Commentary: States That Learn Resilience Need Not Fear Reform

I am pleased to have an opportunity to provide a commentary on the column "It's Never Too Late to Do It Right: Lessons From Behavioral Health Reform in New Mexico" in this issue of Psychiatric Services ( 1 ). In the column Dr. Willging and Mr. Semansky describe a transformation initiative directed by the state's Interagency Behavioral Health Purchasing Collaborative (IBHPC), of which I am chief executive officer. Reflecting on the authors' perspectives has been useful, frustrating, inspiring, and perplexing. It has reminded me that the many stakeholders involved in large-system change bring with them a multiplicity of beliefs and experiences and that their perceptions of what is happening may vary dramatically—somewhat like the three blind men who describe an elephant from touch alone, each with very different and clear perceptions of what the elephant looks like on the basis of personal experience. One role for state behavioral health leaders is to connect all those perceptions into a whole.

Dr. Willging and Mr. Semansky focus primarily on the administrative elements of behavioral health system transformation in New Mexico and the challenges that have been encountered in developing administrative processes that would reduce administrative burden for provider agencies, particularly in underfunded rural and frontier environments; improve bottom-up as well as top-down communication; and establish evaluation procedures that can provide early warning of problems in service delivery. The IBHPC readily acknowledges the presence and importance of the challenges that have been encountered in these administrative domains, although we may differ from the authors in regard to some specifics.

The IBHPC believes that it is important that readers be aware that the goals of behavioral health transformation in New Mexico are much broader and more complex than improving administrative structures and protocols. New Mexico seeks to bring about a cultural shift to resilience and recovery in all aspects of behavioral health—that is advocacy, practice, evaluation, accountability, community empowerment, workforce development, and, most important, consumer and family engagement and involvement. We want our system to change so that the support of recovery and development of resilience are expected, mental health is promoted, the adverse effects of substance abuse and mental illness are prevented or reduced, behavioral health care consumers are assisted in participating fully in the life of their communities, and funds for programs and services are managed effectively and efficiently. I invite readers to share our journey by visiting the IBHPC's Web site at www.bhc.state.nm.us/index.htm .

This commentary offers an overview of some of the more important lessons learned in New Mexico. There are three salient lessons that I believe provide the most meaningful learning opportunities for New Mexico and for others who may embark on similar journeys. First is the importance of managing expectations as we seek to implement a broad and sweeping vision, not only for reform but also for transformation, and of recognizing that it takes time to bring about change, even when it is desired and supported at community and state levels. Second is the critical need for constant communication that keeps the context for change events in clear focus so that people do not jump to conclusions about motives and do not become fearful about administrative or program changes, especially in the midst of the daunting task of developing local voice and direction for behavioral health care in a rural and frontier state. Third is recognizing the inherent tensions in system transformation; for example, bringing about changes in the right way is important, but the need to strike while the iron is hot is often the case in government; reducing administrative burden is necessary but so is ensuring quality improvement and encouraging local engagement in what is fundamentally a centralized administrative structure. There are lessons for the field in each of these challenges.

Do not fear high expectations

Managing complex operations and projects is challenging, but the essential leadership challenges for New Mexico are to address the expectations of the many people who share a vision of system change. Some feel the changes are too slow, too fast, at the wrong time, or not visible enough on the ground where people live and where illness and care interact. Participation means consultation to some and shared decision making to others. Expectations of communities, clients, and providers may bolster each other at times and conflict at other times. State leaders have encouraged high expectations in New Mexico by creating a new dynamic of collaboration among state agencies through establishing the IBHPC and by inviting community collaboration through 18 local collaboratives of consumers, families, and providers.

As in most states, New Mexico had a small mental health planning body. The state now has a Behavioral Health Planning Council of 45 consumers, family members, providers, and advocates, who express both statewide concerns and the concerns of the local collaboratives. The state is also refining and expanding the ways that it works with providers. For example, the newly designated core services agencies have begun meeting regularly to engage in collective learning and share best strategies for implementation. In addition, these providers meet monthly with state officials to discuss policy and practice issues. They also participate in an integrated training workgroup, which advises the IBHPC on the best models for delivery of needed technical assistance and training in core competencies. These structures are certainly not perfect, but they do offer new opportunities for meaningful engagement in IBHPC's vision and opportunities for the IBHPC to learn about the expectations of New Mexicans who are involved in behavioral health system change.

