Best Practice Model Component Criteria for the Best Practice Model Component Expected Results for Consumers and their Families

All services are based on the concepts, principles, and practices of recovery

Recovery includes building internal strengths, building social support networks, and overcoming stigma through activism and self-advocacy.4

  • The system fosters and supports independent thinking and action on the part of consumers.
  • All components of the service system treat consumers as equal partners in service planning and choice.
  • Consumers are offered opportunities and supports to make mistakes.
  • The system treats consumers with the belief and trust that they can shape their own futures.
  • All participants in the system listen to consumers and believe what they say.
  • Consumers' strengths and capabilities are recognized and supported by the system.
  • All elements of the system work with consumers to find the resources and services they want.
  • Key caregivers in the system are consistently and conveniently available to consumers when they need and choose communication and support.
  • Consumers will have greater opportunities to achieve their individual goals.
  • Consumers will experience a reduction in the discrepancy between their expectations and their actual achievements.
  • The community and living environment for all citizens will change through reduced stigmatization of mental illness, improved public attitudes about people with disabilities living and working in the community, and through the development of new community resources.
  • There will be increased opportunities for consumers to work, play, and participate in the community.
  • Consumers will be come empowered and active as citizens and will develop political skills and strength.
  • There will be improvements of quality of life, such as vocational and educational opportunities, independent living, friendships, and contributions to others in the community.5
  • Consumers are taught the skills and knowledge to provide for self-care and to make informed choices and decisions about their services.6
  • Consumers will develop and benefit from greater hope, trust in themselves and their thoughts, enjoyment of the environment, and increased self-esteem.
  • Consumers will develop faith in their own futures, and will improve confidence and skills in working and relating to others.7
  • Consumers experiencing rehabilitation and recovery will utilize fewer hospital days, reduced interactions with crisis services, and less high cost residential and day services.
Best Practice Model Component Criteria for the Best Practice Model Component Expected Results for Consumers and their Families

Self determination and choice

An essential ingredient of consumer recovery and empowerment is self- determination and choice.

  • The public behavioral health system will assure ample opportunities for consumer self- determination and choice through; (a) providing whatever supports are necessary to facilitate consumer self-determination and choice; and (b) assuring that there are a range of options from which consumers can make reasonable choices.
  • Consumers and their families will benefit from an increased variety and flexibility of services and supports that can be tailored to their individual needs and choices.
  • Exercising informed choice of services and supports is a key ingredient in recovery, and will result in improved outcomes and satisfaction for consumers and their families.
Best Practice Model Component Criteria for the Best Practice Model Component Expected Results for Consumers and their Families

Continuity of contact with the system

Consumers emphasize that a lasting relationship with trusted caregivers and continued receipt of needed and chosen services are key elements of each person's personal path to recovery.

  • The public behavioral health system will assure that each consumer has an individual, team, or organization with specific responsibility for developing and maintaining a positive, mutual, and continuous relationship.
  • The system will take steps to reduce staff turnover to increase the consistency and tenure of relationships among system staff and consumers.
  • Consumers will develop comfortable, safe, and growth-producing relationships with one or more caregivers, that will result in enhanced rehabilitation and recovery and will reduce hospitalization and other high cost services.
Best Practice Model Component Criteria for the Best Practice Model Component Expected Results for Consumers and their Families

The system meets CSP principles and service models

The CSP model emphasizes consumer centered strengths- based services, empowerment, cultural and linguistic competence, service flexibility, incorporation of natural supports, accountability to consumers, and coordination and continuity.

  • The system provides active and aggressive outreach, and works to provide or arrange transportation when necessary to facilitate access.
  • The system provides assistance and supports in meeting basic needs for food, clothing, shelter, personal safety, and medical and dental services.
  • The system provides a full array of mental health treatment, including inpatient and partial hospitalization, medications and medication management, individual and group counseling, and residential evaluation.
  • 24 hour seven day-per-week crisis response and stabilization is available in all areas of the state.
  • The system assures development and delivery of a wide range of psychosocial and vocational services, including consumer operated and peer support services.
  • The system works to provide access to affordable supported housing.
  • The system provides education about mental illness to the community and advocates for the rights and dignity of consumers.8
  • Effective outreach and engagement, plus facilitated access to services, will reduce homelessness and incarceration rates for individuals with serious mental illness.
  • Community independence, self-sufficiency, and individual recovery will be enhanced and supported through access to primary health care and adequate food, clothing and shelter.
  • Rehabilitation and recovery will be facilitated through choice of and access to a full range of clinical treatment and psychosocial rehabilitation options.
  • Use of high cost services will be minimized, and individuals will be able to return to pre- crisis level of functioning quickly.
  • The elapsed time between hospitalizations and/or crisis presentations will be increased for most individuals.
  • The community will become more understanding of mental illness, and more supportive of people with serious mental illness living in the community. Both of these facts will stimulate and enhance the recovery process.
Best Practice Model Component Criteria for the Best Practice Model Component Expected Results for Consumers and their Families

Psychosocial rehabilitation service models

Psychosocial rehabilitation services are designed to assist consumers to develop skills and strengths in all the aspects of their lives other than clinical treatment, and thus address skills and strengths related to living, learning, working, loving, socializing, and otherwise participating in community life.

