2006-2010 Statewide Comprehensive Plan for Mental Health Services
Chapter 5
Critically Examining Conceptual Domains, Goals and Objectives

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The first phase of the strategic planning cycle involves a critical examination by all stakeholders of the goals and objectives in the Strategic Plan. The purpose is to ensure their continued relevance and to make adjustments to the planning framework as indicated. In addition, refinements to the goals and objectives are made in the context of the environment in which OMH operates, including consideration of advances in best practices, treatment modalities, and trends and challenges.

This chapter focuses primarily on the stakeholder input in relation to the goals and objectives as well as refinements to the Plan based on this feedback. It also provides a brief analysis of trends and challenges informed by the literature and public mental health system operating environment. Such trends and challenges were considered in revising the goals and objectives.

Creating Conceptual Domains

Stakeholders noted the complexity and interrelated nature of the concepts addressed by the goals and objectives. They recommended clarifying the organizational schema by grouping related goals. Classifying the goals into groups based on common features resulted in the creation of three groupings or conceptual domains:

• Outcomes Domain goals include Goal 1, public mental health promotion and Goal 2, positive outcomes for children, families and adults.
• Mental Health Services Domain goals comprise Goal 3, research to practice, Goal 4, continuous quality improvement, and Goal 5, access to services.
• System Management Domain goals consist of Goal 6, service system capacity, Goal 7, accountability for results and a new Goal 8, care coordination (see below).

The national perspective on each of these domains and their related goals also supports the logic of the organizing framework. What follows is a discussion of the stakeholder input and a brief overview of national and State trends relevant to the domains and their goals.

Outcomes Domain

The goals in the Outcomes Domain (Table 5.1) relate to public health outcomes and individual outcomes. Attention to public health outcomes is a relatively new area of intervention by OMH and other state mental health authorities. The second area, however, has traditionally been a focus of the State public mental health system and is now marked by the development and implementation of relatively mature treatments and supports based on the best scientific evidence.

Table 5.1 - Outcomes Domain

Stakeholder input

Goal 1. As noted previously, stakeholders value the new emphasis by OMH on wellness, resiliency and public health. They strongly endorsed the agency emphasis on suicide prevention and affirmed the benefit of early identification and treatment of eating disorders. Additionally, it was noted that such public health education and awareness efforts should also extend to the provider community. Thus, the goal was modified to take into account the importance of broad education efforts, aimed at the public and providers of mental health services.

Stakeholders advised expanding the last objective under Goal 1 to incorporate other providers from whom consumers seek support, such as faith-based providers and this recommendation is now reflected in the Plan.

Stakeholders also identified a number of initiatives for the future, including targeted education and promotion campaigns related to recovery, stigma reduction, and the benefits of employing individuals with disabilities; increasing understanding of the interrelationship between mental health and physical health; and producing educational materials that are directed at older adults and designed to improve understanding of the value of peer services, and of issues faced by women with mental illness who have children or who are expecting.

Goal 2. This goal appeared as Goal 5 in the previous Plan. The care coordination objective that was part of this goal was moved to a newly created goal, Goal 8, at the recommendation of stakeholders. They urged this separate goal to ensure focused attention on the need for care coordination. Discussions regarding the importance of person-centered, recovery-based outcomes resulted in the creation of Aim 1, which is described in Chapter 4. Stakeholders also asked that Objective 2.1 be stated more clearly. It was revised to place emphasis on the use of mental health services that are based on the strongest scientific evidence.

Among the areas identified as high priority for stakeholders were holistic outcomes addressing important quality-of-life areas, consumer and family participation in identifying outcome measures, and measurement of employment outcomes.

National and State perspectives and trends and challenges related to Strategic Plan refinements

Goal 1. Results from research support the relationship between good mental health and overall physical health. An important aspect of producing positive outcomes for citizens of New York State, and among them, individuals who are diagnosed with serious mental illness, is the recognition that a public mental health approach is vital to broadening mental health awareness and improving public understanding about the prevalence, causes, effects and treatments of mental illness. Just as with other public education campaigns directed at the benefits of smoking cessation and regular physical exercise for optimal cardiovascular health, helping the public to appreciate the connection between mental well-being and overall health can lead to a healthier nation and to improved quality of life for individuals recovering from mental illness.

