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Practicing Recovery: Incorporating a
Recovery Orientation in Hospital Settings
I s s u e 5 : J a n u a r y 2 0 1 6
In This Issue
A Note from the Project Director���������� 2
Putting Individuals at the Center of Care.......................... 2
A Note from the Field: Becoming a Recovery-oriented
Agency............................................................................... 3
Thought Leader: Implementing Recovery-oriented
Practices at Cone Health.................................................... 4
Recovery Story: What About Me? I Am a Person, Not a
“Case”................................................................................ 6
Program Spotlight: Statewide Initiative to Train
Practitioners in Recovery Practices.................................... 8
5 Tips: Five Tips for Adopting a Recovery Framework.... 10
RTP Presentations��������������� 11
Resources������������������� 12
Conferences  Events�������������� 13
RTP@ahpnet.com
www.samhsa.gov/recoverytopractice
Laurie Curtis, MA, CPRP
Project Director, Recovery to Practice
People who work in behavioral health organizations have daily
opportunities to promote wellness and recovery through their
approaches to treatment and support and their many interactions with
the people they serve. In her 2009 article, “A Wellness and Recovery
Model for State Psychiatric Hospitals,”1
Dr. Peggy Swarbrick offers
a framework to help hospitals shift toward more recovery-oriented
environments and services. She makes an important point that wellness
and recovery should infuse all aspects of hospital-based services,
from the environment itself to staff attitudes and language to person-
centered treatment; discharge planning; and assumptions about
individual strengths, capacity, and resiliency.
In this issue of Practicing Recovery, we look at concrete steps
undertaken by several organizations to help transform their systems
to promote and support recovery and wellness. Two psychiatric
nurses report on how they have used the American
Psychiatric Nurses Association (APNA) Recovery to
Practice curriculum to help build knowledge and
understanding within their workforces. A psychiatrist
reflects on his organization’s journey of transformation
toward recovery-oriented services, and a certified peer
specialist shares her thoughts about how hospitals can
both help and hinder the personal process of recovery.
While this issue offers the perspectives of three distinct
types of healthcare employees, a recurring theme is
woven through each of their articles: recovery-oriented
practice incorporates attention to individuals’ overall
wellness, rather than spotlighting only problems and
diagnoses.  l
1.	 Swarbrick, M. A Wellness and Recovery Model for State
Psychiatric Hospitals. Occupational Therapy in Mental Health, July
2009, pp. 343-351.
A NOTE FROM THE PROJECT DIRECTOR
Putting Individuals at the
Center of Care
The Centers for Medicare  Medicaid Services
(CMS) proposed to revise the discharge
planning requirements that hospitals must meet
to participate in the Medicare and Medicaid
programs. The proposed rule puts the person
using services and their caregivers at the center
of care delivery, and prioritizes the goals and
treatment preferences of the person using
services during the discharge planning process.
These improvements should better prepare
people seeking services and their caregivers to be
active partners in planning for their needs during
the next step in their care.
Published in the Federal Register on November 3,
2015, the proposed rule is available online at http://
federalregister.gov/a/2015-27840. We invite Practicing
Recovery readers to review the proposed rule change
and comment during the 60-day comment period. For
more information, visit https://s3.amazonaws.com/
public-inspection.federalregister.gov/2015-27840.pdf.
2
Christopher Gordon, MD,
Senior Vice President, Clinical
Services, Medical Director,
Advocates, Inc
Christopher Gordon, MD, is
senior vice president of clinical
services and medical director of
Advocates, Inc., in Framingham,
Massachusetts. In this capacity,
Chris is responsible for all clinical
programs, including residential
services, outpatient, emergency
services, employment, and
other supports for people with
psychiatric and development
disabilities, brain injury, and
substance use disorders. He is
also an associate professor of
psychiatry at Harvard Medical
School (part-time), where he
has taught on faculty since
1976. Chris is a member of
SAMHSA’s Recovery to Practice
Steering Committee, which
provides input and guidance on
all RTP activities, events, and
products. You can reach him at
chrisgordon@advocatesinc.org.
Becoming a Recovery-oriented
Agency
Iwas honored by the invitation to write an introduction to this issue on
recovery-oriented practice. While I am happy to share a few thoughts
about our journey here at Advocates, I do not want to overstate our
accomplishments. Advocates, Inc., is a nonprofit, human services agency
providing services to people with a range of challenges, including
psychiatric conditions, developmental and cognitive disabilities, brain
injuries, and other behavioral health conditions. We have come a great
distance, but we have further to go to become the recovery-oriented
agency we aspire to be.
In my experience, transitioning to a recovery-oriented practice involves
both positive actions that promote recovery in addition to softening,
avoiding, or tempering factors that may hamper recovery. One
critical positive action that an organization should take is clarifying
the organization’s values. At Advocates, this is an ongoing process of
exploring our values and philosophy through a task force including
people receiving services, staff providing direct care, and administrators.
This group created a document and companion video, The Advocates
Way, to serve as a guide to our practice approach. We use these
materials to orient new staff members and empower the people we
serve to hold us accountable to our ideals.
Fundamental to these values is creating authentic relationships with
the people we serve. In this authentic relationship, the person has a
substantial voice in all decisions affecting that person. To the greatest
extent possible, we afford the person the respect and dignity to
make all critical decisions about his or her own life. Even when we
must act unilaterally or in direct contrast to the person’s wishes—for
example, committing an individual to a hospital for their own or others’
safety—The Advocates Way provides guidance for how to protect the
individual’s rights and dignity, while doing all that we can to mitigate the
trauma of these events.
