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Article3-MarylandsSharedLeadershipApproachtoMentalHealthTransformation-PartnershipsThatWork.pdf
PSYCHIATRIC SERVICES � ps.psychiatryonline.org � July 2012 Vol. 63 No. 7 663333
In 2005, Maryland received a men- tal health transformation grant from the Substance Abuse and Mental Health Services Adminis- tration. Maryland’s transformation efforts have differed from those in other grantee states and have evolved into a shared leadership approach that harnesses the power of leaders from all sectors of the community. This column describes Maryland’s reform efforts, focus- ing in particular on the develop- ment of the position of a peer em- ployment specialist to improve placement of consumers in em- ployment. This shared leadership approach has the potential to en- hance long-term sustainability of reform initiatives and uses fewer state resources. (Psychiatric Ser- vices 63:633–635, 2012; doi: 10.11 76/appi.ps.201200212)
In the mid-2000s, the New Free-dom Commission and the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA) initiated state efforts to redesign pub- licly funded behavioral health sys- tems to increase recovery orientation, evidence-based treatment, and self- directed care (1). They envisioned centrally administered reforms led by senior officials who were chosen and supported by the governor’s office in each state. Maryland’s transformation proposal stated, “[S]uccess or failure
will rise and fall on the degree of strength and conviction of the Chief Executive” (2). Maryland’s effort evolved in a way that was different from efforts in other states that re- ceived transformation funding. Mary- land took a shared leadership ap- proach that harnessed the power of leaders from all aspects of the com- munity, with full support from the governor and his administration.
In this column, I describe several dimensions of Maryland’s innovative reform: its process, the state’s context, and the benefits of this approach and its risks in terms of potential disagree- ments between community leaders about the goals of the state transfor- mation effort. Finally, I present an ex- ample of the shared leadership ap- proach in action.
Early transformation grant leadership structure In October 2005, Maryland became one of seven states to receive a men- tal health transformation grant from SAMHSA. As in other states that re- ceived such grants, the state’s execu- tive office created a transformation working group (TWG), which was originally composed of department heads from several executive agencies and key leaders from the advocacy community. As the grant required, the TWG began a year-long process to develop a comprehensive plan for mental health system reform in Mary- land. During that year, however, it be- came clear that Maryland voters were likely to select a new governor from a different party, which would result in the replacement of almost all of the TWG’s original members when the governor’s cabinet changed.
Maryland’s mental health commu- nity became frustrated with the grant’s planning and implementation process. Stakeholders became dissat- isfied with the development of a new comprehensive plan because they felt that Maryland already had a strategic direction and was losing valuable im- plementation time in designing a new one. In addition, the community viewed the process led by the gover- nor’s office as “top down” and espe- cially frustrating in light of the antici- pated change in state leadership. Fur- thermore, stakeholders felt that the TWG, with its composition of numer- ous department heads and only a few mental health advocates, excluded many mental health leaders. During the election season, the mental health community was vocal and united in expressing to both gubernatorial can- didates its requests for a new process.
Responding to community con- cerns, the new governor and his ad- ministration agreed to significantly broaden transformation leadership. As a first step, the TWG was reconsti- tuted; the format of an open town hall meeting was chosen in order to ex- pand participation to anyone interest- ed in working on the reform, includ- ing consumers, providers, family members, youths receiving services, and other advocates and community leaders. Building on existing plans and efforts, smaller working groups were created to implement initiatives that met the following criteria: readi- ness to begin work, community sup- port, the mental health system’s exist- ing capacity to implement the initia- tive quickly, and prospects for the ini- tiative’s long-term sustainability.
The transformation effort inten-
Maryland’s Shared Leadership Approach to Mental Health Transformation: Partnerships That Work RRaaffaaeell MM.. SSeemmaannsskkyy,, PPhh..DD..,, MM..PP..PP..
The author is affiliated with Nantasket Roads Health Care Consulting, 4004 Beecher St., NW, Suite 304, Washington, DC 20007 (e-mail: rmsemansky@gmail. com). Fred C. Osher, M.D., is editor of this column.
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tionally built on existing state re- sources, mental health system strengths, and initiatives of state and local governments, providers, and stakeholders (3). Working groups chose initial projects with the greatest probability of success to build mo- mentum before tackling more diffi- cult issues. Responding to stakehold- er impatience, the work of transfor- mation initially focused on develop- ing solutions to weaknesses and gaps in the mental health service system that had been identified in prior plans and needs assessments.
Maryland’s approach and its advantages Maryland’s approach evolved into a shared leadership effort led by Daryl Plevy, J.D., with support from the new governor (personal communication, Nov. 2010). In 2007, Ms. Plevy was ap- pointed director of the Maryland Transformation Office and tasked with harnessing existing efforts and identi- fying leadership at all levels, with a view toward maximizing change. A shared leadership approach was a nat- ural fit for Maryland—a state that has a long-term stable leadership at the provider and stakeholder levels. As a result of long-term relationships among many key players, a high level of agreement existed about transfor- mation priorities. Since introduction of managed care in the 1990s, Mary- land’s behavioral health system has embraced change positively and has viewed change as an opportunity for system improvement. In sum, there was little resistance to using transfor- mation grant funding to reform the be- havioral health care delivery system.