  • See above: The system assures development of and access to a full range of psychosocial rehabilitation services, including psychosocial clubhouses, consumer-operated drop-in centers, supported employment, supported education, and peer counseling services.
  • Consumers will learn skills, gather knowledge, and experience success in ways that support the recovery process. The result for the long term is reduced dependence on high intensity, high cost services, reduced life-cycle costs to the public behavioral health system, increased independence, self-sufficiency, and community tenure for consumers. The benefit for consumers and their families is independence, self-determination, and the pride and satisfaction gained by becoming productive members of society.
Best Practice Model Component Criteria for the Best Practice Model Component Expected Results for Consumers and their Families

Early Intervention

Early intervention is better for consumers and their families because it reduces the long-term negative effects of the illness and initiates the recovery process at a time when the disabling effects of the illness are minimal and personal and family resources are not yet exhausted. Early intervention also has beneficial consequences for the public behavioral health system, in that it has the potential to reduce the life-cycle costs of services and supports for a substantial number of individuals with serious mental illness.

  • The system assures quick response and early intervention for consumers and their families. This takes place soon after the onset of the illness, and includes outreach to consumers and family members, education about the illness, and linkage to consumer and family peer support organizations. This early intervention also includes highly skilled and strengths-based assessment and diagnosis, and may include psychological and neurological testing. Protocols for medication management include trials with atypical antipsychotic medications as the first choice for psychotic symptom amelioration.
  • Successful early intervention strategies will reduce the long term disabling effects of the onset of serious mental illness. This means more rapid return to pre-onset functioning levels, reduced dependence on high cost services, and earlier initiation of the recovery process. When the system starts with individuals and their families from a position of hope and a belief in recovery, then the recovery process is usually briefer and less difficult.
Best Practice Model Component Criteria for the Best Practice Model Component Expected Results for Consumers and their Families

Comprehensive Crisis Services

Crisis services provide a number of important functions for consumers and the behavioral health system. These include crisis response and stabilization, diversion form hospital or other high cost services, and returning of individuals to pre-crisis functioning as quickly as possible. They also often function as the front door intake system for after hours and on weekends.

Comprehensive crisis services also function for the community, providing the first line of response to individuals in crisis no matter what the cause of the crisis may be. They also assure that emergency room, ambulance, law officer, and jail resources are not inappropriately utilized for behavioral health crises.

  • Regional behavioral health systems include a twenty-four hour, seven day per week, 365 day per year central telephone response system staffed by qualified mental health professionals and having immediate capacity for face-to-face assessment plus on-call consultation with a psychiatrist.
  • The regional crisis response systems have the clinical capacity and legal authority to approve or deny admission, voluntary or involuntary, to any public (operated or paid) psychiatric inpatient facility.
  • The crisis response systems assure timely access to appropriate clinical specialties, such as board-certified or board eligible child psychiatrists.
  • Each crisis response system has mobile capacity, in which teams of mental health professionals and peer counselors are available to respond in a timely manner9 to psychiatric crises wherever they present, including hospital emergency rooms, individual homes, and local jails. The mobile units also have the capacity to transport or arrange for transport of individuals in crisis to an appropriate evaluation and stabilization facility.
  • The crisis response systems have access to a variety of short-term (23 hour to 14 day) adult and child holding and intensive residential treatment resources for crisis stabilization and hospital diversion.
  • The crisis response systems arrange for appropriate linkages with other healthcare resources, to arrange for medical clearance, toxic screens, lab work related to rapid medication titration, and medical and non- medical detoxification.
  • Each crisis response system has direct access to cultural and linguistic clinicians and translation services to facilitate assessment and crisis stabilization.
  • Individuals presenting in psychiatric crisis will receive a timely and clinically appropriate response that assesses the crisis, resolves presenting issues, refers to crisis stabilization resources, and refers to the least intensive services possible.
  • This response system will result in use of psychiatric hospital admissions only when clinically necessary, and thus will establish a rational and objective link between the clinical needs of the service population and the bed capacity of the psychiatric hospital system.
  • The crisis response system will also reduce and ameliorate the disabling effects of the crises, thereby enabling individuals with serious mental illness to return to pre-crisis levels of functioning more quickly and with less intensive resource utilization.
  • The crisis response system will result in facilitated access to the public behavioral health system, by referring individual presenting after normal business hours to the appropriate component of the behavioral health system for follow-up.
Best Practice Model Component Criteria for the Best Practice Model Component Expected Results for Consumers and their Families

Assertive Community Treatment - Intensive Case Management10

Assertive Community Treatment (ACT) and intensive case management (ICM) are the models most commonly used to provide intensive mobile services to consumers who are: (a) at very high risk of hospitalization or otherwise losing community housing and supports; and (b) who are unwilling or unable to participate in or benefit from traditional clinic or facility-based services