At the international and national levels, several calls to action underscore the critical nature of relying upon our growing base of biological, social and psychological knowledge as well as mental health resources to help address priority public health concerns. ^{1,2 ,3,4, 5} Coupled with these calls have been ongoing efforts at the state and local levels to respond to these public health challenges through targeted education and advocacy initiatives, including public messages aimed at conveying hope and reducing the stigma that often holds back individuals from seeking mental health care. At the Federal and state levels, suicide awareness and prevention efforts are a major focus of the public health mental health system.

Suicide has been referred to as a "silent epidemic" because many who attempt it are adept at hiding their psychic pain, because other people are often reluctant to inquire about a person's state of mind, and because it is prevalent. In the United States alone someone completes suicide every 17 minutes. In 2002, 31,655 Americans took their own lives and suicide was the third leading cause of death among youth and young adults of 15-to-24 years of age. Though suicide is a serious problem among youth and adults, the death rate from suicide continues to be highest among older adults ages 65 and over.⁶ Each year some 650,000 individuals receive emergency treatment for suicide attempts.⁷ In 2002, New York lost 1,292 lives to suicide;⁸ this number was only surpassed by five other states, including California, Texas, Florida, Pennsylvania and Ohio. For every death, there are scores of family and friends whose lives are devastated emotionally, socially and economically. As described previously in Chapter 4, suicide awareness and prevention is of high priority for New York State and currently an area of intense activity within New York's Local communities.

Goal 2. The structures, processes and outcomes of mental health treatment and support only began to receive close consideration in the early to mid-1980s.^9,10 Over the last 10 years, in particular, this attention has shifted at all levels of government from evaluating the performance of providers primarily through the measurement of "outputs" such as the number of individuals served in a program to assessing how individuals are doing as a result of the mental health treatment and supports offered.¹¹ In other words, the extent to which individuals are meeting their recovery goals is a primary focus of today's public mental health system.

Nationally, the Substance Abuse and Mental Health Services Administration (SAMHSA) has been collaborating with states to measure client outcomes and use this information to improve mental health services.¹² A web-based tool, the National Outcome Measures (NOMs), is being employed to aid policymakers and budget planners in making key decisions, using resources wisely, and improving the performance of the public mental health system, thereby enabling individuals to attain and sustain recovery. Launched in 2005, the NOMs initiative provides states with mental health and substance abuse prevalence, treatment and funding data and, as new data become available, it will offer cross-year comparisons to examine changes over time. The outcome measures in NOMs cover a limited number of domains, including evidence-based practices, employment and education, access and cost. The measures embody meaningful outcomes for individuals served. SAMHSA is striving to "achieve a performance environment with true accountability,"¹³ a direction also embraced by OMH.

The area of individual outcomes represents a traditional focus of activity within OMH. With the introduction of the Winds of Change campaign in 2001, OMH embarked on change strategies directed at building awareness through stakeholder collaboration; developing and implementing practices based on the best scientific evidence; incorporating quality measures to monitor performance; and sustaining change by using performance data to continually improve the quality of services and their outcomes. While considerable work remains, much progress has been made toward achieving Goal 2, which is now in the phase where performance information is being used systematically to drive accountability for results of mental health services and supports.

Recognizing the crucial role information plays in improving systems of care and producing the best outcomes possible, OMH has been capitalizing on the strengths of information technology to continue to build its performance management infrastructure and model reporting tools. It has also been participating in a number of national efforts to use data to improve decision making, most notably the Center for Mental Health Services Mental Health Statistics Improvement Program and the State Performance Indicator Pilot, and the Joint Commission of the Accreditation of Healthcare Organization ORYX performance measurement system. This work by OMH provides a strong foundation for its commitment to transform its public mental health system, relying largely on outcomes monitoring to drive positive change.