The shared leadership approach in action Workforce-related issues came up fre- quently in previous state mental health plans and in community feed- back during the first transformation year, October 2005–September 2006. Stakeholders expressed a need for greater understanding of the chal- lenges facing consumers of communi- ty-based services who wanted to enter the workforce. The TWG worked with stakeholders to identify an organiza- tion with workforce knowledge. The Sar Levitan Center at Johns Hopkins
University is a social policy group with expertise in improving workforce prospects of marginalized popula- tions, such as ex-offenders and out-of- school youths, and the center became a contractor for transformation ef- forts. As a first step, the Levitan Cen- ter conducted 27 focus groups in 2008–2009 across the state with con- sumers, providers, and families to learn more about mental health sys- tem issues (personal communication, M. Pines, Levitan Center, Nov. 2010). Focus groups specifically identified returning consumers to the labor mar- ket as an area in need of rethinking because of widespread misconcep- tions among all stakeholders about la- bor market functioning and ways to surmount particular barriers experi- enced by consumers. From these ef- forts, a project evolved to expand con- sumer knowledge about labor markets and employment options with the goals of improving employment prospects and increasing income.
Efforts to promote consumers’ in- terest in work were based on Mary- land’s existing strength in evidence- based supported employment, which the state has delivered since 2002, achieving consumer employment rates as high as 47%—among the best in the nation (4). Before the transfor- mation grant, Maryland institutional- ized delivery of high-fidelity support- ed employment for participating providers through an infrastructure redesign, creation of a single point of entry, incentive payments to programs with high fidelity, and braided funding from the state, Medicaid, and the Di- vision of Rehabilitation Services.
Through the focus groups, the Lev- itan Center gained a greater under- standing of barriers to consumers’ reentry into the labor market. First, many consumers feared entering the workforce because of misinformation about the potential negative effect on their income, housing, and medical benefits. Second, they needed infor- mation to better understand the em- ployment market. Third, they were often unaware of other local re- sources and experienced difficulty ac- cessing existing employment training resources.
Staff of the Levitan Center and members of the Maryland Consumer
Leadership Coalition (the coalition), who had been already been meeting separately since 2007 to establish guidelines for consumer workforce de- velopment and to improve rates of consumer employment, joined togeth- er to explore ideas and approaches for improving consumer knowledge and access to employment opportunities. In discussions with the Levitan Cen- ter, the coalition articulated con- sumers’ needs to understand the non- financial benefits that accompany em- ployment, such as motivation, self-es- teem, and social contacts. These initial meetings involved frank discussions between the two organizations and other workforce groups about mission, workforce issues, and expertise, as well as relevant funding and regulatory is- sues. These discussions increased each organization’s understanding of the other’s work and of the potential bene- fits to be gained from collaboration and set a solid foundation for new ef- forts and long-term sustainability.
The position of peer employment resource specialist (PERS) was devel- oped to recruit and train consumers to guide unemployed consumers in labor force reentry, help them access existing job search and training re- sources, and create a career path for consumers. The core idea was to in- volve consumers who were already a part of On Our Own of Maryland or other consumer-run programs.
Staff of the Levitan Center, working alongside consumer leaders, created a comprehensive manual and program to train consumers serving as PERS in providing information, advice, and support to other consumers. The 123- page manual and the associated inten- sive training, which involved work- force experts and consumer-trainers, reflected the Levitan Center’s re- search-based knowledge of critical ele- ments for successful employment ef- forts: placing consumers in good jobs, seeing consumers as primary cus- tomers and using their needs to drive the program; and recognizing employ- ers as customers equally important as consumers (5).
To educate consumers about the po- tential impact of work on benefits, the PERS initiative explained the impact of monthly pay on income supports, explained where to find the formula
PSYCHIATRIC SERVICES � ps.psychiatryonline.org � July 2012 Vol. 63 No. 7663344
describing the amount of money that can be earned while maintaining ben- efits, and noted that a Social Security Administration employment specialist was the best source to determine actu- al impact. To understand employers’ needs, the consumers trained as PERS were encouraged to establish relation- ships with local businesses and eco- nomic development officers and learn about labor market needs. To expand the use of existing resources, this ini- tiative identified and explained the as- sistance available from the state’s voca- tional rehabilitation program and from community organizations in the areas of human resources, education, and workforce development.
Responding to recommendations from the coalition, the transformation initiative contributed resources for the Levitan Center and the coalition to de- velop a manual and a comprehensive PERS curriculum to train consumers in the new role. Two-day training ses- sions have occurred at several loca- tions in the state, and as of April 2012 nearly a hundred consumers had been certified as PERS. The inclusion of a consumer-presenter who discussed his or her own fears and concerns about returning to work and a benefits coun- selor who explained the potential fi- nancial impact and answered ques- tions from training participants on their individual situations became im- portant parts of the training. Based on the requests of trained PERS, several additional one-day, in-depth, topical training sessions were provided with the goal of continuing to assist them with the deployment of the skill set to be effective employment advocates.
