Converting Partial Hospitals to Community Integrated Recovery Centers
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- Evans, A., Okeke, B., Ali, S. et al. Community Ment Health J (2012) 48: 557. doi:10.1007/s10597-011-9449-y
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This paper describes the conversion of partial hospitals into recovery-oriented programs as part of system transformation. Steps included: participatory planning with stakeholders; strength based assessment of resources and needs; technical assistance; and changing funding strategies. Over a period of 8 years, use of partial hospitals decreased as persons with serious mental illnesses were transitioned to community integrated recovery centers. Preliminary outcomes suggest that these programs are more effective in engaging people in the community activities of their choice, confirming previous findings that showed that partial hospitals can be converted to recovery-oriented programs that focus more directly on promoting community inclusion.
KeywordsRecovery Transformation Community Partial hospitalization Community integrated recovery centers
As much as 20 years ago, calls began to emerge for an end to the use of partial hospital programs for persons with serious mental illnesses (e.g., Hoge et al. 1992). Partial hospitals arose initially out of recognition that this population did not always require 24 h structure and support, and that intensive treatment could be provided for people experiencing acute episodes of disorder outside of the hospital, as long as they had a stable and supportive place to sleep at night. In this sense, the creation of partial hospitals played a key transitional role in allowing mental health systems to decrease their reliance on inpatient care and to begin to explore alternative ways of providing intensive clinical services in community settings. With the introduction of managed care into public sector mental health, however, the necessity of such step-down modalities was called into question. The last 20 years has now shown, in fact, that many of the benefits to be derived from partial hospital programs can be derived at lower cost and with more flexibility by intensive outpatient programs that do not have the rigid attendance requirements (and, as a result, do not meet the stringent funding criteria) of traditional partial hospitals (Hoge et al. 1993; McReynolds 2002).
With the more recent emergence of the recovery movement (DHHS 2003), new questions have been raised about the institutional legacy and narrow focus of these programs. Success of the “place then train” model of psychiatric rehabilitation suggests that participation in intensive or prolonged clinical services may not be required as a precondition for facilitating a person’s access to and entry into naturally occurring community activities such as employment or education (Corrigan and McCracken 2005). This idea received much empirical support when the state of New Hampshire experimented with converting its partial hospital and day programs to supported employment programs utilizing the IPS (individualized placement and support) approach (Drake et al. 1994). Within the context of recovery transformation efforts, the partial hospital model thus no longer appears as necessary as a step-down or transition from inpatient care to the “life in the community” envisioned by the New Freedom Commission on Mental Health (DHHS 2003). Systems of care engaged in the transformation process have therefore begun to consider reallocation of the resources devoted to this service modality.
This paper describes the efforts of one such system of care, led by the City of Philadelphia’s Department of Behavioral Health and Intellectual Disabilities Services (DBHIDS), to convert its partial hospital programs to a new model of a community integrated recovery center that would shift the focus of care from clinical stabilization to connecting the person to the naturally occurring community activities of his or her choice. This paper describes the participatory planning process involved in this conversion; the roles of technical assistance and changes in funding; the resulting service mix; and preliminary outcomes achieved. Confirming the positive lesson learned by the New Hampshire experiment, the City of Philadelphia is now able to attest to the fact that, with adequate access to opportunities and the supports needed to take advantage of them, persons with serious mental illnesses are able to take on a variety of meaningful and valued social roles in their community.
Pennsylvania, like many other states, invested significant resources in the development of a large numbers of partial hospital programs during the late 1960s into the 1970s. During this initial period of deinstitutionalization (Rothbard and Kuno 2000), partial hospitals began as programs with an emphasis on medication management, group treatment, and assorted activity groups. With this model, agencies could serve, and capture reimbursement for, relatively large numbers of persons on a 5 days a week, 6 h a day basis. In addition to creating a steady income stream for providers, these programs provided a kind of backbone for the state’s outpatient system of care, alleviating its previous reliance on prolonged inpatient care. Unfortunately, these programs were quickly populated with persons transferred from state hospitals after prolonged stays, and the culture of chronicity that permeated these institutions transferred to these new programs as well. As a result, programs typically lacked hope or energy, many participants were heavily medicated and appeared unmotivated, and staff typically assumed that these individuals were too severely disabled to benefit from active rehabilitation. Further, the only expected outcomes or indicators of success for these programs was their ability to keep participants out of the hospital—a modest goal that was unfortunately characteristic for the time.
