New Research: State/Local MH Program Directors Have High Hopes for Impact of Self-Direction

NYAPRS Note: Just out: a team from the Human Services Research Institute, Boston College School of Social Work, and the University of Maryland School of Public Health has released research they conducted on self-direction with groups of state and local mental health program directors associated with the National Association of State Mental Health Program Directors and the National Association of County Behavioral Health and Developmental Disabilities Directors. 
Under this model, “individuals who use publicly funded mental-health services, and who have an interest in selecting their recovery supports, develop a person-centered plan and make use of a flexible budget to purchase goods and services to meet their long-term health and wellness goals.”The respondents concurred about the potential for self-direction to improve systems through “the introduction of new market dynamics through enhanced participant choice and spoke of its potential to rebalance services and supports from costly and undesirable inpatient and emergency interventions to community-based services and supports.” They also endorsed the critical value of choice and self-determination and underscored the important role that peer-run agencies can play.

Comments: Giving control and choice to recovering people to purchase the goods and services they need to advance their health, recovery and lives in the community has long been a very high priority for NYAPRS, which is why I recently agreed to chair the Mental Health Self-Direction National Advisory Committee. Data from peer supported self-direction programs has shown that people often use these funds to advance their wellness (joining health clubs), health (making use of alternative methods of treatment and getting dental care) and employability (computers and routers to apply for jobs; assistance with resume prep and benefits advisement and new clothing to prepare for interviews; access to transportation (mass transit passes) to get to and from work.
New York State is becoming a leader in this area since self-direction is one of our approved Medicaid Home and Community Based Services that is currently being piloted in 2 areas and is slated to come online for all HCBS enrollees in the coming year or so.

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MENTAL HEALTH LEADERS’ VIEWS ON SELF-DIRECTION

What do mental health program directors around the nation think of self-direction, and what do they see as likely to help or hinder its adoption? 
Self-direction is emerging as a promising model of service delivery for people with serious mental health conditions, and one that aligns with the federal focus on individualized, person-driven care to effect recovery. Under the model, individuals who use publicly funded mental-health services, and who have an interest in selecting their recovery supports, develop a person-centered plan and make use of a flexible budget to purchase goods and services to meet their long-term health and wellness goals. But what impact will self-direction have on the mental health system in general, and how do state and county program directors view it? We conducted an exploratory survey (n = 46) and interviews (n = 17) with program directors to find out.

Self-Direction marks a paradigm shift from existing service system arrangements, shifting control over public resources to individual participants rather than reimbursing traditional providers for services they render. Mental health program directors hold a pivotal role in self-direction’s adoption and implementation, so we wanted to gauge their interest and understand their views on this emerging practice.

The Study. Working with two national organizations representing state and county mental health directors, we offered an informational webinar on self-direction to mental-health program directors. All 84 attendees (representing 35 states and DC) were invited to take an online survey immediately after the webinar. Of the 46 survey respondents, 29 agreed to a follow-up interview with our research team. In total, 17 interviewees were successfully contacted and interviewed.

Results. A strong majority (87%) expect self-direction to have either a high or moderate impact on the mental health system in coming years. Three-quarters indicated self-direction as either a high or moderate priority for their agency, and over three-quarters associate self-direction with such benefits as stronger service user choice and voice, greater flexibility, enhanced recovery, increased community integration, and improved service quality. When asked to rate factors that will help facilitate self-direction, nearly all respondents (98%) rated its emphasis on self-determination and recovery as important; 42% rated service user interest/demand as important, and 40% rated its cost-effectiveness as important. When asked to indicate barriers to the adoption of self-direction, 54% rated “less control for providers” as a challenge, and 32% rated “less control for payers” as a challenge.

Discussion. Respondents pointed to the potential for self-direction to improve systems through the introduction of new market dynamics through enhanced participant choice. They spoke of its potential to rebalance services and supports from costly and undesirable inpatient and emergency interventions to community-based services and supports. However, interviewees were unclear to what extent these benefits might be realized because self- direction has yet to be taken to scale in a mental health context.

Additionally, the availability of recovery- oriented services and potential cultural barriers such as doubt about the choice- making capacity of persons with serious mental health conditions could impede adoption. To successfully implement self- direction, leadership will likely need to build the capacity for appropriate services and supports and implement training to challenge perceptions about participant capacity for choice and recovery. Peer-run organizations and enhancing the visibility and role of people with lived experience in the mental health system may support the success of these efforts.

Conclusions. Adoption and successful implementation of self-direction appears to hinge on several important facilitators. First, findings suggest self-direction is most likely to take root in a system that is sufficiently recovery-oriented—with a well-developed peer support workforce and a robust network of community-based supports for housing, employment, and community inclusion. Strong leadership—particularly among policymakers, advocates, and administrators who can act as change agents for self-direction—is also important. Clear and actionable implementation guidance is critical. Finally, effective communication of outcomes research paired with personal stories that bring data to life will promote the adoption and ongoing support for mental health self-direction.

KEY POINTS
o Mental health program directors are interested in implementing self-direction and have high expectations for its impact on systems and individuals.
o Successful implementation hinges on several key factors: a true recovery orientation, effective grassroots advocacy, strong leadership, implementation support, and the ability to clearly communicate its outcomes.

For more information. See Croft, B., Simon-Rusinowitz, L., Loughlin, D., and Mahoney, K. “Mental health leadership perspectives on self-direction,” published online in the journal Social Work in Mental Health on December 4, 2017. Available at: https://doi.org/10.1080/15332985.2017.1395783.
Or contact the first author. Bevin Croft (bcroft@hsri.org) is a research associate on our Behavioral Health team.
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