  • The system assures access to ACT or ICM for individuals needing and choosing such services and at risk of frequent hospitalization, homelessness, and/or incarceration.
  • Assignment to an ACT or ICM team is based in clinical level of care criteria, but criteria for remaining with an assigned team are flexible to assure that an individual does not have to change teams as her/his level of functioning changes.
  • Team services are provided primarily in the home, place of employment, or other non- facility-based settings.
  • Teams are multidisciplinary and are trained in substance abuse, dual diagnosis, and employment skills as well as mental health interventions.
  • To the extent possible, teams include peer counselors and other consumers-as- providers.
  • At risk and/or difficult to engage consumers will use fewer hospital admissions, fewer hospital days, and fewer presentations in crisis.
  • At risk consumers will maintain independent housing and independent employment for longer periods of time.
  • Consumer satisfaction and positive outcomes will be improved through assured continuity of contact with the system and through assertive outreach on the part of ACT and ICM teams.
Best Practice Model Component Criteria for the Best Practice Model Component Expected Results for Consumers and their Families

Implementation of evidence-based clinical treatment best practices

Meeting clinical practice and utilization guidelines is important for a number of reasons. First, these guidelines result in better clinical and personal outcomes for most consumers. Second, they facilitate the recovery and rehabilitation process, and minimize the potential for long term dependence on clinical service modalities. Third, appropriate and therefore minimal utilization of expensive inpatient and other intensive clinical services permits the maximum amount of public resources to be focused on more cost-effective community support and recovery-oriented programs.

  • Statewide evidence-based clinical protocols and treatment guidelines are promulgated for consistent application throughout the public behavioral health system.
  • The clinical protocols and guidelines govern all aspects of clinical treatment, and address both diagnosis-specific best practice interventions and specific treatment modalities.
  • Clinical practice guidelines reflect best practices in rehabilitation and recovery, and emphasize community services and supports, as well as focusing on clinical treatment.
  • All clinical and service program staff in the system are trained on a routine basis in both existing and new treatment protocols and guidelines.
  • Competency standards are applied on a regular basis to assure full competency at all levels for delivering evidence-based best practice protocols and guidelines.
  • Quality management and improvement functions at all levels of the system work to (a) assure proper implementation of best practice protocols and guidelines; and (b) to test and implement evidence-based improvements in clinical practice and service delivery.
  • Quality improvement of best practice guidelines and protocols will be enhanced though quantitative analyses of behavioral health utilization, costs, outcomes, and satisfaction, and by qualitative, on going clinical and peer review evaluations.
  • Clinical and consumer-based outcomes will be consistently achieved and improved.
  • There will be a direct and documented link between individual consumer's diagnoses, level of functioning, and strengths-based assessment and the amount, duration, and scope of services provided.
  • Consumers will neither over-use nor under- use needed and chosen services.
  • The costs of treatments and services will be directly linked to the clinical needs of consumers and the outcomes produced for consumers.
  • The public behavioral health workforce will have the correct values, knowledge, and skills to deliver clinically appropriate and effective services.
  • Behavioral health consumers in Arizona will be assured of receiving the best evidence- based treatments and services, and that these will improve as new evidence is accumulated about best practices.
  • Arizona will contribute to the growing national body of evidence-based best practice as well as benefiting from the receipt of such information.

4For example, see Fisher, Daniel M., MD. Empowerment and Rehabilitation: Boston University Center for Psychiatric Rehabilitation; Coping and Recovery: Ralph, Ruth, Ph.D., et. al.; Recovery Issues in a Consumer Developed Evaluation of the Mental Health System Proceedings - Fifth Annual Conference on Mental Health Services Research and Evaluation, Arlington, VA February, 1996

5The above points were derived from Rapp, Charles A., Shera, Wes, and Kisthardt, Walter, Research Strategies for Consumer Empowerment of People with Severe Mental Illness. Social Work Volume 38(6) November 1993

6The above points were derived from Ralph, Ruth, Ph.D., et. al. Recovery Issues in a Consumer Developed Evaluation of the Mental Health System Proceedings - Fifth Annual Conference on Mental Health Services Research and Evaluation, Arlington, VA February, 1996 Page 6

7Ralph, Ruth, Ph.D., et. al. al. al. Al. Recovery Issues in a Consumer Developed Evaluation of the Mental Health System Proceedings - Fifth Annual Conference on Mental Health Services Research and Evaluation, Arlington, VA February, 1996

8For example, see Sproul, B. A., Models of Community Support Services: Approaches to Helping Persons with Long Term Mental Illness NIMH August, 1986

9Usually one half hour in urban communities, and one hour in rural settings.

10ACT teams are customarily comprised of a part time psychiatrist, a psychiatric nurse practitioner, one of more masters level social workers, and various combinations of peer counselors, employment counselors, and substance abuse specialists. With ACT teams, the entire team is responsible for each consumer assigned to the team. ICM teams typically have access to a psychiatrist and a psychiatric nurse practitioner, but these individuals may participate in a number of other teams. ICM teams are usually comprised of masters and bachelor level social workers, sometimes joined by peer counselors or other specialists. Although the members function as a team, each team member will typically have his/her own assigned consumers.

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