The 1970s and 1980s saw the State of Pennsylvania attempt to implement some advances in psychosocial rehabilitation, such as efforts to replicate the Clubhouse model first developed by Fountain House in New York in the 1950s. The Medicaid fee-for-service environment of the time funded only partial hospitals, however, and therefore alternative programs were limited by the small amount of state program (i.e., non-Medicaid) dollars available. In the late 1990s, the State Office of Mental Health and Substance Abuse Services began to modify the state Medicaid plan to include psychiatric rehabilitation as an in-plan service. By this time, there was wide spread disaffection by all parties (state, city, providers, service users, and families) with the partial hospital model and regulations for many of the reasons described above.
In addition to the need for workforce development, the system was not yet prepared to fund, monitor, or regulate such community integration services.
The new directions in psychiatric rehabilitation include a variety of strategies to increase the community integration and independence of people with psychiatric disability. Unfortunately, many rehabilitation professionals are neither aware nor appropriately prepared to provide the level of services that are needed by individuals with psychiatric disabilities to re-enter the community and function in the workplace (p. 62).
System Transformation to Recovery
In order to realize this vision, it was made clear to all stakeholders that all aspects and components of the existing system of care would need to be reviewed and reformed to be in alignment with these values and principles; that, in other words, “business as usual” was no longer adequate to the tasks at hand.
The process of pursuing a fulfilling and contributing life regardless of the difficulties one has faced. It involves not only the restoration but continued enhancement of a positive identity and personally meaningful connections and roles in one’s community. Recovery is facilitated by relationships and environments that provide hope, empowerment, choices, and opportunities that promote people reaching their full potentials as individuals and community members (DBHIDS RAC 2006).
In relation to the partial hospital component of the system, a consortium of stakeholders agreed to enact a vision of a new model of service provision in which people with mental illnesses were assisted to identify their own life goals, choose the supports from a flexible menu of options that they hoped would be effective in facilitating their pursuit of these goals, develop a social network that would support their efforts, and, in general, work toward reclaiming the life they desire to lead in the community. Required by this approach was a broadening of the conventional range of outcomes targeted by mental health care, to include such issues as employment, education, physical health, socialization, sexuality, spirituality, and participation in a faith community of one’s choice. Both the Clubhouse model and supported employment model mentioned above were considered for replication, as both have been relatively successful in improving employment outcomes (Macias et al. 2006; Schonebaum et al. 2006). Such a narrow focus on employment was considered too restrictive, however, as the Philadelphia vision encompassed, and thereby required, more diversity in the “choices and opportunities that promote people reaching their full potentials as individuals and community.” Thus, while retaining employment as one focal point, the new service modality was to have a broader and more inclusive view of the variety of roles people may aspire to, including the many other avenues through which persons in recovery may become reintegrated into the life of the community. Broadening the scope of this service beyond employment to include education, physical health, socialization, and the other areas described above required many changes in program structure and operation, including the development of additional community partnerships (beyond those with employers), the development of new resources and new staff competencies, and changes in funding and monitoring, to be described below.
Laying the Groundwork
In keeping with their commitment to participatory planning and implementation, the first official transformation event to be held by DBHIDS leadership in relation to the partial hospital conversion initiative was a 2-day conference attended by more than 500 people including service providers and many people who were currently enrolled in the partial hospital programs. The conference was used to generate enthusiasm, introduce key recovery concepts, confirm state and county support, and review recovery-focused day program models operating locally and in other parts of the country. The response to this event was very positive and established the momentum needed to proceed with planning and implementation efforts.