An important part of the context in which the IBHPC works toward its vision and a message that it continues to emphasize is that this transformation is a ten-year process. Along this journey the road curves and the pace alters, and advocates like Dr. Willging and Mr. Semansky can understandably grow frustrated with those curves and changes in momentum. However, each year the state has seen growth in the empowerment of local collaboratives and the Behavioral Health Planning Council. For example, the local collaboratives have formed a group that is specifically working to ensure their sustainability when funds from the Mental Health Transformation State Incentive Grant end. The IBHPC has responded to Native Americans in New Mexico by adding three additional local collaboratives to represent their interests. And the Behavioral Health Planning Council now focuses its work through five dedicated statutory subcommittees with specific work priorities. Just as individuals in recovery require higher expectations in order to change their lives, we must move forward without fear of high expectations in order to bring about transformation in New Mexico, and we must learn how to constantly communicate with all stakeholders about our setbacks and successes.

Communicate, communicate, communicate

Communication is easier when a major change process is beginning or as goals are approached and successes are evident. It is more difficult during the middle of a ten-year process, in the place where inspiration and cause for celebration are less evident and the hard work to implement a vision is occurring on multiple fronts. R. M. Kanter ( 2 ) of the Harvard Business School has called the place where New Mexico stands in its transformation process "the miserable middle," reminding us and other organizations that embark on such a system change that everything looks like a failure in the middle. This is the place where the detailed, complex work takes place, and everyone sees that it is harder to do than most expected.

The IBHPC finds that communication is especially important five years into this change—communication about the hard work as well as about the successes. A commitment to quality improvement necessarily raises new fears as well as new hopes, especially during a major system transformation. Consumers and providers across New Mexico have embraced the pilot phase of a quality service review process, have appreciated the locally driven protocols of this process, and have encouraged the IBHPC to find ways to expand the use of that process to drive practice change that is oriented toward recovery and resilience. In communicating the success of the pilot phase to other communities, the IBHPC has used video clips of consumers and providers as well as written materials. We learned that written communication, however accessible, is only one mode of communication and needs reinforcement through face-to-face discussions, relationship building, and expanded opportunities to share ideas and critiques as we move into the full-implementation phase.

In the middle of this transformation period, the IBHPC has also had lively and positive interactions with the legislature's interim committees about the performance of the new Statewide Entity (SE)—OptumHealth New Mexico. Dr. Willging and Mr. Semansky's column leaves the impression that the IBHPC took action to address provider complaints about claims processing and slow payment by the SE only as a result of the legislative hearings in October and November 2009. That is not the case; the IBHPC had been taking action for months before the hearings. This is a good example of the perception and communication challenges. Not all communication is readily visible or noticed, even in the most transparent of systems. In fact, before the legislative hearings the IBHPC met regularly with providers; notified legislators of provider complaints and the concerns of the Oversight Team, which is staffed by personnel from multiple state agencies; brought in consultants to assess the SE's system issues; held a variety of meetings with corporate leaders and the Governor's office; and required the SE to submit a corrective action plan. A formal sanction letter was delivered to the SE at the end of October 2009. Whereas monetary sanctions were imposed on the previous SE in the third year of its contract, this sanction took place only four months into the new contract. This quick response was possible because of significant improvements in the IBHPC's internal communication as well as in contract oversight functions.

I agree with the authors that early warning is important. However, rather than rely on a particular information technology system, the IBHPC constructed a number of ways to monitor the contractor. In addition to reviewing regular reports and data, we listened to the complaints of providers, talked with provider associations, set up a command center with the SE to address current concerns on a daily basis, and developed tracking systems for the multiagency Oversight Team. These intense communications led to both a sanction and a directed corrective action plan for the current SE. Out of this process, we believe we have established more effective and timely reporting of claims and other data.

