Transformation: ACMHA, The President’s Commission,And the Change that we Seek

(How DO we) Be the change that we want to see in the world.

Mohandas Gandi

(Can we become) A small group of thoughtful people (to) change the world. Indeed, it's the only thing that ever has.

Margaret Mead

Beginning (and concluding) thoughts…

Our Ideas: Comments on Selected Group Recommendations

• De-stigmatize mental illness through direct contact, education, legislation– So much talk about stigma, so little action

• Gauge audiences, tailor effective messages to influence power– YES to using communications technology

• Next year: “Success Off” (Transformation successes)– Time to use a strengths-based approach!

• ACMHA’s agenda should include innovation/ transformation skill development– YES: much known, little applied about science of change

• Align business and financing models– Crucial: it’s not just policy and program

• Support adoption of the 10 IOM rules to guide care delivery– Yes: IOM frame is right, IOM report on mental health will be “next new

thing” providing momentum to field

But: Group Recommendations Perhaps Reflect a Too-Low Priority on Some Key Issues

• Recovery: 5x…Are We Clear About the Vision? (and resilience, equity)

• Medicaid: 1x…One recommendation re: the Biggest Funding Stream? (NB lots of conversation)

Illustrative Medicaid Dynamics; Ohio Department of Mental Health

Community GRF (502+508+408) and MedicaidFY 1990 – FY 2007 (est) Deflated 3% per year

millions

$200

$150

$100

$50

$0

-$50

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-$150

$200

millions

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-$1501990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

Medicaid FFPMedicaid MatchRemaining GRF

20072006

The Squeeze

Group Recommendations Perhaps Reflect a Too-Low Priority on Some Key Issues

• Recovery: 5x…Are We Clear About the Vision? (and: resilience, equity)

• Medicaid: 1x…One recommendation re: the Biggest Funding Stream? (NB lots of conversation)

• IT/Internet/Software…One Mention: with Internet, Network of Care, Emergence of EMR, shouldn’t we be more focused?

Provocative Questions About Group’s Dialogue(Observations of “Roving Reporter” Arthur Evans)

• Inclusiveness: More usual suspects, or others?• Transformation: Is it a process or outcome? (yes)

If we are “doing transformation” is it enough?• What is the end point?

– Treatment system change?– Changed societal approach to mental health and illness

• Do we assume transformation and success requires more resources? Is this right? Is it likely?

• Are transformations often stimulated by crisis? Can we do this without a crisis?

• Can we learn from our history?– Deinstitutionalization– What happened following the Carter Commission

Some Reflections

• Revisiting the Commission’s logic

• Thinking about change

President’s Commission: The Contextand the Commission’s Approach

– Presidential Commissions Are:• Rare Opportunities in Mental Health

– Don’t blow it… with White House, shareholders

• “Recommenders” not “Implementers”– Do the job we were assigned, AND– Leave a menu of opportunities

Transformation was not Achieved by the Commission: It Depends on Action

that We and Others Will Advance

What Problems Does Transformation Address? The NFC’s Diagnosis of Mental Health Care

• The public mental health system is not oriented to recovery:– Late detection/intervention – Not consumer-centered, or deeply oriented to recovery…

unintended ”maintenance” focus– Uneven quality/poor use of evidence based interventions,

massive workforce problems

• While care is not accessible in sectors/settings where it is needed:– Schools, early education, child welfare, JJ– Health care settings, law enforcement/criminal justice,

workplaces, disability programs

Child

County

DMH

M.H. Care

Court

Clinic

Social Services

Income Support

School

Case Mgt.

SAMHSA-CMHS

Transformation is needed because OF REFORM: Our old mental model of community mental

healthFederal level

State level

Local level

Coordinated Care

Meds

Funding?

FamilyChild

County

DMH

M.H. Care

Court

Meds

Social Svce

Income Support

LEA/School

Case Mgt.

DSS Ed/SpEd..

Justice Medicaid

State Medicaid Agency

ACFCMHS Education SSA

Complexity of Services and of Change after “Reform”

HRSA

Clinic ?

Health DYS BDD

Because “Reform is Not Enough”…The Commission Proposed:

• Transforming Mental Health Care, not Reforming It• Vision for Mental Health in America• National (and State and Local) Goals

Vision For A Transformed Mental Health System

We envision a future where recovery and resilience are the expected outcomes and when mental illnesses can be prevented or cured.

We envision a nation where everyone will have access to early detection and the effective treatment and supports essential to live, work, learn and participate fully in their communities.

This is Why “Reform is Not Enough”…The Commission Proposed:

• Transforming Mental Health Care, not Reforming It

• But, what is “transformation”?– Not: reform…to be “implemented” or “rolled out”– Linked Actions, at Many Levels– Large and Small Actions adding up to Dramatic

Change– Change in Processes, Not Just Programs (e.g.

“Using the Skills of Consumers and Families to Advance Recovery and Resilience”)

New Business Models and Products Transforming their Markets

Businesses with Internal Transformations

24 -7 Copying Services across the country

Discounts with leather and screens

On-Line Auctions with volume

When it absolutely positively has to be there overnight – Order tracking and services

Discount Flights with transparent pricing for peanuts

From private banking to the #1 worldwide servicer of mutual funds and pensions and investment management of pensions.From Tweed to teen fashion with lust

Mainframes to Services; in and out of PCs.

The home of the Macintosh finds new music and a shuffle

Search the world with google-bots

Examples of Business Transformation (Dick Dougherty)

Political Transformation: Which Approach Has Been

Effective?• Democratic Strategy

• Republican Strategy (since early ’80s)

Big Focused Money

Concept Generators

Concept Communicators

Political Machinery

President

This is Why “Reform is Not Enough”…The Commission Proposed:

• Transforming Mental Health Care, not Reforming It• But, what is “transformation”?

– Not: reform…to be “implemented” or “rolled out”– Linked Actions, at Many Levels– Large and Small Actions adding up to Dramatic Change– Change in Processes, Not Just Programs (e.g. “Using the

Skills of Consumers and Families to Advance Recovery and Resilience”)

• Transformation is adaptive change…nonlinear change occurring via a “punctuated equilibrium” model

• Transformation is like Recovery:– A process as well as an outcome– To paraphrase Ed Knight: No one can “transform”

someone else…each must do their own work…. hope and supports are essential

Seven Ways of Leading (HBR April ’05)Managers Can Grow. WE can Grow. We can Grow Others.

Alchemist Generates social transformation 1%

Strategist Generates org. transformations Inquiry. Vigilance. Vulnerability

4%

Individualist Weaves personal/org. goals: good consultant, venture mgr.

10%

Achiever Meets strategic goals: “Manager” 30%

Expert Logic/expertise…Good at tasks 38%

Diplomat “Glue” personality…Supportive 12%

Opportunist WIN…Good in Sales, Crises 5%

Action Logic Characteristics/Strengths % Mgrs

What Are Our Responsibilities? What Can Leaders Do?

• First, do as little harm, and provide as little energy-sapping “leadership” as possible

• Balance stabilizing and de-stabilizing forces. • Be clearer about which changes are transformational• Create capacity, don’t “roll out”:

– Hope, motivation, energy for change– Tools

• Toolkits plus• Information and platforms for learning

– Infrastructure for change: • Support, participate in Leaning Communities• I. D. and support: Salesmen, Mavens, and Connectors

• Facilitate “flow”

(How WILL we) Be the change that we want to see in the world.

Mohandas Gandi

(Let ACMHA Become) A small group of thoughtful people (to) change the world.

Margaret Mead

Beginning (and concluding) thoughts…

Thank You