A second important mechanism employed by DBHIDS to initiate and sustain collaborative planning involved the issuing of a Request for Information (RFI) survey. The RFI presented an opportunity for providers of partial hospital services to: (1) raise questions and convey apprehensions regarding the pending transformation and associated funding issues, and (2) communicate their own ideas and programmatic visions for transforming their existing programs. DBHIDS then generated an extensive list of responses to stakeholder issues that served both to inform and to reassure contracted agencies. It should be noted that providers were expected to complete their RFI responses in consultation with service recipients and their significant others as well as personnel from every level of their agencies. This step reinforced the expectation that people recovering from mental illnesses would play a primary role in efforts to plan, implement, and operate the new programs along with existing agency leadership and staff. While employing the RFI extended the time devoted to initial planning activities, it allowed a number of potential obstacles to be identified and addressed early on in the process. This resulted in an increased clarity about what would be required for successful conversion that served to expedite later planning stages, potentially saving time by avoiding missteps along the way.
Information gathered via the RFI process then influenced the development of a Request for Transformation Plans (RFTP) that was issued to all agencies operating partial hospitals that were targeted for conversion to recovery-focused services. The RFTP included an option to submit a full proposal, indicating a desire to pilot this initiative, or a less detailed plan that would involve phasing into the transformation at a later date. This approach allowed for the identification of those service providers who were most motivated and most ready to pursue immediate transformation. It also allotted more tentative agencies additional time to develop detailed transformation plans and to benefit from the lessons learned by the pilot sites.
Each agency involved in this process was required to develop a Change Management Team (CMT) to play a central role in designing and implementing their agency’s transformation plans. These teams were comprised, at a minimum, of recovering persons and their significant others, direct service providers, and program directors. CMTs were also invited to attend planning, coordination, and training sessions convened by DBHIDS. The direct and active participation of program participants in this process served to keep the transformation “honest” and transparent, and to infuse the process with hope and energy conveyed by people who were excited about the increased opportunities anticipated by the new services. Expert consultants were also assigned to work closely with each agency to offer support regarding the design and subsequent implementation of transformation plans.
Collaboration with the state throughout the planning process was needed to conceptualize service models and allow transformed programs the flexibility to provide blended clinical and psychiatric rehabilitation services delivered both on-site and in the community. This local and state government partnership yielded several important provisions, including a decision that the new programs would jettison their partial hospital program licenses and assume dual Outpatient and Psychiatric Rehabilitation Service (PRS) licenses. Dual licensure presented complexities; however, it was deemed necessary to regulate the combined treatment and psychosocial rehabilitation components of these hybrid programs. The State also granted several key exceptions to PRS regulations including those needed to permit the flexibility required to deploy staff support off-site in community settings.
Finally, to facilitate the transformation process, participating agencies were provided with non-Medicaid funding for 2 months. This funding afforded the agencies the time and space needed to allow for the unfettered implementation of transformation plans without the need to comply with past (partial hospital) or future (outpatient and rehabilitation) licensure regulations. By the conclusion of this 2-month period, agencies were expected to have their new programs and dual licenses in place. At this juncture, payment for these services transitioned from time-limited, non-Medicaid funding to Medicaid reimbursement. Medicaid dollars supporting these services are currently allocated to contract agencies on a monthly basis in an amount equal to 1/12th of their annualized, budgeted costs. Invoicing is employed to ensure that payments do not exceed expenditures. This mechanism avoids the pitfalls associated with traditional fee-for-service reimbursement and grants providers the flexibility to provide site-based and community-based services in direct response to the needs of program participants.
The Importance of Process
Several aspects of the partial hospital conversion process that reflect the broader transformation approach of the City of Philadelphia are worthy of note. A first principle was that the process was to be both community focused and community inclusive. In other words, if the vision was one of people in recovery becoming reintegrated into the communities of their choice (thus community focused), it was important that the community be considered as a partner early, rather than later, in the process (thus community inclusive). The behavioral health system can no longer function in isolation from the broader community with the expectation that people in recovery will be “welcomed back” once their treatment and recovery are completed (Davidson et al. 2007). Rather, the community is understood to be one of the main beneficiaries of the fruits of recovery (along with recovering persons and their families), and a key stakeholder who needs to be at the table in articulating and implementing the recovery vision. This was operationalized in the Philadelphia transformation process, in part, through the provision of funding and support to community coalitions and to small, community-based, faith-based, and grass roots organizations to develop, support, and improve recovery-focused services in their communities.
