Archive for February, 2011

February 24, 2011

Peer Support Services — the Service of the Future…

by Richard Edwards

…and at this rate, it always will be. Ba dum bum. Thank you, thank you…I’m here all week.

North Carolina–attempting to infuse its public system of supports to people with mental illness with a recovery-focused approach, has received Medicaid (CMS) approval to launch a Peer Support Services (PSS) definition.  You can read about it here, starting on page 95. The service, which has been approved in varying models in eleven states, utilizes individuals who have mental health issues themselves, and have successfully maintained their personal recovery, in engaging persons with mental health issues in active treatment.

In the substance abuse field, historically, many substance abuse counselors were, and are, persons in recovery themselves. In my graduate training as a counselor, I encountered many in the SA treatment field who believed you could not be an effective counselor to people dealing with alcoholism and addiction, unless you had a similar background. At the time, I was pretty quick to say that was poppycock–but that was partially because it threatened my role as a professional, without a personal history of addiction and recovery. Over the years, I have come to appreciate that peers in mental health recovery can establish rapport with those they support in a way I will never be able to.  And that rapport is vitally important, because recovery is, in many ways, about showing up–and a qualified Peer Specialist can be particularly effective in helping people see the importance of taking personal responsibility for their health and well-being.

So, from that perspective, I think it’s fantastic that Peer Supports is set to go live in NC in July, 2011.

Unfortunately, Peer Supports may only be “live” in the academic sense–available in theory, but not in practice. Here’s why…

First of all, the rate for PSS ($22/hour) is simply too low to be seriously considered. I’ve spoken with several providers, who all say they would lose significant amounts of money (well over $100k by one estimate) providing this service over a year.  Any provider agency who does their homework will come to the conclusion that the rate is insufficient for the service as it is defined.

Secondly, only CABHA-certified providers (Critical Access Behavioral Healthcare Agencies) can provide PSS, and CABHAs are already straining under the costs of their own infrastructures (see previous post–“Mental Health Reform is Dead!”), not to mention the requirement that CABHAs provide services that also lose money like psychiatric management and outpatient therapy. Given these pressures, it is very unlikely that an organization is going to expand into another service that is so obviously under-funded.

Thirdly, the current definition is very restrictive, and will require intensive management and oversight. For instance–

  • PSS requires a full-time licensed or provisionally-licensed supervisor who cannot bill for any services her/himself;
  • PSS is a short-term service–maximum six months per year, which doesn’t really seem to match up with outcomes typically associated with recovery;
  • PSS has to be provided with outpatient therapy–so only the people you serve on an outpatient basis are eligible, which further limits potential referrals;
  • PSS–because of a weekly, individual supervision requirement–discourages the employment of many skilled Peer Specialists who only want to work part-time; and full-time employment means…
  • Productivity requirements of 60% per week–meaning 24 hours of a 40 hour workweek must be billable activity. Sound easy? It’s actually very difficult when you add travel (this service is community-based); meetings; documentation; supervision; etc…

These requirements may not seem onerous to the casual observer, but add them to insufficient funding, and they present a very high barrier.

Lastly, there are currently few CABHA providers that  have any significant experience with Peer Support Services, unless they have been running an Assertive Community Treatment Team (ACTT), or recovery-focused services such as a Peer Drop-In Center or Recovery Center.  And even if they have been running an ACT Team, they may have as few as one Certified Peer Specialist in their organization.  The point is, few CABHAs really understand Peer Support Services, but they do understand that, poorly handled, the well-being of the people supported, and the people employed, is at risk.

Ironically, many of the peer-run organizations who have the most experience and skill at providing and administering peer support services aren’t qualified to deliver Peer Support Services under the new definition, because they don’t have a Medical Director, a Clinical Director, and a QM/Training Director (i.e., they are not CABHAs).

So, for now at least, the future of PSS in NC remains, well, in the future. And while this might sound like I blame the authors of the defintion at the state, that is absolutely not the case. Service definitions, like the one for PSS, are really not so much definitions as they are conversations, and they occur over years, even decades, between persons served, providers, advocacy organizations, state and federal governments, and the general public.

So rather than throw up my/our hands, my angle is that we need to take the long view on peer support services, because the potential upside for people with mental health issues–indeed all people with disabilities–is too great to be ignored. The current service definition and the accompanying rates–inadequate though they are–are part of the process of bringing these supports to NC’s citizens dealing with mental illness. And this means committing to staying at the table of making peer support services a reality today, with or without the defined service.

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

February 16, 2011

Circling Person-Centeredness

by Richard Edwards

For those in the field of supporting people with disabilities, you undoubtedly know about Person-Centered Thinking as a movement, and as an approach to providing individualized support services. For those outside of the field, you can read about it here, here and here. But what I want to write about is not so much person-centeredness, as a concept, but how we have tried to enforce it in NC.

For many services that include goal or plan development in NC, a six-hour training course in person-centered thinking is a standard requirement. Recently, the state initiated an additional six hours of training for specific services to persons with mental health issues (children and adults). The reason given–that state personnel had reviewed many person-centered plans that were not, in fact, person centered, and so, they were doubling the training requirement.

