Jeremy North*, a 26-year-old male diagnosed with schizophrenia, received all of the services prescribed by Arizonaís public mental health system according to the latest rules and regulations: initial assessment, treatment, and case manager assignment, all within the required time frame by licensed health care professionals.
So why is Jeremy out on the streets and homeless today? Did the system fail him, or did he fail because of his illness? Is it because of lack of adequate funding, lack of will, lack of knowledge, lack of programs and trained personnel, lack of family support or legal constraints? Is it all or none of these things?
*A composite portrayal
Mired in Process
The fact of the matter is that there isnít one state in the country that has adequate resources to meet the growing demand for mental health services. Arizona is in the middle of the pack in terms of public per capita funding. But lack of money doesnít mean there arenít things we can do now to improve the lives of persons suffering from mental illnesses and disorders. The MHDNA-commissioned Into the Light study of Arizonaís public behavioral health system outlines a number of improvements that ought to be made while we continue to advocate for substantial additional funding.
One suggested improvement is to focus more time, energy and resources on consumer outcomes and less on process assessment and accountability through regulation. In Jeremyís case, instead of focusing on whether providers followed the correct processes and regulations for delivering services, we should shift our primary attention to assessing whether Jeremy actually got better: did he show noticeable improvement in his behavior, find adequate housing or return to his family, achieve stable employment, a supportive social life, and so on.
Easier Said Than Done
This sounds like common sense, but itís easier said than done:
Multiple agencies and individuals have to agree on one set of outcome indicators that determine the success or failure of the public system. The hard part isnít deciding what to include, but what to leave out. Like most activities that comprise different agendas and interest groups, the process can be intensely political.
You need data that can actually determine whether the individual improves. It may be easy to determine whether he stabilized during his stay in the hospital and was discharged to a subsidized apartment with an assigned case manager, but it is harder to follow him over time to determine whether he found employment and reconnected with a stable social environment. You have to put resources into data collection and assessment, just like you do treatment.
No one wants to be held accountable for outcomes they canít control. If affordable housing isnít available, itís hard to hold the mental health system accountable for finding it. If the system stabilizes an adolescent with a severe emotional disorder and then discharges him to a family with a history of drug abuse and domestic violence, the eventual outcome may be beyond the realm of any one public agency to impact, especially when the courts and other agencies enter the picture.
The "C" Word
The act of refocusing attention from process and regulatory issues to outcomes, properly done, can unleash enormous energy and potential for reform. A whole new mindset can take hold. When you assess your own work in terms of concrete outcomes and have access to the outcomes that others in the system are producing, you engage in the inevitable comparison of performance across agencies in the network.
In short, one "C" word Ė comparison Ė breeds another "C" word: competition. And thatís not necessarily a bad thing.
Competition can improve performance. It can instill pride and determination, and bring a sense of urgency and purpose to oneís work that produces positive benefits for everyone.
But competition can also produce fear and resentment, especially when itís unfair. You canít expect people to compete well if they donít have adequate resources and training, if they are disadvantaged because of geographical or cultural differences, or if the standards of comparison and the scorecard for performance are not uniform and appropriate to the task at hand.