Through the community coalition initiative, seven community coalitions were funded, each of which was comprised of a combination of community-based organizations and faith-based organizations that are rooted in their communities, along with a licensed behavioral health care provider. Among the goals of this initiative were building collaborative working relationships between existing community and faith-based groups, licensed behavioral health care providers, and DBHIDS in order: (1) to improve the ability either to prevent behavioral health problems before they arise or to intervene early before they become so serious that they compromise the functioning of community members; (2) to identify areas of concern in specific communities that make children and adults more vulnerable for developing serious behavioral health issues and raise community awareness about those issues; (3) to develop collaborative community-based strategies for addressing the identified concerns; and (4) to support effective grassroots strategies that currently exist in the community and to provide opportunities for organizations to refine their knowledge, skills, and abilities in providing prevention and early intervention services. The seven coalitions were in a variety of identified geographic areas of the city and targeted an array of potentially vulnerable individuals and groups.
Through a mini-grant program, one-time grant awards of up to $10,000 were made to grass roots, community, and faith-based organizations, as well as small behavioral health provider organizations, to develop and implement changes within current programs to address the behavioral health needs of children and/or adults and their families. The funds were primarily designed to be used for capital improvement and infrastructure needs in support of transforming programming to be resilience and recovery-oriented, as in the partial hospital conversion described above. Funding through this initiative was provided to more than 75 organizations.
Other community initiatives have targeted faith-based and arts-based organizations and cultural subgroups, such as the Lesbian, Gay, Bisexual, and Transgender (LGBT) community. The Faith-Based Initiative aims to build partnerships with city churches, mosques, and synagogues to provide another way to connect people with behavioral health conditions to needed support and services. The Arts Initiative involves a collaboration between DBHIDS and the City of Philadelphia’s Mural Arts Program and community groups. This unique project addresses the challenges, and seeks to dispel the stigma, of behavioral health issues by conveying visually powerful messages of hope and optimism in culturally accessible ways. The LGBT Initiative focuses transformation efforts on providing pathways for members of the LGBT behavioral health community to experience recovery in their own lives without being hindered by personal prejudice or discrimination based upon sexual orientation and/or gender identity. Finally, the Philadelphia Recovery Community Center (PRCC) is a peer-based initiative that serves as a safe and positive sanctuary for people in recovery, their families, and members of the community by providing a secure venue for sober socializing and a welcoming and warm physical place for accessing needed services, such as housing, planned leisure activities, and community service. All of these initiatives only became possible by broadening the scope of traditional behavioral health relationships as well as outcomes to include the neighborhoods, organizations, groups, and places that make up the life of the Philadelphia community to which people in recovery strive to belong.
A second important principle of the city’s transformation efforts was to work in partnership with both the recovery and the provider communities in relation to developing the guiding vision and required services mix, in identifying and addressing the regulatory and payment barriers, and in implementing new concepts into service practices. Similar to the approach taken to community coalition building, this set the stage for the unfolding of a parallel process of strength based collaboration. DBHIDS committed itself to relating to providers in a strength based fashion by focusing on their assets, their goals, and what they perceived as barriers and concerns that impeded their ability to improve their services. This collaboration was key in identifying the obstacles that needed to be removed or overcome in implementing the new community integrated recovery center model that replaced the traditional partial hospitals and also enabled agency directors and program managers to adopt the same strength based and supportive approach with supervisors and line staff. For the direct care staff to be willing to give up previous practices and enthusiastically embrace the opportunity to explore new ideas and news ways of relating to their clients, it was important for them to be valued members of the CMTs and to identify new sources of reinforcement in their work and new sources of status in their jobs. In yet a further parallel to these changes, it was hoped that the strength based approach adopted by supervisors and program managers would translate into the staff relating to their clients in a similar fashion.