Mental Health Services Domain

OMH and major stakeholders have identified three areas under the Mental Health Services Domain (Table 5.2). They include three goals: research to practice, continuous quality improvement and access to services.

Stakeholder input

Goal 3. Goal 3, which was Goal 4 in the previous Plan, was revised slightly to acknowledge the contribution of clinical and services research. Importantly, the goal reflects the collaborative nature of research by including the consumer community's contribution to research findings that help to improve the overall quality of services. Overall, stakeholders expressed pleasure at the recognition in the 2005 Plan of the outstanding work of the Nathan Kline Institute and the New York State Psychiatric Institute. Moreover, stakeholders urged a continuing State investment in the important work of these institutions. Stakeholders also voiced approval for the Children's Research Symposium, which was coordinated by OMH, and affirmed the need to strengthen ties between the scientific community and the general public.

Table 5.2 - Mental Health Services Domain

Based on stakeholder feedback, minor revisions to the objectives were made for clarity. Objective 3.1 was expanded to specify the inclusion of treatment, and Objectives 3.3 and 3.4 were revised to acknowledge the importance of new treatments and service delivery models based on the best scientific evidence available. Wording in Objective 3.4 was also changed to clarify that "relevant" audiences are "key stakeholder" audiences. Objective 3.5 now stresses the need to provide technical assistance to providers and policy makers and Objective 3.6 makes explicit the involvement of stakeholders in assessing the social cost and burden of mental illness.

A future area of concern for stakeholders is the aging of the New York State population and the growing importance of research into geriatric mental health issues.

Goal 4. This continuous quality improvement goal was Goal 2 in the previous Plan. Underscoring the importance of person-centered, recovery-based goals to quality services, stakeholders urged the inclusion of a new objective. Objective 4.1 was added to underscore the importance of these views. Stakeholders also advised revisions to the remaining objectives to make explicit their link to evidence-based practices and to clarify the meaning of "capacity." Thus, service quality was emphasized in Objective 4.2, and the word "capacity" in Objective 4.4 was changed to "tools and resources" and in Objective 4.5 to "capability."

In looking toward the future, stakeholders affirmed the value of vocational training in helping individuals with mental illness to reach their fullest potential. Some also voiced support for Assisted Outpatient Treatment, suggested incorporating family psychoeducation into licensing and certification standards, and stressed the essential nature of cultural competence to the delivery of evidence-based practices.

Goal 5. This goal, which was previously Goal 6, was modified at the recommendation of the stakeholders to define "special populations" as those including individuals who are vulnerable and/or underserved. Moreover, the goal statement now reflects the concern expressed by stakeholders that all children with serious emotional disturbance and all adults with serious mental illness have access to appropriate and effective services.

Based on the recommendation of stakeholders to create a new goal addressing care coordination, OMH moved to Goal 8 the objective stating, "Improve the coordination of services for individuals who require intensive levels of care coordination, including people served by the SPOA system, ACT teams, and the Assisted Outpatient Treatment program."

Stakeholders also advised better defining the words "improving services" in each objective. The words "access to appropriate and effective services" were put in place of "improved services." Another suggestion for clarity that was acted upon included specifying other groups of individuals who are vulnerable and/or underserved: in Objective 5.2, children with serious and emotional disturbance and developmental challenges; Objective 5.8, individuals with co-occurring mental health and substance use service needs; and Objective 5.9, individuals with mental illness in need of access to safe and affordable housing.

Areas of priority identified by stakeholders included measurement of access to child and adult inpatient services, children's clinics, peer programs and supports, case management, and housing. Stakeholders also indicated that another important priority would be to measure access to all appropriate and effective services for individuals who are not eligible for Medicaid.

National and State perspectives and trends and challenges related to Strategic Plan refinements

Mental health treatment and support for children with serious emotional disturbance and adults with serious mental illness have been historically a major responsibility of state and local governments. And, as with this and any other major investment of resources by the government, attention has been increasingly focused on wise utilization of resources. The value of treatment and supports is evidenced by improved functioning, health outcomes and quality of life.