This is, I believe, completely wrong-headed. Let me count the ways.

1. Person-centeredness is not, in my experience, knowledge-based; but rather, culture-based. We seem to believe that new staff aren’t “getting it” in six hours, so we’ll make it twelve, which completely ignores the fact that person-centeredness is more about how you relate to people–something that can be explained in a few words, such as “Nothing about me without me,” or, “Do unto others as you would have them do unto you.”  I’m not in any way suggesting this should be sufficient…clearly, it isn’t.

But what you cannot achieve, in any training, is an approach that has to be practiced and reinforced repeatedly over time, because it is contrary to the traditional ways that people with disabilities have been viewed–as helpless, as unable to contribute, as needing to be told what’s best for them. No one comes to this field as a blank slate–these kinds of dehumanizing messages still permeate society. There are, sure, light-bulb moments that can be created in a training setting, but by and large, I’ve found that the person-centered approach is something that has to be integrated into one’s worldview through practice and supervision, not through seminars. Even 12 hour ones.

2. State systems are typically not person-centered. This may come as a shock, given the emphasis, but most of the really important decisions about services and supports are made before a provider ever meets a person seeking services. What services are available? Who can provide it? In what quantity? At what locations? For what diagnoses? By which provider agencies? Using what interventions? Targeting what issues? All of these questions have often already been answered, and then providers are told to be person-centered, when the service system itself reinforces the misguided notion that the professionals know best.

There are some exceptions to this–there is a self-directing option in NCs waiver service array to persons with intellectual and/or developmental disabilities, but this is only available if you have a low annual budget, and only if you have one of the finite number of slots in the program. The really great thing about this program, however, is that it gives the individual and her/his family the opportunity to design a system of supports that meet the needs of the individual, rather than choose from a menu that may or may not fit–resulting in over-serving or under-serving the individual. You can read more about self-directed services at the Center for Medicaid & Medicare Services here, and the World Institute for Disability, here.

3. The state system is not person-centered, part II. There are assessment tools for developing truly person-centered plans, such as Essential Lifestyle Planning and the Personal Outcome Measures. My personal preference is for the Personal Outcome Measures assessment tool, but the truth is, public funding in NC does not cover the cost of developing truly person-centered plans. The amount of time it takes to interview the individual and the person and/or people that know her/him best are not reimbursed adequately, and so of course the process gets short shrift. This isn’t acceptable, but is a much more rational explanation for “cookie cutter” goal plans than assuming the training time needs to be doubled.

(By the by, the cost of doubling the training for person-centered thinking is wholly the responsibility of the provider. There was no rate increase, no cost adjustment, no attempt whatsoever on the part of the state to subsidize this training.)

4. We’re still not measuring person-centeredness. It is what is measured that gets attention, and again, we are confusing process with outcome. We assume that process (12 hours of training) assures an outcome (person-centered goals and plans). That assumption is false. If the state really cares about person-centeredness–it should measure person-centeredness, not training time. The Council on Quality & Leadership (for whom I work part-time, full disclosure) has developed a new accreditation model that focuses on person-centeredness, almost exclusively, because that’s how you get at what really matters to people.

Think about that for a moment…person-centeredness is about getting at what really matters to people. And my angle is that prerequisite trainings as the ones mentioned can only circle around person-centeredness, because the person is typically only present in the abstract. More talking about people isn’t what’s needed. More talking to people is.

But that’s just my angle. What’s yours?

February 3, 2011

Reading the Signs…for Symptoms

by Richard Edwards

A colleague in the field of human services told me this story, and I had to pass it along…

An individual living in a residential support setting had developed a habit, it seemed, of pulling the fire alarm. Since the fire alarm connects directly to the fire department, it was kind of a big deal, and the staff believed he was doing it for the attention and excitement of having the fire department pull up with big red trucks and sirens a-blaring.

So, responding as professionals–as we are wont to do–they called an interdisciplinary team meeting and set up a behavior plan, with charts to track the behavior and hopefully identify key triggers and antecedents to get at what the communicative intent of the behavior might be.

A week later, this colleague friend of mine called the home to ask how it was going, and the staff told her it wasn’t a problem anymore–problem solved.  Surprised, my friend asked what they had done to effect this remarkable change in behavior? What specific intervention had they used to identify and ameliorate the triggers that led to this disruptive, attention-seeking habit?

The home supervisor told her, “Well, I was looking at the fire alarm, and I noticed that it said “PULL” on it.” Like so…

She continued, “So, I put a sign above it that said, “DON’T”…so that it looked like this…”

“…and he hasn’t pulled it since.”

So, all this time, while we, the professionals, were trying to curb a maladaptive behavior, he was probably wondering why no one else was reading the directions.

My angle is that this story illustrates our tendency in human services to look for symptoms, even when none is there; to assume there is a negative aspect to behavior that may be, in reality, the most reasonable response to the messages in our environment.

And, major kudos to the service provider who, as we all should, took the time to look at that environment through the eyes of the person she supports.