Section I: Introduction

History

Philadelphia has had a long history of innovation in the behavioral health field, beginning with the work of Dr. Benjamin Rush (1746-1813), the first to propose a disease concept of "chronic drunkenness" and to advocate specialized treatment services for this condition. The city's leadership role continued with the closing of the state hospitals in the late 1980s and the more recent formation of Community Behavioral Health (CBH), the nation's largest city-controlled managed behavioral healthcare organization. This document represents the next step in the evolution of Philadelphia's efforts to create a more effective and efficient system of care. This system is based on the latest thinking in the field, empirical evidence and another essential element: the preferences of the individuals and families receiving services.

These practice guidelines are framed by the notions of recovery and resilience. It is this framework, and an unwavering belief in recovery and resilience in behavioral health, that should be the basis for service delivery. The document is presented in three sections:

I. Introduction

II. Overview of the Framework

III. Strategies in the Four Domains

The guidelines presented in this report represent the collective vision of many people. Hundreds of stakeholders—including people in recovery, providers, family members, advocates and staff of the Philadelphia Department of Behavioral Health and Intellectual disAbility Services (DBHIDS)—participated in focus groups across the behavioral health system, contributing their ideas and perspectives about existing strengths, best and promising practices and opportunities for growth.

Their feedback has been blended with the lessons learned from Philadelphia's transformation efforts over the past 30 years, several exciting national trends and the empirically informed practices documented in the literature. Together they form the foundation for Philadelphia's new practice guidelines.

Momentum from National Trends

Several national trends are propelling the dramatic changes unfolding within the City of Philadelphia's behavioral health system. These trends include national health care reform efforts, mental health transformation processes, the recovery advocacy movement in the addiction field, the emphasis on resilience in children's behavioral health and findings published in the Institute of Medicine's Quality Chasm report.

Health Care Reform: Quality, Outcomes and Accountability

The historic health care reform legislation enacted on March 23, 2010 holds the potential to transform the landscape on which all healthcare services are delivered. In addition to extending health care coverage to an estimated 32 million more Americans, health care reform promises to improve the quality of care and increase the focus on outcomes and accountability.

Some of the implications of health care reform for behavioral health include:

• an increased focus on the coordination between and integration of specialty behavioral health services and primary care;

• a greater focus on comprehensive, "whole health" approaches that address the full range of needs of individuals receiving services;

• increased focus on supporting people in lower levels of care (e.g., services in community-based settings) rather than higher, more restrictive services (e.g., residential, inpatient, partial hospitalization programs);

• greater attention to treatment outcomes and provider accountability; and

• a focus on measures that will enhance the infrastructure (service systems and providers) to support the delivery of effective services (e.g., greater utilization of health information technology).

Mental Health Transformation: A Place in the Community

These substantive reforms in behavioral health policy and practice are not occurring in a vacuum. In recent years, behavioral health systems around the country have initiated efforts to transform their service systems by realigning their policies, services and structures to promote resilience and recovery. In the mental health arena, the work of the New Freedom Commission on Mental Health prompted much of this restructuring. Created in April of 2002, this Commission was charged with the task of examining the problems and gaps in mental health service delivery systems nationwide and recommending solutions to finally achieve the promise of "a life in the community" first made when the deinstitutionalization movement began half a century earlier. Following several years of study and input from thousands of people nationwide, the Commission concluded that existing mental health systems were not organized to reach the single most important goal for people receiving services, the goal of recovery. To address that challenge, the Commission articulated the following vision:

"We envision a future when everyone with a mental illness will recover, a future when mental illnesses are detected early, and a future when everyone with a mental illness at any stage of life has access to effective treatment and supports—essentials for living, working, learning and participating fully in the community" (DHHS, 2003).

Neither the Commission's findings nor its vision was surprising to many people receiving mental health care. Over the previous two decades, the nation's mental health consumer movement had grown and advocated just these kinds of changes in the nature of service delivery. What was new was that their vision of recovery and community inclusion had now been adopted by the nation's mental health system.

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