employment. Not to mention the construction work that goes into maintaining facilities that are falling apart.

And the problem with this seemingly symbiotic relationship is that people with disabilities are stuck in the middle. As long as we continue to divert funds to institutional care, there will never be enough money to support people living in the community. And as long as there isn’t enough support for people to live in the community, there will always be a need for institutional care.

NC’s people with disabilities deserve better than 43rd in the nation.

April 18, 2011

Services Aren’t the Answer

by Richard Edwards

Recently, I read an article from the Stanford Social Innovation Review that is a must-read for anyone in or receiving human services. You can read the article here. (Some of the articles require a subscription, but this one is free. Warning: pdf file.)

Part of the reason the article struck me so was that it echoed something I’ve suspected for a long time, which is that the public human service system is essentially flawed, at a very basic level.

A few years ago, I did a pecha kucha presentation around social capital and its potential impact on the lives of people with disabilities. Social capital can be understood as the resource that exists within our relationships. One of the obstacles for people with disabilities in building social capital, as I pointed out in the presentation, is the service system itself, which wraps people in services, thereby insulating them from the community. The result is that communities abdicate their role of taking care of their members with social capital–friends and family–relying on financial capital instead. And people with disabilities and their communities become less relevant to each other.  This isn’t natural to the way members of a community live and interact.

A colleague told me today that people with schizophrenia function much better in daily life in Kenya than they do in the United States. With all the services and medications and financial capital we have available–how is this possible?

These stories illustrate for me the inherent flaw in fee-for-service supports through the public human services system, despite its good intentions. Part of what people really lacked in the institutions decried in the 60s and 70s was a network of friends and family who would watch out for them. In the 21st century, we still don’t help people make or remake these connections, relying instead on professionals to act as surrogates.

The Stanford article focuses on education–specifically dropout rates–and how the city of Cincinnati tackled poor school performance as a community. Instead of targeting individual schools or individual students, the community tackled poor school performance as a whole, yielding a much greater collective impact.

I think this point–though focused on education–is important for human services to absorb as well.

My angle is that if we pay for a service, we get a service. Paying for a service in 15″ increments means we focus on the process instead of the outcome, because 15″ of anything is unlikely to be all that useful (unless it’s an introduction). And so we perpetuate service, instead of freedom from service–which is what we all really want.  I’m not saying that we eliminate services off the bat–but at some point, we need to get beyond providing services which offset a problem, to tackling the problem itself.

But that’s just my angle…what are your thoughts?

March 31, 2011

Privatizing Education in NC

by Richard Edwards

This week I attended a lunch and learn sponsored by NC Policy Watch around Charter Schools in NC. NCPW has a page about the ongoing negotiations here.  You can also read a paper supportive of charter schools here, and more about the political football that’s being played here. Based upon the attendees, I was expecting a crowd of advocates who had largely made up their minds about charter schools, and generally, I wasn’t wrong.

There are a lot of strong opinions. Earlier in the week, I had spoken by phone with Eddie Goodall at the NC Alliance for Public Charter Schools, a strong advocate for charter schools expansion, and Senate Bill 8, which not only lifts the cap on charter schools, but eliminates the minimum enrollment (currently set at 65), and wouldn’t require charter schools to provide either transportation or nutrition to its students, but still allows charters to get the same rate per child as public schools.  Certainly he has a stake in this, and questions have been asked whether he’s an advocate or a lobbyist, but his main point to me was, “if it’s good for kids, and it’s good for taxpayers, we’ll figure out how to make it happen.” Seems eminently reasonable. But are charter schools good for kids?

Dr. Helen Ladd from Duke U. presented some good but dated (2002) statistics about problems associated with charter schools in NC–including increased racial segregation and decreased performance overall among students who transitioned from regular public schools to charter schools in the early years (1998 to 2002). You can read a draft of Dr. Ladd’s research online (warning: pdf).

Rep. Rick Glazer, from Fayetteville, followed, speaking on the history of charter schools in North Carolina, having been in the legislature when the original law was passed. Despite some pretty bad experiences with charter schools that failed early on, Rep. Glazier voiced support for expansion of charter schools in a limited role. There is an opportunity for independent, progressive organizations to run quality school settings and act as a learning lab for innovative practices, something that large schools systems find difficult to do. Too many charter schools too quickly, however, leads to decreased standards of quality, lost in the proliferation–as it did in the late 90’s when charter schools were new in NC.

Interestingly, both Rep. Glazier and Mr. Goodall from the NC Alliance for Charter Schools agree on this point–NC made it too easy for public charter schools to be set up in the early going, and our children paid the price. What started as an opportunity to be innovative and progressive led to a retail mentality in our schools. There needs to be a higher bar set for such a fundamental service–our educational system–than simply who can complete the application and show themselves as willing and able,  without any track record of success.

For those of you accustomed to reading my angle about human services to people with mental health issues or people with intellectual or development disabilities…what does this sound like?

 

 

March 21, 2011

CABHA–One Year Later

by Richard Edwards

Last week, I presented to the Mental Health Subcommittee at the NC Legislature on the Critical Access Behavioral Healthcare Agency (CABHA) implementation. We had been asked by Benchmarks NC, an advocacy organization to which my employer belongs, to speak on our experience with implementing the Critical Access Behavioral Healthcare Agency model over the past twelve months.

You can view my presentation here, but the main points are these: we have found the CABHA model to be very effective in our organization; but woefully underfunded; and that the transition to a CABHA-based provider community is far from over.

In terms of cost, the primary costs of the CABHA model are the personnel costs of the Medical Director and Clinical Director, for which there has been no additional funding. That’s significant given that these are likely two of the highest paid positions in any mental health organization. But now that we’ve been at this for over a year, it is impossible for me to imagine going back to having physicians without a Medical Director, or not having the support of our Clinical Director in responding to a crisis or developing support plans for the individuals we serve. Their impact has just been too valuable, even if we decided not to be a CABHA in the future.

The challenge this presents for our agency and others is that CABHA is a one-way street, in a way. If your Medical Director and Clinical Director are really doing their jobs, they become linchpins in the organization, and there’s no way to get around how much benefit they bring. That said, if the state doesn’t do more to support the CABHAs, the sustainability of the CABHA model is in doubt, begging the question–if CABHA is a one-way street, where does it dead-end?

Beth Melcher, from the NC Department of Health & Human Services, spoke to the subcommittee first and told the members, plainly, there are too many CABHAs (approaching 200). You can see the full list here. There are certainly more than anyone anticipated, but does that mean there are too many? Maybe, maybe not–but the truth is, there are more CABHAs than will survive. Here’s one reason why…Community Support Team.

Currently on the list are 71 CABHAs providing Community Support Team (CST), which is a service for adults with mental health and/or substance abuse issues. That is fully a third of the total, and CST has not only had additional training requirements put on it in the past six months, but has actually had hours available cut from 15 hrs/week (maximum) to 3 hrs/week (on average), and has had a rate cut on top of all these changes. Agencies are exiting CST as quickly as they can, because the rate simply cannot support the service. But these 71 CABHA agencies are providing CST, and will continue to provide CST, because they have to demonstrate a continuum of services–meaining, a variety of enhanced mental health or substance abuse services–meaning, they are a on a one-way street.

Without CST, they lose their CABHA status. With CST, the whole agency could go under. And without significant changes in the way the state supports CABHAs, we will continue to see rapid attrition of providers as reality sets in.

So while we have turned a corner in the mental health system, we are not, to mix a metaphor, out of the woods.  My angle is that CABHA is the right direction, but without additional support, it could mean another dead end.

But that’s just my angle–what are your thoughts?