Practice Guidelines for Recovery-Oriented Care for Mental Health and Substance Use Conditions Connecticut Department of Mental Health and Addiction Services Second Edition—December 2008 Early Reviews of the Second Edition “These guidelines support the vision of transformation in the state of Connecticut. At a time when we are working to partner with people in recovery and their families, this document provides us with the directions as to how to move the system to the next level ... one in which there truly is a life in the community for all and where discrimination against those with behavioral health disorders is a thing of the past.” Pat Rehmer, Deputy Commissioner Connecticut Department of Mental Health & Addiction Services ~~~ “At a time when we are transforming mental health services toward a resiliency- focused recovery-based system of care, these revised Recovery Practice Guidelines are both timely and relevant. I was excited to be given the opportunity to preview them.” Colette Anderson, Chief Executive Officer Connecticut Department of Mental Health & Addiction Services Western Connecticut Mental Health Network ~~~ “I want to express my gratitude to … those who contributed to the DMHAS Practice Guidelines for Recovery-Oriented Care document. I certainly appreciate the time and effort dedicated to writing the guidelines and even more impressed with the attention given to culture and cultural competence throughout. This is an excellent piece of work that presents a win-win situation for DMHAS and the state operated and funded agencies.” Jose Ortiz, Director of the Office of Multicultural Affairs Connecticut Department of Mental Health & Addiction Services ~~~ “This document lays the foundation for building the bridge between treatment and the recovery community. Created by collaboration, it is a blueprint for making the necessary changes to become a recovery-oriented system of care. These Guidelines raise the bar to a new level, especially regarding housing and women’s services!” Barbara Geller, Director of State-Wide Services Connecticut Department of Mental Health & Addiction Services ~~~ “This document is an amazing contribution to Connecticut’s health care system and the field as a whole. The practice guidelines provide an integrated mental health and substance use framework in which high quality, recovery-oriented services are within reach for individuals with co-occurring disorders. The guidelines help us to be more informed as we work with people to make recovery happen.” Julienne Giard, Co-Occurring Program Manager Connecticut Department of Mental Health & Addiction Services ~~~ 1 “No right is held more sacred, or is more carefully guarded, by the common law, than the right of every individual to the possession and control of his[/her] own person, free from all restraint or interference of others, unless by clear and unquestioned authority of law.” — United States Supreme Court (Union Pacific Railway Co. v. Botsford) Prepared for the Connecticut Department of Mental Health and Addiction Services by the Yale University Program for Recovery and Community Health (Tondora, Heerema, Delphin, Andres- Hyman, O’Connell, & Davidson, 2008). 2 Foreword by Commissioner Thomas A. Kirk, Jr., Ph.D. The document that you are about to read continues the precedent set by the 2006 edition and remains an extraordinary tool in its origins, content, and value. This edition represents a truly giant step forward in our multi-year, systemic journey initiated in 2000 to create a recovery-oriented health care system in Connecticut. In this edition, we take the vision articulated in the first edition a couple of significant steps farther, in particular by building on important, cutting-edge work being done by several DMHAS workgroups that may, in the past, have been viewed as being on parallel tracks with the recovery initiative. This edition is intended especially to be responsive to the questions that have emerged over the last decade from practitioners, people in recovery, and others, as leaders in the Cultural Competence, Co-Occurring …these guidelines stress Disorders, Preferred Practices, Trauma, that it is at the level of each Gender, and Primary Health Care initiatives person served—in have been asked how their respective domains relate to the new recovery paradigm. This collaboration with his or revision was undertaken with this primary her family—that all of the concern in mind; that is, to “connect the dots” advances introduced over between these various initiatives and to the last decade come integrate them all within the overarching together in the provision of framework of a recovery-oriented system for recovery-oriented care. all of Connecticut’s citizens. The Introduction to this edition explains the thinking that allows for such integration. Fundamentally, these guidelines stress that it is at the level of each person served—in collaboration with his or her family—that all of the advances introduced over the last decade come together in the provision of recovery-oriented care. Since release of the first edition, this approach to integration has been articulated and promoted through adoption of Commissioner’s Policy Statement #33 requiring Individualized Recovery Planning. It is through the mechanism of an individual recovery plan that we ensure that in the care provided to each person and family: ⇒ practitioners are responsive to the person’s gender and cultural background; ⇒ practitioners assess for and are sensitive to histories of trauma; ⇒ practitioners are alert for identifying and addressing co-occurring conditions; ⇒ based on the informed decisions of the person and his or her family, practitioners employ the best interventions currently available; and ⇒ practitioners are attentive to medical issues and the impact of psychiatric medications on the person’s overall health and well-being. 3 In addition to incorporating standards from each of these initiatives and bringing them together in the service of supporting each person’s unique recovery, this edition of the practice guidelines is informed by the Institute of Medicine’s framework for ensuring quality care for mental health and substance use conditions. This framework emphasizes that quality care is safe, timely, person-centered, effective, efficient, and equitable, and is increasingly being adopted by health care systems across the U.S., as it embodies an important advance in increasing the quality and responsiveness of health care throughout all areas of medicine. In this edition, these domains have been integrated with the nine primary domains of recovery-oriented practice described in the first edition to yield a total of six domains. In a synergistic way, these domains take the IOM framework and adapt it specifically to the provision of recovery- oriented care; care that is provided in the community as well as in the clinic, and that takes as its first challenge engaging into trusting and caring relationships people who are at times reluctant and distrusting of health care in general, and of care for mental health and substance use conditions especially. The framework we established for the DMHAS recovery initiative was designed to involve six basic tasks, which we defined as follows: 1) developing core values and principles based on the input of people in recovery; 2) establishing a conceptual and policy framework based on this vision; 3) building workforce competencies and skills; 4) changing programs and service structures; 5) aligning administrative and fiscal policies; and, finally, 6) monitoring, evaluating, and adjusting these efforts.1 The first edition of the guidelines corresponded to the first three of these tasks, which were primarily carried out from 2000-2006. This second edition provides the road map for the remaining three tasks, which will be the focus of DMHAS efforts over the next several years. These guidelines will provide key directions Taken together, we believe for future efforts. To assist in the process of that all of these efforts and further system transformation, the guidelines will be supplemented by additional tools and tools, carried out and practice change strategies, including policy utilized in collaboration with development, changes in contractual language the recovery community, and expectations, the introduction of a highly public and private non-profit innovative, strength-based electronic recovery practitioners, and other management information system, and stakeholders, will result in a advanced training and education. Taken truly transformed system of together, we believe that all of these efforts care for mental health and and tools, carried out and utilized in collab- substance use conditions. oration with the recovery community, public and private non-profit practitioners, and other 1Davidson, L., Kirk, T., Rockholz, P., Tondora, J., O’Connell, M.J. & Evans, A.C. (2007). Creating a recovery- oriented system of behavioral health care: Moving from concept to reality. Psychiatric Rehabilitation Journal, 31(1): 23-31. 4 stakeholders, will result in a truly transformed system of care for mental health and substance use conditions. One in which we can all take considerable pride, but, more importantly, one in which any Connecticut citizen in need will find a welcoming, safe, and supportive environment filled with encouraging and skilled staff available and dedicated to helping them along the way. In the first edition, I mentioned that I believe that successful initiatives have a thousand fathers and mothers and