The implementation of scientifically based practices proven to be effective in producing better outcomes is one important approach to maximizing the value of these health care costs at the state and local levels. Through the implementation of these practices, individuals have been able to receive evidence-based treatments and services designed to ameliorate symptoms and improve daily functioning. Despite gains made, a substantial gap remains between clinical practice and treatment approaches based on firm scientific evidence.^14,15

The gap persists in part because of the time necessary for providers, as well as state mental health authorities, to become knowledgeable and skillful in providing evidence-based interventions; a lack of fiscal policies that hold practitioners and mental health authorities accountable for doing away with practices that do not help people and for providing evidence-based practices; and barriers to funding that make it difficult to provide evidence-based practices.¹⁶ Additionally, another factor contributing to the gap is the complexity of implementing evidence-based practices in real-world settings. The evidence base on successful implementation approaches, while not robust, is expanding and sustained efforts at improving knowledge, such as the "Implementing Evidence-based Practices Project" co-sponsored by SAMHSA and the Robert Wood Johnson Foundation, are continuing.¹⁷

Thus, in trying to close the gap between what has been learned through research and what is being practiced in clinical settings, state mental health authorities are being challenged. They not only face the responsibility for ensuring the provision of evidence-based practices, but also the elimination of treatments and services not scientifically proven to promote mental health and well-being. The process demands a level of accountability for results, mechanisms to foster the public financing of evidence-based care, systems for monitoring and measuring progress, and attention to continuous quality improvement. Importantly, the process also requires a focus on access to appropriate and effective services to enable individuals to achieve the best outcomes possible.

OMH's commitment to the process is exemplified in a number of ways. OMH has been an active participant in the development of the Evidence-based Practice Implementation resource kits for medication management, wellness self-management, and Assertive Community Practices. Through grant funding from SAMHSA, it is also actively evaluating cultural adaptations to the Family Psychoeducation Evidence-based Practice Implementation Resource Kit, which is described in Chapter 4 under Aim 3. Additionally, OMH created the AOT Quality Improvement Planning Panel in November 2005, which held its first meeting recently in New York City. The 16 members of the Panel represent a broad spectrum of stakeholder groups, and have a wide range of perspectives on how to enhance care and treatment for individuals who meet the criteria for AOT. During this kickoff meeting, the panel reviewed historical data on the operation of the AOT program and discussed future information needs for both effective implementation of the quality improvement initiative and for compliance with the new reporting and evaluation requirements contained in the five-year extension of Kendra's Law. The Panel also brainstormed more than 60 initial recommendations for possible quality improvement projects, focusing on such areas as standardizing AOT processes across the State; improving the clinical quality of AOT treatment plans; ensuring cultural sensitivity; combating stigma; increasing public awareness through education and outreach; and enhancing workforce development and retention. Next steps for the Panel include the development of a conceptual framework for quality improvement based on the initial recommendations, and prioritization of the various potential projects. At least four additional meetings will take place throughout 2006 to continue these efforts.

System Management Domain

Effective and accountable management of the public mental health system is at the core of the System Management Domain (Table 5.3). Service system capacity, accountability for results, and care coordination are the three main elements of the System Management Domain.

Stakeholder input

Goal 6. This goal was Goal 7 in the previous version of the Plan. Stakeholders advised clarifying Objective 6.1 to focus on the capability of these systems to provide appropriate and effective services; in Objective 6.3, expanding the description of "culturally competent" services to "culturally and linguistically competent" services; and better defining the phrase "articulate cost-effectiveness" in Objective 6.6. These refinements were made as suggested.

Areas identified as high priority for stakeholders included concern about the growing reliance on Medicaid reimbursement, the increasing number of individuals who lack health insurance, less availability of third-party insurance, and the adverse impact of Medicaid managed care. Stakeholders identified inpatient capacity, employment opportunities, housing, clinic capacity, children's services and transportation as priority areas for performance measurement.

