State Mental Health Policy: Maryland's Shared Leadership Approach to Mental Health Transformation: Partnerships That Work

In the mid-2000s, the New Freedom Commission and the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA) initiated state efforts to redesign publicly funded behavioral health systems to increase recovery orientation, evidence-based treatment, and self-directed care (1). They envisioned centrally administered reforms led by senior officials who were chosen and supported by the governor's office in each state. Maryland's transformation proposal stated, “[S]uccess or failure will rise and fall on the degree of strength and conviction of the Chief Executive” (2). Maryland's effort evolved in a way that was different from efforts in other states that received transformation funding. Maryland took a shared leadership approach that harnessed the power of leaders from all aspects of the community, with full support from the governor and his administration.

In this column, I describe several dimensions of Maryland's innovative reform: its process, the state's context, and the benefits of this approach and its risks in terms of potential disagreements between community leaders about the goals of the state transformation effort. Finally, I present an example of the shared leadership approach in action.

Early transformation grant leadership structure

In October 2005, Maryland became one of seven states to receive a mental health transformation grant from SAMHSA. As in other states that received such grants, the state's executive office created a transformation working group (TWG), which was originally composed of department heads from several executive agencies and key leaders from the advocacy community. As the grant required, the TWG began a year-long process to develop a comprehensive plan for mental health system reform in Maryland. During that year, however, it became clear that Maryland voters were likely to select a new governor from a different party, which would result in the replacement of almost all of the TWG's original members when the governor's cabinet changed.

Maryland's mental health community became frustrated with the grant's planning and implementation process. Stakeholders became dissatisfied with the development of a new comprehensive plan because they felt that Maryland already had a strategic direction and was losing valuable implementation time in designing a new one. In addition, the community viewed the process led by the governor's office as “top down” and especially frustrating in light of the anticipated change in state leadership. Furthermore, stakeholders felt that the TWG, with its composition of numerous department heads and only a few mental health advocates, excluded many mental health leaders. During the election season, the mental health community was vocal and united in expressing to both gubernatorial candidates its requests for a new process.

Responding to community concerns, the new governor and his administration agreed to significantly broaden transformation leadership. As a first step, the TWG was reconstituted; the format of an open town hall meeting was chosen in order to expand participation to anyone interested in working on the reform, including consumers, providers, family members, youths receiving services, and other advocates and community leaders. Building on existing plans and efforts, smaller working groups were created to implement initiatives that met the following criteria: readiness to begin work, community support, the mental health system's existing capacity to implement the initiative quickly, and prospects for the initiative's long-term sustainability.

The transformation effort intentionally built on existing state resources, mental health system strengths, and initiatives of state and local governments, providers, and stakeholders (3). Working groups chose initial projects with the greatest probability of success to build momentum before tackling more difficult issues. Responding to stakeholder impatience, the work of transformation initially focused on developing solutions to weaknesses and gaps in the mental health service system that had been identified in prior plans and needs assessments.

Maryland's approach and its advantages

Maryland's approach evolved into a shared leadership effort led by Daryl Plevy, J.D., with support from the new governor (personal communication, Nov. 2010). In 2007, Ms. Plevy was appointed director of the Maryland Transformation Office and tasked with harnessing existing efforts and identifying leadership at all levels, with a view toward maximizing change. A shared leadership approach was a natural fit for Maryland—a state that has a long-term stable leadership at the provider and stakeholder levels. As a result of long-term relationships among many key players, a high level of agreement existed about transformation priorities. Since introduction of managed care in the 1990s, Maryland's behavioral health system has embraced change positively and has viewed change as an opportunity for system improvement. In sum, there was little resistance to using transformation grant funding to reform the behavioral health care delivery system.

The shared leadership approach in action

Workforce-related issues came up frequently in previous state mental health plans and in community feedback during the first transformation year, October 2005–September 2006. Stakeholders expressed a need for greater understanding of the challenges facing consumers of community-based services who wanted to enter the workforce. The TWG worked with stakeholders to identify an organization with workforce knowledge. The Sar Levitan Center at Johns Hopkins University is a social policy group with expertise in improving workforce prospects of marginalized populations, such as ex-offenders and out-of-school youths, and the center became a contractor for transformation efforts. As a first step, the Levitan Center conducted 27 focus groups in 2008–2009 across the state with consumers, providers, and families to learn more about mental health system issues (personal communication, M. Pines, Levitan Center, Nov. 2010). Focus groups specifically identified returning consumers to the labor market as an area in need of rethinking because of widespread misconceptions among all stakeholders about labor market functioning and ways to surmount particular barriers experienced by consumers. From these efforts, a project evolved to expand consumer knowledge about labor markets and employment options with the goals of improving employment prospects and increasing income.

Efforts to promote consumers' interest in work were based on Maryland's existing strength in evidence-based supported employment, which the state has delivered since 2002, achieving consumer employment rates as high as 47%—among the best in the nation (4). Before the transformation grant, Maryland institutionalized delivery of high-fidelity supported employment for participating providers through an infrastructure redesign, creation of a single point of entry, incentive payments to programs with high fidelity, and braided funding from the state, Medicaid, and the Division of Rehabilitation Services.

