Building a Recovery-Oriented System of Care

Session # CIa
October 28, 2011
10:30 AM
The Philadelphia Story Continues: Building a
Recovery-Oriented System of Care (ROSC):
a fully collaborative model of integrated care.
Sean Gallagher, PhD, Network Development, Community Behavioral Health, Philadelphia
Department of Behavioral Health and Intellectual disAbility Services. (email at
[email protected])
Nancy P. Hanrahan, RN, PhD, Associate Professor, University of Pennsylvania School of
Nursing. (email at [email protected])
Matthew O. Hurford, MD, Chief Medical Officer, Community Behavioral Health and Special
Advisor to the Commissioner, Philadelphia Department of Behavioral Health and
Intellectual disAbility Services. (email at [email protected])
Collaborative Family Healthcare Association 13th Annual Conference
October 27-29, 2011 Philadelphia, Pennsylvania U.S.A.
Faculty Disclosure
We have not had any
relevant financial relationships
during the past 12 months.
Learning Assessment
As part of the Panel Presentation, the presenters
have reserved 15 minutes in a Question and Answer
section to maximize the learning opportunity
through greater interaction, clarifications and
exchange of ideas.
Please hold all questions until the Q and A section.
Learning Objectives
List the core values of a Recovery-Oriented System of Care
Describe the relationship between collaborative care and
recovery-oriented care
Describe a Person-Directed approach to treatment
Identify Tools for System Transformation
Expected Outcomes
Increased understanding of integrated healthcare practice
using and expanded view of collaborative care
Increased knowledge about the transformation of large
behavioral healthcare system towards a RecoveryOriented System of Care (ROSC)
Review of research project in an acute care setting that is
reflective of a ROSC.
Practice Gap & Supporting
Philadelphia has been engaged in a System Transformation
process since 2005 that focuses on developing a RecoveryOriented System of Care (ROSC)
This transformation has impacted every aspect of system
operations; including treatment provision, policy
development, stakeholder training, business practice, and
funding strategies.
A detailed documentation of this process can be found on
our website at where an extensive
section on the Tools for Transformation is available for
review and download.
Collaborative Care
Sean Gallagher Ph.D.
Network Development
Community Behavioral Health
Department of Behavioral Health and
disAbility Services
Philadelphia History of Recovery
1776 - Declaration of Independence
written and signed in Philadelphia. This
document upheld that all Americans have
the “the right to life, liberty and pursuit of
1792 – Dr. Benjamin Rush, the “Father of
American Psychiatry” built a wing in
America’s first hospital to “provide
humane care to persons suffering with
mental illness”.
1817 – Friends Hospital was the first
private mental hospital in the United
States, developed by the Quakers “to
facilitate the recovery of agitated minds”
Integrated Healthcare - 2010
CFHA’s 2010 Conference on Remaking National Healthcare
examined integrated healthcare in various ways, presenters
offered innovative ways to increase the level of collaboration
with other healthcare professionals in a effort to improve
healthcare delivery.
Philadelphia’s Health Federation and the Department of
Behavioral Health presented a five year pilot project to
develop an integrated treatment model in several urban
Federally Qualified Health Centers.
The outcome is a promising integrated healthcare team
approach that includes a behavioral health consultant as a full
member of the team who provides timely/targeted strategies
offering BH resources/supports in real time.
Collaborative Healthcare - 2011
In reviewing, the 2010 CFHA conference on collaborative
and integrated care, a key element was often absent. In
Philadelphia, this key element has become a focal point.
This key element, once included, dramatically changes the
dynamic of collaborative care as it is typically constructed.
Integrated healthcare cannot be truly collaborative until
the recipient of the healthcare service becomes a fully
recognized and active partner in the planning and delivery
of services.
In Philadelphia, providing person-directed care is the
main reason for developing a Recovery–Oriented System
which can then achieve a fully collaborative model.
Recovery Transformation
Matthew O. Hurford, MD,
Chief Medical Officer
Community Behavioral Health
Special Advisor to the Commissioner
Philadelphia Department of Behavioral Health
and Intellectual disAbility Services
Transformation towards a
Recovery-Oriented System of
Care (ROSC)
Aligning Concepts:
Changing how we think
Aligning Practice:
Changing how we use language
and practice at all levels;
implementing values based
Aligning Context:
Changing regulatory environment,
policies and procedures,
community support
Ten core values that have guided the
development of transformation principles and
strategies, and will continue to guide the
implementation process;
Four service domains in which the strategies
will be carried out; and
Seven system goals: concrete, action-oriented
goals that organize and focus the strategies.
Strength-based Approaches that Promote Hope
Community Inclusion, Partnership and Collaboration
Person and Family-directed Approaches
Family Inclusion and Leadership
Peer Culture, Support and Leadership
Person-First (Culturally Competent) Approaches
Trauma-informed Approaches
Holistic Approaches Toward Care
Care for the Needs and Safety of Children and
Partnership and Transparency
Assertive Outreach & Initial Engagement
Clinical Services: Screening, Assessment,
Service Planning & Delivery
Continuing Support & Early Re-intervention
Community Connection & Mobilization
Seven System Goals
Integrate Behavioral Health, Primary Care and
Recovery Support Services
Create an Atmosphere that Promotes Strength,
Resilience and Recovery
Develop Inclusive, Collaborative Service Teams and
Provide Services, Training and Supervision that Support
Recovery and Resilience
Provide Individualized services to Identify and Address
Promote Successful Outcomes through Empirically
Informed Approaches
Support Recovery and Resilience Through Evaluation
and Quality-improvement Processes
Developing a Transitional Care
Model for Serious Mental
Nancy Hanrahan, PhD, RN
Phyllis Solomon, PhD
Matthew Hurford, MD
Purpose: Modify and test the feasibility of a
transitional care model for serious mental illness
Study participants:
Age 18>
Patient at Pennsylvania Hospital; consented
Primary psychiatric condition + Major medical problem
Intervention: 90 days of post-hospital service with a
psychiatric nurse practitioner.
Outcomes: reduce readmissions, provide timely
physical and mental health care, bridge complex
systems of care.
Advisory group of key stakeholders
Pilot random controlled study
20 control and 20 intervention
Control: treatment as usual
Intervention: Psychiatric nurse practitioner (NP)
Meet in hospital
Home visit within 48 hours
Phone calls as needed
Medication management
Attend appointments
Education for client and non-mental health providers
Therapy: brief, problem focused
Recovery principals
Early Observations
NP interventions are needed and to avert
High demand for accurate translation of client
information among providers
Interpret health and mental health care needs
Provide education and counseling (client, CM,
Timely assessment and treatment of immediate
health care needs.
Higher rates of rehospitalization than expected
Note: this study is not completed and observations are thus
likely to have some degree of bias
Preliminary Thoughts
Rehospitalizations are due to complex social
circumstances (i.e. homelessness & poverty)
Blend Transitional Care Model with strong
social service component.
Psychiatric Nurse Practitioner
Case Manager
Peer support
Silos of Systems: SOS campaign
Session Evaluation
Please complete and return the
evaluation form to the classroom monitor
before leaving this session.
Thank you!

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