Goal 7. Accountability for results was Goal 3 in the previous Plan. In this area, stakeholders described the planning process as improved, more open and transparent. Stakeholders supported greater accountability at the State and Local levels, the establishment of clear and measurable standards, and greater accessibility to data. Additionally, stakeholders endorsed efforts to infuse the planning process with performance data-driven processes.

Table 5.3 - Mental Health Services Domain

The objective in the previous Plan related to care coordination was moved from this goal and placed under Goal 8. Upon recommendation of the stakeholders, a new objective, Objective 7.4, was also added under this goal to indicate intent to improve the State and Local capacity for identifying and addressing disparities in access to and quality of mental health services based on culture, age and gender.

Stakeholders indicated that in the future, the statewide mental health planning process, including the identification of priorities, should continue to strive for greater community, County and regional input.

Goal 8. Stakeholders noted substantial opportunities to improve coordination at all levels of the public mental health system, between State agencies, County agencies, human service agencies and social services agencies; between providers; and between providers and government agencies.

An eighth goal, Care Coordination, was added to the Strategic Plan and two care coordination objectives previously appearing in the 2005-2009 Statewide Plan - 3.2 and 6.6 - were moved to Goal 8. These two objectives now appear as Objectives 8.2 and 8.3 in the revised Strategic Plan. A new care coordination objective was also been added, 8.1, which focuses on the specific care coordination needs of children and their families.

Among care coordination areas of priority, stakeholders identified care coordination for individuals with co-occurring disorders as a priority. This included individuals with co-occurring mental and physical health needs, co-occurring mental health and substance abuse needs, co-occurring mental health and developmental disability needs, and children with multiple systems needs.

National and State perspectives and trends and challenges related to Strategic Plan refinements

In its Interim Report to the President, the New Freedom Commission described our nation's mental health delivery system as fragmented and in disarray, causing unnecessary and expensive disability, homelessness, school failure and incarceration. It cited unmet need and impediments to care for children and adults with serious mental illness, high disability and unemployment rates for individuals with serious mental illness, and the necessity to promote mental health and suicide prevention efforts. Importantly, the Interim Report noted the needless waste of resources and lost opportunities for recovery.¹⁸

Preserving and building system capacity, managing resources effectively and efficiently, and streamlining and integrating operations to promote coordinated care are important to ensuring quality care and achievement of recovery goals. Strategies to integrate care at all levels of the system are key to serving individuals with the most serious illness, intervening early to detect and treat mental illness in early childhood, and elevating mental health as a national priority.

An important catalyst to managing the public mental health system effectively is a well-educated and prepared workforce. In today's work settings, providers face financial challenges in recruiting and retaining a qualified workforce, have insufficient training in evidence-based practices, and are given little incentive to change.¹⁹ Under such circumstances, mandating change is unlikely to lead to the uptake of evidence-based practices and quality improvements. Providing members of the workforce with opportunities and incentives to gain skills and knowledge about evidence-based approaches is another critical challenge faced by the public mental health system.

Programs such as the Home and Community-based Services Waiver for children with serious emotional disturbance and the innovative Western New York Care Coordination Program, a cross-County collaborative initiative to manage effectively and infuse performance and accountability principles and practices into community mental health settings, strive to provide effective care coordination. They are designed to empower service recipients and their families, effectively prepare providers with recovery-based skills and knowledge, enable proven clinical practices to be applied in the context of cultural and linguistic competency, permit the flexible allocation of resources based on the needs of individuals, facilitate care coordination among multiple providers, and promote active participation in the monitoring of clinical and service outcomes.

The process of formally hearing from stakeholders during the spring and early summer of 2005 and receiving feedback during other opportunities for input was fruitful and provided substantive contributions to strengthening OMH's planning foundation. (A copy of the full Strategic Plan is found in Appendix 1).

