Arizona's public behavioral health system has many participants, constituents, and interested observers. All of these see the public behavioral health system from different perspectives, and have varying opinions about what works well in the system and which elements of the system need improvement. State officials are justifiably proud of the public behavioral health system on "the cutting edge of mental health service delivery reform."¹ On the other end of the spectrum, advocates have pursued legal action in attempts to improve public behavioral health for adults with serious mental illness and children with serious emotional disorders.

Which perspective is correct? What is the true state of the Arizona public behavioral health system?

St. Luke's Charitable Health Trust has sponsored a strengths-based assessment of the public behavioral health system in Arizona to better understand Arizona's public mental health care system and to recommend changes that would further improve services for people with mental illness. The study is one of the first steps of a Trust-initiated five to 10 year effort to improve the system of care in Arizona for persons suffering from mental illness or significant behavioral problems. It was initiated to create a more enlightened public climate that would be receptive to appropriate treatment that ensures dignity and self-respect.

The elements of this study include:

• Developing a template of behavioral health "best practices" relevant to Arizona's current system;

• Conducting a strengths-based assessment of the current system as compared to the best practices template;

• Recommending initiatives and strategies to facilitate dissemination of current best practices information and enhance and improve the public behavioral health system in Arizona.

The Trust has emphasized a strengths-based assessment for two reasons. First, the Trust wished to avoid the production of a highly critical "expert" report that engenders defensiveness rather than concrete and positive system changes. Second, the Trust recognizes that positive improvements must be built on the existing foundation of care, and thus existing strengths should be identified and enhanced as a first step in fostering system-wide improvements.

St. Luke's Charitable Health Trust is a Phoenix-based independent grantmaking organization formed in 1995 as the result of the sale of the St. Luke's Health System. Focused principally on the health needs of underserved and disenfranchised populations, it operates a community-based grants program, a medical assistance program through a network of community health providers, and program initiatives in the areas of access to care and mental health.

The centerpiece of St. Luke's mental health initiative is the creation of the Mental Health Dissemination Network of Arizona (MHDNA). MHDNA is a coalition of public and private organizations and individuals formed with a mission to become an independent source of analysis, dissemination and advocacy for the application of sound research to mental health issues in Arizona. Initially, MHDNA may recommend projects and strategies for funding to the Trust. Over time these will be combined with other funding sources and public/private partnerships to bring more energy, resources and creativity to bear on pressing mental health issues. Concurrent with the completion of this study, MHDNA has implemented a web site designed to be a source of information about evidence-based best practice of importance both to Arizona and to other public behavioral health entities throughout the United States.

To complete the study, St. Luke's Charitable Health Trust engaged the Technical Assistance Collaborative, Inc. (TAC). TAC is a Boston-based non-profit actively involved in providing consultation and technical assistance to national, state and local health and behavioral health organizations to design and implement publicly funded systems of care, service delivery approaches, and supported housing. TAC has worked in more than 45 states and over 60 local jurisdictions to foster and facilitate improvements in behavioral health and related health and human services organizations.

To engage an entity with extensive experience in Arizona and to facilitate the database analysis component of the study, TAC formed a partnership for this project with William M. Mercer, Incorporated (Mercer), which has its behavioral health practice headquarters in Phoenix. Mercer has a history of high quality data collection and analysis in public behavioral health systems. Mercer has already conducted extensive analysis of the Arizona Health Care Cost Containment System (AHCCCS) data and related utilization and cost data from the Regional Behavioral Health Authorities (RBHAs). Mercer also assisted the state in preparing its request for proposals (RFP) for behavioral health services in Maricopa County.

In concert with the St. Luke's Charitable Health Trust and the MHDNA Steering Committee, TAC and Mercer conducted a detailed assessment of the Arizona public behavioral health system. At the same time, data and information from other states and local jurisdictions were reviewed, as was the literature regarding evidence-based best practices in the field of behavioral health. Specifically, the team:

~ Conducted a thorough document review, including reports generated by and/or about the Arizona system, and similar reports from other jurisdictions;

~ Conducted an exhaustive literature review, compiling evidence-based best practice information relevant to Arizona's needs and local conditions;

~ Analyzed three years of utilization and expenditure data from the Arizona behavioral health system and compared this data with similar information from other jurisdictions;

~ Conducted over 25 focus groups with consumers, families, providers, staff and other stakeholders throughout Arizona;

~ Conducted over 100 key informant interviews, ranging from elected and appointed state officials, physicians, judges, program managers, advocates, individual consumers and family members, and a variety of other informants knowledgeable about public behavioral health services in Arizona;

~ Visited over 50 program sites, including all RBHAs, many directly operated or contracted program sites and several programs outside the behavioral health system, including school, jail and court programs.

Best practices in public behavioral health are multi-dimensional. That is, best practices are defined by several different domains, including vision and values, systemic implementation, and point-of-service excellence in clinical and program delivery. These domains, or conceptual approaches to best practices, are discussed in greater detail in Chapter III of this report. The practical criteria used to select specific best practices for inclusion in this report are:

~ There have been qualified evaluations of the program model or clinical practice, and the positive effects of the approach(es) are described in peer-reviewed literature.

~ The practice or approach has become a nationally accepted best practice and has been widely used as a standard and guideline for program implementation and service delivery for a substantial period of time.

~ The team has knowledge and experience with the practice or approach from successful and beneficial implementation in other jurisdictions.

~ The practice or approach is relevant to Arizona local conditions and definitions. It addresses gaps or needs in the current service system; and/or

~ The implementation of the practice or approach is feasible within the current Arizona public behavioral health system.

The extensive data analysis, literature review, information collection and field observations led to:

~ A comprehensive, objective and multi-faceted picture of the Arizona public behavioral health system;

~ A clear understanding of the environment, both statewide and nationally, in which the system operates;

~ Development of preferred practice templates that can function both as a guideline and set of benchmarks for implementing improvements in Arizona's public behavioral health system;

~ Documentation of where the current system deviates from the preferred practice template and identification of priorities to be addressed in improving the system;

~ Recommendations for specific strategies for Arizona, its behavioral health partners, and for MHDNA to begin the process of improving the current system.

This information is summarized in the body of this report, and in more detail in the Best Practice Supplement that accompanies this report.

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