In recognition that a wide range of stakeholders wants to know what is happening in our constantly changing environment, the IBHPC re-established a communiqué in March 2010, called "In the Know." Twice a month I write a brief e-mail message to all stakeholders about the latest issues, concerns, and events and provide a rationale for the IBHPC's current actions. The content is also posted on the IBHPC Web site ( www.bhc.state.nm.us/bhnews/newsletterintheknow2010.html ). It provides the opportunity to highlight issues or actions that would otherwise get lost "behind the scenes." So far, the feedback has been good, and I think it helps address the challenge of managing expectations. Readers of this commentary can expect that communication, both internal and external, will be an ever-present challenge in system transformation.

Always remember that tensions are not failure

Any endeavor to transform a complex system will highlight inherent tensions and generate new ones. The column points to a few examples of inherent tensions in the administrative realm. Dr. Willging and Mr. Semansky criticize the IBHPC for using top-down processes. Certainly there are more top-down processes than we would like. We believe in the correctness of one of the guiding principles established by the Substance Abuse and Mental Health Services Administration: transformational change must be accomplished from top-down and bottom-up processes simultaneously. Readers who work in state government know that part of our job is to continually balance a tension between acting when there is a hot-iron opportunity to advance our aims and introducing a change in a more comfortable and gradual manner that may be the right way in a theoretical sense. Another example of the inherent tensions we experience is between efforts to improve quality and to reduce administrative burden. The latter is rarely an isolated goal and can appear to conflict with quality goals. Improved reporting requirements may be needed to improve the quality of care. Changes in administrative requirements may offer needed data to support and evaluate efforts to change practices or practitioner behavior. We share the frustration felt by many that administrative challenges still exist, but we balance that frustration with the hopes that spring from seeing each small and large change in practices that affect consumers and families and that move us closer to our recovery and resilience goals.

Another tension in New Mexico is that we are encouraging local engagement in what is a fundamentally centralized administrative structure. New Mexico is predominantly a rural state in which behavioral health is not a county-run service system. Changes in practices and administrative processes in New Mexico often need significant state support, which can be experienced as top down. The IBHPC has therefore chosen to focus its attention on receiving bottom-up feedback on state initiatives from local collaboratives, the Behavioral Health Planning Council, and provider groups. The current focus on establishing core services agencies includes multiple mechanisms for feedback and advice from providers on implementation.

I wholeheartedly agree that with more resources the IBHPC would—and would want to—offer more supports for implementing changes. As we engage in the hard, complex work in the middle of this transformation, we know that we must not regard tensions as failures, and our success will come from making effective use of both open conflict and open collaboration.

Practice resilience

A final word to our colleagues is to practice resilience in the face of the multitude of challenges that invariably accompany major system change. Even the most optimistic of change champions will feel anxiety in the miserable middle of a transformation. New Mexico is a state with a rich history of resilience, in its cultures and peoples as well as in the inspiring lives of behavioral health clients. What we learn from the people we serve and from each other is that this time in the middle is a time to renew our investment in the principles that underlie transformation and to carefully note signs of hope.

I see many signs of hope in New Mexico. The IBHPC continues to build processes, routines, and structures that will sustain transformation and remain long after current teams and players are gone. We work under a state statute that holds us to a long-term commitment. We are rebalancing the children's behavioral health system to reduce dependence on out-of-home care, and we are working with communities to develop both child and adult systems of care. We are working to implement a strong supportive housing plan and are seeing its fruits in excellent relationships with the state housing authority and with the new local lead agencies for supportive housing as well as in the construction and opening of housing. Adolescents in transition and adults now have more opportunities to succeed in their recovery while living in their communities. We see hope in our experiences with drop-in centers and consumer projects and in the enthusiasm we hear as we invest in consumer wellness centers across the state. Changes in practice for treating co-occurring disorders are now embedded in our system. A model for serving veterans and military families has been established to more holistically serve what is a new and growing special needs population in every state. We have successfully implemented new recovery-based programs and have found new ways to engage consumers, families, and providers as we implement the comprehensive community support services that are at the heart of our transformation.

There are many more signs of hope that I could mention. I invite readers to follow our progress via the IBHPC Web site and to consider the lessons we have offered here. Let us know what you too are learning as you transform your practices and systems.