Archive for ‘Uncategorized’

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?

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?

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 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?

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 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.

January 28, 2011

An Unbalanced Mind–Thoughts on Jared Loughner

by Richard Edwards

(Note: this post probably seems a little out of date, but it has taken me a while to collect my thoughts. Still not sure if I’m there…)

Jared Loughner is, in very plain terms, mentally ill. I’m not a diagnostician, but that seems to me to be the truth of it.

Immediately following the shooting of Rep. Giffords and many others at a speaking event in Arizona, there were emails and blog postings and press releases from NAMI and MHA and the National Council for Behavioral Healthcare around the lack of evidence to show that people with mental health issues are any more violent than the general population.

And research shows that that’s true–you can read about it here, here and here–and it’s important that we don’t paint all people with mental health issues as criminally violent. Studies show that mental illness does not lead to violence, although the likelihood goes way up when you add substance abuse to the mix. So let’s not stigmatize the millions of Americans with mental health issues–many of whom are successfully managing serious and persistent mental illness–by assuming they will–or even could–become the next Jared Loughner.

But in recent weeks, following President Obama’s Tucson speech, I notice the conversation turning to mental health support services….Did we do enough? Should the Community College where Jared Loughner attended classes done more? Should the community have noticed? Should his parents have noticed and taken action? Not so much discussion about whether the national discourse was to blame, but much more about the nitty gritty–at the ground level, what went wrong? This too, seems appopriate to me. In order to prevent the next Jared Loughner, we need to understand the current one.

Several national advocacy agencies are pointing to declining services in Arizona and elsewhere for people with mental health issues as cause for concern. There is also such a thing as mental health first aid, and it’s not hard to imagine how a well-informed community could have recognized the signs of Jared Loughner’s paranoia, before it reached crisis levels, and, given the tools to act, intervened. However, services to people with disabilities and mental illness cost money, and in states across the country, including NC, which faces a 3.7 billion dollar shortfall in FY11-12, money is in short supply.

But doesn’t that sound like we want it both ways? We need to improve access to mental health services for people like Jared to prevent this kind of tragedy from happening–a tragedy which, in the end, also happened to Jared. But how do we advocate for more services on that basis without playing up the potential for violence, and thereby stigmatizing the millions of Americans who deal with emotional or mental health issues everyday and have no propensity for violence whatsoever?

My angle is that Jared’s mental illness had a direct relationship to his crime, but criminal insanity is a legal term, not a diagnosis, and one charged with understandably negative feelings about loopholes and savvy criminals who walk, scot-free. But if Jared Loughner could have been helped with services because he was mentally ill, and if that intervention could have prevented the criminal and insensate act that resulted from his mental illness, and if we think we simply can’t afford those services…

What kind of wall will Arizona build now?

Jared Loughner is, in very plain terms, mentally ill. And his kind of illness took his mind and the lives of 9 people with it, not to mention the nightmare-free existence so many people in Tucson thought they would live until a few weeks ago. In making a way forward from this tragedy, there is, I believe, a middle path–service without segregation; awareness without paranoia; and yes, fiscal restraint without neglect–this is the kind of balance Jared Loughner’s mind couldn’t maintain.

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

November 30, 2010

Miangle 2.0

by Richard Edwards

Recently, I changed my twitter handle to @miangular (partly because @miangle was taken), but I thought it was time I changed the blog name as well to match the whole theme.  The larger part of this is just consistency, and the importance of it when trying to deliver a message–in this case, my advocacy for people with disabilities and the services and supports they need to live fully in their communities.

So, the look is different, but the content will be similar–advocacy, non-profit leadership and personal interests. Same as the old boss, I suppose, but still boss.