We've been hearing a lot of rumors about what's happening in New York lately-lots of interesting news about changing times. We have a friend there who always knows what's really happening, so we asked him to give us the scoop. Our “go-to” guy is none other than Harvey Rosenthal, executive director of the New York Association of Psychiatric Rehabilitation Services (NYAPRS). Harvey, a major player in the New York behavioral healthcare system since 1993, has put his heart into promoting services and policies that advance the recovery, rehabilitation, and rights of people with psychiatric disabilities.
We tried to think of some provocative questions for Harvey that would inspire him to give us some fearsome wake-up calls and scare us a little. Harvey not only came through with thought-provoking answers, but he also took us to a new level of understanding how the future could unfold in ways that promote recovery-based services.
Tell us Harvey, what's really going on in New York these days? What's the big picture? Harvey: New York's political environment is at an all-time low, with a $9.2 billion budget deficit, another late budget and legislative deadlock, and a lame duck Governor. This could be discouraging, but as you know, problems like these often create opportunities for transformation.
Glad you can maintain a positive attitude about all this. Are there positive forces at play to help you with the transformation? Harvey: Sure, there are. One of our strongest assets is a leader with a strong vision for recovery-Mike Hogan [Commissioner, NYS Office of Mental Health]. Leadership is critical when it comes to turning a crisis into a transformation, allowing us to build on promising trends contained in national healthcare reform (with its emphasis on prevention and integrated care) and mental health and substance abuse parity legislation. The recovery, community integration, and consumer and peer services movements give us a strong set of principles on which we are building. Tight budgets and challenging times often give rise to creative solutions. So in spite of all the problems, we have some assets we can harness and draw strength from. We think we can use our strengths to overcome our problems, just like we teach people in recovery to do.
How's that working for you?
Harvey: This is an opportunity to make changes that would otherwise be politically very difficult. Right now, however, there's a lot of pressure to make changes that will produce better outcomes and be less expensive to provide.
Sounds like a great idea. Can you give us some specifics about what you're planning?
Harvey: Sure. I think what we are doing falls into four broad categories. I'll describe them for you:
Service reform. We're renaming and changing the focus of our traditional outpatient services. The new name symbolizes the changes we plan to make. The Office of Mental Health (OMH) calls it PROS (Personalized Recovery Oriented Services). PROS's priorities are helping people to build skills and supports for community living, encouraging the development of increased wellness self-management, health and financial literacy, employment readiness, and community-based housing opportunities. Another very promising OMH initiative in development are new Recovery Centers, which are peer-run resource centers intended to foster employment and educational goals, benefits advisement, asset development, wellness self-management, and crisis diversion. We're also restructuring our outpatient clinic system to include a new peer community outreach and engagement component. These initiatives will continue to transform our service focus from maintenance to recovery, resilience, and a full life in one's community.
Community integration. New York has set up a 19-member Most Integrated Setting Coordinating Council aimed at supporting state agencies to set Olmstead-related goals we hope will help move people and public dollars from segregated to integrated community settings. There's a strong focus on housing and employment, and OMH is heading up a $14 million Medicaid Infrastructure Grant that is working with consumers, providers, government, and employers to raise awareness and success in increasing our employment rates.
Integrated care. Our Health Department tells us that 20 percent of our Medicaid beneficiaries use 75 percent of the resources. For the most part, this 20 percent is composed of folks with multiple problems including psychiatric issues, substance use, and major medical conditions. We are developing a plan to serve them in ways that will better meet their needs and also be less costly for the overall system. (Readers, next month we plan on dedicating our column to this conundrum, so stand by for some good ideas on how to save money while providing better services to this group of folks.)
Peer services. We are seeing peer services mature and take substantial roles in meeting our most pressing challenges. For example, NYAPRS is building upon our 15-year-old, nationally replicated Peer Bridger model that has helped thousands to successfully transition from state hospitals to the community. In partnership with OptumHealth, we are moving to offer Peer Bridging services to Medicaid managed care beneficiaries and Peer Wellness Coaches to what the state is calling ‘high needs, high cost’ individuals. PEOPLe Inc. has developed a peer crisis respite program that is being replicated across the state and nation. As healthcare systems seek to improve their outreach and engagement to people they're currently failing to serve adequately, peer services' appeal, effectiveness, mobility, and relative affordability will make it a critical component going forward.
You know, Harvey, it's sounding like you think New York could actually emerge from this crisis in better shape. Is that what you're thinking?
Harvey: Yes! If the budget crisis doesn't cause us to lose critical mental health funding, services, and staff, we should be able to come out of this more focused on recovery and offering better, more relevant, and more modern services.
What will you be happy to see disappear?
Harvey: I'd love to see an end to the perennial conflict and distraction [caused] by efforts to wrongly play up a violent image of people with psychiatric disabilities to expand the use of forced outpatient treatment initiatives like our Kendra's Law.
What do you worry about most?
Harvey: Our new vision depends heavily on the availability of affordable housing and employment opportunities. I worry that these will be challenging to develop and to make continuously available to people who use our services.
I am also concerned about our critical need to expand prison diversion, treatment, and re-entry initiatives, and to see cultural competence become heavily intertwined with recovery movements. Communities of color get prison and forced treatment in tragically disproportionate amounts. These present huge challenges that require a lot of collaboration and cooperation between state agencies.
What will the New York system look like in the future if you have your way?
Harvey: In the wake of national healthcare reform and mounting frustrations with our poorly coordinated, ‘siloed’ mental health, substance abuse, and healthcare systems, there are growing predictions about the end of public mental health systems as we know them. We should be working to help create skills and strengths-based systems that will integrate our best tools (wellness self-management, advance directives, peer services, employment readiness, and housing support) within the broader healthcare system.
Along the way, I'd love to see New York and other states adopt the new (1915.i) Medicaid home and community-based services option and extend waiver-like self-directed care with individualized budgets to people with psychiatric disabilities. That'd take us so far beyond the more passive, site-based, ‘chronic’ systems we still have today.
Well, there you have it: a state in turmoil with political and financial problems. But with a vision of recovery and committed mental health leadership at all levels, the transformation continues. Political and financial crises are the times when vision and leadership are most important, and Harvey has given us a picture of a state that will go forward in spite of very real difficulties. We thank Harvey for his hopeful perspective.
Lori Ashcraft, PhD, directs the Recovery Opportunity Center at Recovery Innovations, Inc. in Phoenix. She is also a member of Behavioral Healthcare's Editorial Board. William A. Anthony, PhD, is Director of the Center for Psychiatric Rehabilitation at Boston University. Behavioral Healthcare 2010 June;30(6):8-9