The explicit assertion that the funder (i.e., DBHIDS) was not the seat of expertise and wisdom but that transformation was a partnership activity (equality as the elevation of the other). This involved frequent meetings and phone conversations between DBHIDS management staff and program staff regarding mutual goals and the development of new relationships and a new level of trust that allowed for reciprocity in learning.
Strong linkage between the DBHIDS internal Day Transformation Planning Team and each provider via a designated Recovery Consultant. Having a strong proponent for, and expert in, recovery practices assist each provider onsite to develop a deeper connection and relationship between the provider community and DBHIDS.
Allowing the provider organization choice (a recovery basic) in selecting specific services within the structure developed jointly for the RFP. (Past efforts at system change identified strong resistance to true adoption of different practices when the selection of the practice was selected by the funder and externally imposed.)
Frequent learning forums hosted by the consultant staff to develop and nurture a culture of learning and to foster norms of sharing, support, and cooperation between direct service staff and DBHIDS leadership on the one hand and service recipients on the other.
Key Decision Points and Lessons Learned
Developing a “home grown” vision of resilience and recovery that emphasizes that what people primarily want is a valued life in which they occupy normative social roles in naturally occurring community settings (as opposed to artificial program settings).
Recognizing that recovery involves personal choices among multiple domains of functioning and cannot be limited to a one dimensional outcome, whether that be clinical stability or employment.
Agreements among all parties that the primary locus of interventions, to be consistent with the focus on recovery-oriented outcomes, is in the community where people are attempting to live, work, learn, play, and love.
Taking advantage of the shift in service model to hire people in recovery trained as Certified Peer Specialists to add a new and highly effective component to the behavioral health workforce.
Moving from Medicaid funded van transport to forms of self transport that are available in urban centers with the added support of mobility training, freeing up funds needed to achieve a better mix of community integrated, recovery-oriented services.
Eliminating barriers to recovery-oriented practice that derive from traditional fee-for-service funding structures and partial hospital regulations and which do not allow for community based interventions including skill practice in real world settings and the utilization of mainstream resources (e.g., literacy programs, community and cultural centers).
During the first 8 years of this process, preliminary outcomes have suggested that the conversion from partial hospitals to community integrated recovery centers has been effective in at least three related ways. First, dropping the partial hospital license and regulations and shifting to a more flexible reimbursement structure enabled staff to spend more time in the community (an increase of over fivefold) providing in vivo support and personally connecting people to the naturally occurring community activities of their choice, resulting in fully 75% of program participants receiving some offsite services. Second, in part, perhaps as a result of the deployment of staff in the community, 79% of participants who identified employment as their goal were successfully connected to employment, 74% of those who identified education as their goal were successfully engaged in school, and 99% of those who aspired to do volunteer work were able to participate in volunteering. In accounting for these relatively high percentages of successful placements, it is worth noting that DBHIDS has focused considerable energy on expanding the range of educational and vocational options available to Philadelphia residents.
These include partnerships with community colleges and an exponential increase in the employment of peer staff both within DBHIDS itself and within its funded community-based agencies. Third, and perhaps as a result of these first two changes, program participants experienced on average a 35% decrease in their use of crisis response services once engaged in a community integrated recovery center, with various centers ranging from a 27 to a 63% reduction. While not the results of a controlled experiment, these outcomes are encouraging and certainly warrant further study.
As was originally shown in New Hampshire by Drake et al. (1994), the conversion of day hospitals into community integrated recovery centers that has been carried out as one core component of the transformation process in the city of Philadelphia provides confirmation that partial hospitals can be successfully converted to recovery-oriented programs that focus more directly on promoting the community functioning and inclusion of persons with serious mental illnesses. Unlike New Hampshire, the Philadelphia experiment did not focus solely on employment outcomes, but showed that it also is possible to connect participants to educational and volunteer roles in natural community settings. Other systems that are engaged in their own transformation processes are encouraged to make similar efforts to reallocate existing resources that are not being used to promote recovery or community inclusion to make the inclusive and strength based efforts, and changes in funding mechanisms, described in this report to re-orient the work of dedicated providers to assisting people to meet their own goals for a meaningful life in the community.