OMH is grateful for the seriousness with which individuals approached the public input process, is hopeful the new Strategic Plan accurately and completely reflects the complexity of thoughts and recommendations expressed, and looks forward to ongoing stakeholder engagement in future planning efforts. By continuing to capture a broad representation of perspectives and ideas, OMH is striving to ensure that the agency establishes priorities reflecting the importance of recovery and client-centered care for individuals and their families.

Chapter 6 describes the balanced scorecard approach used to examine areas of divergence between the Strategic Plan and national and State trends and challenges. It examines opportunities to foster alignment between the agency's goals and objectives and its activities. It also presents the strategic priorities that have emerged from this collaborative process, the initiatives selected and budgetary support recommended.

Notes:

1. World Health Organization. (2001). The World Health report 2001 - mental health: New understanding, new hope. Geneva: Author.
2. New Freedom Commission on Mental Health. (2003). Achieving the promise: Transforming mental health care in America. Final report. DHHS Pub. No. SMA-03-3832. Rockville, MD: Department of Health and Human Services, Substance Abuse and Mental Health Services Administration.
3. Office of the Surgeon General. (2005). The Surgeon General's call to action to improve the health and wellness of persons with disabilities. Rockville, MD: Department of Health and Human Services, Public Health Service.
4. Office of the Surgeon General. (1999). The Surgeon General's call to action to prevent suicide, 1999. Rockville, MD: Department of Health and Human Services, Public Health Service.
5. Office of the Surgeon General. (1999). Mental health: A report of the Surgeon General-Executive summary. Rockville, MD: Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health.
6. Centers for Disease Control and Prevention. (2005). Preventing suicide. Atlanta: Author, National Center for Injury Prevention and Control.
7. Institute of Medicine. (2002). Reducing suicide: A national imperative. Washington, DC: National Academies Press.
8. New York State Office of Mental Health. (2005). Suicide - Deaths and death rates per 100,000 residents from the 2000-2002 vital statistics data as of August 2004, age adjusted to the 2000 United States population. In Saving lives in New York: Suicide prevention and public health, Volume 3 data book. Albany, NY: Author.
9. McGlynn EA, Norquist GS, Wells KB, Sullivan G, & Liberman RP. (1988). Quality-of-care research in mental health: Responding to the challenge. Inquiry, 25(1), 157-70.
10. Salzer MS, Nixon CT, Schut LJ, Karver MS, & Bickman L. (1997). Validating quality indicators. Quality as relationship between structure, process, and outcome. Evaluation Review, 21(3), 292-309.
11. Institute of Medicine. (1997). Improving health in the community: A role for performance monitoring. Washington, DC: National Academies Press.
12. Substance Abuse and Mental Health Services Administration. (2005, July/August). Measuring outcomes to improve services. SAMHSA News, 13(4), 11.
13. See the SAMHSA National Outcomes Measures website at http://www.nationaloutcomemeasures.samhsa.gov/ .
14. Institute of Medicine Committee on the Quality of Health Care in America. (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academies Press.
15. Lehman AF, Steinwachs DM, & Survey Co-Investigators of the PORT Project. (1998). Patterns of usual care for schizophrenia: Initial results from the Schizophrenia Patient Outcomes Research Team (PORT) client survey. Schizophrenia Bulletin, 24(1), 11-20.
16. Lehman AF, Goldman HH, Dixon LB, & Churchill R. (2004). Evidence-based mental health treatments and services: Examples to inform public policy. New York: Milbank Memorial Fund. Available online at http://www.milbank.org/reports/2004lehman/2004lehman.html .
17. See the "Implementing Evidence-based Practices Project" web site at http://mentalhealth.samhsa.gov/cmhs/CommunitySupport/toolkits/employment/userguide/phases.asp .
18. New Freedom Commission on Mental Health. (2002, October 29). Interim report to the president. Available online at http://www.mentalhealthcommission.gov/reports/Interim_Report.htm .
19. Lehman et al. Evidence-based mental health treatments.

Comments or questions about the information on this page can be directed to the Office of Planning.