The PERS manual explained the step-by-step process for enrolling consumers in the Maryland One-Stop Career Centers. These centers are the primary workforce investment re- source for the public, but few con- sumers had been successfully access- ing the system. The workforce system was also interested in improving con- sumer participation. Interviews con- ducted by On Our Own of Maryland and the Consumer Quality Team of Maryland identified consumer frus- tration with the initial computer-as- sisted intake at the One-Stop Career Centers as the principal barrier to completing the intake process.
Discussion The SAMHSA transformation grant ended in 2011. The state is optimistic that the shared leadership approach will ensure that many of the projects initiated under the grant will be sus- tained. The SAMHSA transformation grant accelerated existing change ini- tiatives within the publicly funded be- havioral health system. Grading the States, the report of the National Al- liance on Mental Illness, indicated that Maryland’s grade in the category of recovery supports, which includes supported employment, increased from a C– in 2006 to a B in 2009 (6,7). A state survey of consumers also indi- cated consumers’ self-rating of that recovery and resilience increased by 5 percentage points compared with an increase of 1 percentage point for consumers in other states that re- ceived transformation grants (8).
The shared leadership approach, in which public and private organiza- tions at all levels played leadership roles in various initiatives, evolved in response to the mental health com- munity’s requests for a greater role in the transformation initiative and re- sulted in innovative solutions. States without stable leadership within provider and stakeholder communi- ties or those lacking strong agreement among stakeholders and elected offi- cials on the reform’s goals may not have similar experiences. However, this approach worked for Maryland. The state’s experience showed that successful collaborative efforts span- ning public agencies require ongoing support from an organization with relevant expertise, staff time, and fi- nancial resources to bring the parties together and then help design and implement the effort. Using this ap- proach, the state gained new and vi- able products and resources that ad- dressed the needs of consumers and other stakeholders: a curriculum manual for PERS and a new career path for consumers as PERS, with more than 100 consumers trained as PERS. In addition, the shared leader- ship approach tapped into existing re- sources, such as the One-Stop Career Centers, and expanded existing ef- forts by including new partners, such as the Levitan Center.
Ms. Plevy, transformation leader,
stated that the long-term sustainability of the initiatives begun under the re- form is built on a key principle: to de- termine what works to each system’s advantage, leaders need to know how each system defines success and then base their work on areas where there is an intersection of interests. If projects are developed in this way, there is a better chance for leaders to leverage resources and improve the service de- livery system, thus enhancing the chances for sustainability.
Acknowledgments and disclosures
This study was supported by a consulting agreement with the Systems Evaluation Cen- ter, Division of Services Research, Department of Psychiatry, University of Maryland School of Medicine, Baltimore, under a SAMHSA Trans- formation State Incentive Grant (SM57459). The views expressed are the author’s alone and do not reflect the opinion of the Maryland De- partment of Health and Mental Hygiene. The author thanks Denise Camp, B.S., Jim Calla- han, B.A., Herb Cromwell, M.Ed., Marion Pines, B.A., Daryl Plevy, J.D., and Jeff Richard- son, M.S.W., for insightful comments on the manuscript.
The author reports no competing interests.
References
1. Center for Mental Health Services: Coop- erative Agreements for Mental Health Transformation State Incentive Grants. Rockville, Md. Substance Abuse and Men- tal Health Services Administration, 2004
2. State of Maryland, Mental Health Transfor- mation Grant Proposal. Baltimore, Mental Hygiene Administration, June 1, 2005
3. Garfield RL: Mental health policy develop- ment in the states: the piecemeal nature of transformational change. Psychiatric Ser- vices 60:1329–1335, 2009
4. Maryland Transformation State Incentive Grant. Comprehensive Mental Health Plan: Year 4 Update. Baltimore, Mental Hygiene Administration, 2009
5. Sar Levitan Center: A Tool Kit for Peer Em- ployment and Resource Specialists (PERS). Baltimore, Johns Hopkins University, 2010
6. Inventory of Resources/Needs Assessment Report. Baltimore, University of Maryland, Systems Evaluation Center, 2006
7. Aron L, Honberg R, Duckworth K, et al: Grading the States, 2009: A Report on America’s Health Care System for Adults With Serious Mental Illness. Arlington, Va, National Alliance on Mental Illness, 2009. Available at www.nami.org/gtstemplate 09.cfm?section=grading_the_states_2009
8. Maryland Mental Health Transformation Incentive Grant: Continuation Grant Year 5. Baltimore, Mental Hygiene Administra- tion, 2009
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/ENU (DSC Distiller 7 Basic - Non Ad Managment) >> >> setdistillerparams << /HWResolution [2400 2400] /PageSize [612.000 792.000] >> setpagedevice