Through the focus groups, the Levitan Center gained a greater understanding of barriers to consumers' reentry into the labor market. First, many consumers feared entering the workforce because of misinformation about the potential negative effect on their income, housing, and medical benefits. Second, they needed information to better understand the employment market. Third, they were often unaware of other local resources and experienced difficulty accessing existing employment training resources.

Staff of the Levitan Center and members of the Maryland Consumer Leadership Coalition (the coalition), who had been already been meeting separately since 2007 to establish guidelines for consumer workforce development and to improve rates of consumer employment, joined together to explore ideas and approaches for improving consumer knowledge and access to employment opportunities. In discussions with the Levitan Center, the coalition articulated consumers' needs to understand the nonfinancial benefits that accompany employment, such as motivation, self-esteem, and social contacts. These initial meetings involved frank discussions between the two organizations and other workforce groups about mission, workforce issues, and expertise, as well as relevant funding and regulatory issues. These discussions increased each organization's understanding of the other's work and of the potential benefits to be gained from collaboration and set a solid foundation for new efforts and long-term sustainability.

The position of peer employment resource specialist (PERS) was developed to recruit and train consumers to guide unemployed consumers in labor force reentry, help them access existing job search and training resources, and create a career path for consumers. The core idea was to involve consumers who were already a part of On Our Own of Maryland or other consumer-run programs.

Staff of the Levitan Center, working alongside consumer leaders, created a comprehensive manual and program to train consumers serving as PERS in providing information, advice, and support to other consumers. The 123-page manual and the associated intensive training, which involved workforce experts and consumer-trainers, reflected the Levitan Center's research-based knowledge of critical elements for successful employment efforts: placing consumers in good jobs, seeing consumers as primary customers and using their needs to drive the program; and recognizing employers as customers equally important as consumers (5).

To educate consumers about the potential impact of work on benefits, the PERS initiative explained the impact of monthly pay on income supports, explained where to find the formula describing the amount of money that can be earned while maintaining benefits, and noted that a Social Security Administration employment specialist was the best source to determine actual impact. To understand employers' needs, the consumers trained as PERS were encouraged to establish relationships with local businesses and economic development officers and learn about labor market needs. To expand the use of existing resources, this initiative identified and explained the assistance available from the state's vocational rehabilitation program and from community organizations in the areas of human resources, education, and workforce development.

Responding to recommendations from the coalition, the transformation initiative contributed resources for the Levitan Center and the coalition to develop a manual and a comprehensive PERS curriculum to train consumers in the new role. Two-day training sessions have occurred at several locations in the state, and as of April 2012 nearly a hundred consumers had been certified as PERS. The inclusion of a consumer-presenter who discussed his or her own fears and concerns about returning to work and a benefits counselor who explained the potential financial impact and answered questions from training participants on their individual situations became important parts of the training. Based on the requests of trained PERS, several additional one-day, in-depth, topical training sessions were provided with the goal of continuing to assist them with the deployment of the skill set to be effective employment advocates.

The PERS manual explained the step-by-step process for enrolling consumers in the Maryland One-Stop Career Centers. These centers are the primary workforce investment resource for the public, but few consumers had been successfully accessing the system. The workforce system was also interested in improving consumer participation. Interviews conducted by On Our Own of Maryland and the Consumer Quality Team of Maryland identified consumer frustration with the initial computer-assisted intake at the One-Stop Career Centers as the principal barrier to completing the intake process.

Discussion

The SAMHSA transformation grant ended in 2011. The state is optimistic that the shared leadership approach will ensure that many of the projects initiated under the grant will be sustained. The SAMHSA transformation grant accelerated existing change initiatives within the publicly funded behavioral health system. Grading the States, the report of the National Alliance on Mental Illness, indicated that Maryland's grade in the category of recovery supports, which includes supported employment, increased from a C- in 2006 to a B in 2009 (6,7). A state survey of consumers also indicated consumers' self-rating of that recovery and resilience increased by 5 percentage points compared with an increase of 1 percentage point for consumers in other states that received transformation grants (8).

The shared leadership approach, in which public and private organizations at all levels played leadership roles in various initiatives, evolved in response to the mental health community's requests for a greater role in the transformation initiative and resulted in innovative solutions. States without stable leadership within provider and stakeholder communities or those lacking strong agreement among stakeholders and elected officials on the reform's goals may not have similar experiences. However, this approach worked for Maryland. The state's experience showed that successful collaborative efforts spanning public agencies require ongoing support from an organization with relevant expertise, staff time, and financial resources to bring the parties together and then help design and implement the effort. Using this approach, the state gained new and viable products and resources that addressed the needs of consumers and other stakeholders: a curriculum manual for PERS and a new career path for consumers as PERS, with more than 100 consumers trained as PERS. In addition, the shared leadership approach tapped into existing resources, such as the One-Stop Career Centers, and expanded existing efforts by including new partners, such as the Levitan Center.

Ms. Plevy, transformation leader, stated that the long-term sustainability of the initiatives begun under the reform is built on a key principle: to determine what works to each system's advantage, leaders need to know how each system defines success and then base their work on areas where there is an intersection of interests. If projects are developed in this way, there is a better chance for leaders to leverage resources and improve the service delivery system, thus enhancing the chances for sustainability.