For us, nothing has been more powerful than heeding and honoring
the voices of people receiving services and their support networks. Peer
specialists and peer advocates are the true paradigm shifters, helping
us appreciate the many paths people may take to leading fulfilling
lives. The concept “nothing about us without us” is a powerful mantra.
Including the people we serve in clinical meetings, operational planning,
and quality improvement changes everything.
For me as a psychiatrist, becoming more recovery-oriented has involved
appreciating that my medical training, which can be of such great
service to many people, holds unintentional risks to recovery. The very
language of illness and disease conveys ideas of irredeemable damage,
diagnoses can feel like life sentences, and medical assertions often carry
Continued on page 11
A NOTE FROM THE FIELD
3
My 40 years’ practice as a psychiatric nurse in
mental health and substance use is rooted in
the fundamental value that all people deserve dignity
and respect. In 2012, I completed the APNA (American
Psychiatric Nurses Association) RTP course on integrating
recovery-oriented practices into the care provided to
people with behavioral health conditions. As Cone
Health’s nursing professional development specialist, it
was my job to get the word out and incorporate this
evidence-based practice throughout our six-hospital
system. This article presents some of the ways in which we
have launched those changes at Cone Health.
The need to embrace hope for a better future and deliver
person-centered, trauma-informed, culturally sensitive
care to people seeking services drove changes to the
clinical culture at Cone Health. The administration
charged my colleagues and me with ensuring that
recovery-oriented values would drive Cone Health’s
cultural transformation. Our approach to operationalizing
this transformation was first to form a team that was
inclusive, collaborative, contagious, and inspiring. Key
sponsors and stakeholders, including the hospital’s
president, vice president, and supervisors; local mental
health organizations; psychiatrists; counselors; and people
who receive services and their families joined us in this
Implementing Recovery-oriented Practices at
Cone Health
By Barbara Akins, RN, BSN, FCN
Barbara Akins, RN, BSN, FCN,
Accreditation/Quality Patient Safety
Coordinator and Professional Nursing
Development Specialist, Cone Behavioral
Health Hospital
Barbara “B” Akins is a registered nurse with
Cone Behavioral Health Hospital in Greensboro,
North Carolina. In 2012, she completed the
American Psychiatric Nurses Association (APNA)
Recovery to Practice curriculum, Acute Care
Psychiatric-Mental Health Nurses: Preparing
for Recovery-oriented Practice, which aligns
with SAMHSA’s national initiative and The Joint
Commission’s standard on patient-centered
communication. You can reach B at
Barbara.Akins@conehealth.com.
THOUGHT LEADER
4
effort. Everyone was enthusiastic about
making these changes across our large
regional healthcare system.
In 2013, we launched a hospital-
wide project, “Recovering
Recovery in Mental Health,
Substance Abuse, and
Chronic Illness,” which
emphasized serving the
whole person while also
acknowledging that we
cannot split a person
into pieces as they
navigate their mental
health, substance use, and
medical conditions. Since
many of those we serve are
admitted with chronic illness
diagnoses, we recognized
the need to educate staff
throughout the hospital system.
To meet this need, we developed
print materials and posters and
conducted in-service training for staff
during lunch sessions at all six hospitals.
Simultaneously, staff developed and
conducted psychoeducational group sessions for
psychiatric nurses and mental health technicians across
Cone Health’s nursing units. These group learning sessions covered topics such as support systems, wellness,
recovery, personal development, leisure and lifestyle changes, relapse prevention, and healthy coping skills.
This training required significant resources: meeting rooms, refreshments, registration and coordination
capacity, and trainers.
In 2013, we conducted our first Psychiatric Nursing Academy, an annual program for RNs who recently
graduated and passed their boards; the RTP training is part of the Academy curriculum. In addition, we trained
certified substance abuse counselors within the community in SAMHSA’s 10 Guiding Principles of Recovery,
including their application to chronic illness.
Throughout the transformation, the hospital’s surveys of people seeking services have shown significant
improvement. Our baseline 71 percent rate of satisfaction in April 2013 increased to 88 percent in September
2013. We continue to disseminate the RTP Program and now have 10 staff trainers. We also provide Handle
with Care training, a crisis intervention system and verbal de-escalation program that incorporates recovery
approaches in how we talk, listen, and engage with the people we serve. This practice is interwoven
throughout our hospital, Cone Health System, and the community.
Taking steps toward recovery requires great courage, self-
acceptance, developing a positive and meaningful sense of identity,
and regaining belief in one’s self. We know that it starts with
speaking, and although breakdowns may occur, breakdowns create
breakthroughs. Our journey continues.  l
SAMHSA’s
10 Guiding
Principles of
Recovery
Learn more about SAMHSA’s 10
Guiding Principles of Recovery.
5
They say a picture tells a thousand stories. Before we look at
the bigger picture of person-centered hospital care, use your
imagination and suppose that I am sharing snapshots with you:
photos of my dogs swimming in the Shenandoah River; camping
with friends; me riding my bike; trees, animals, and sailboats on
the Potomac River.
Now, imagine that we are watching an old movie. I am seven
years old, sitting in a neighbor’s window. My mom is inside our
house next door. I have not seen her or my brother and sisters,
or been in our house for so long it seems like years. I last saw
my dad lying in the street. I wanted to lie down beside him; I do
not know what “died” means. The neighbor’s kids are excited;
their mom just brought home hot Krispy Kreme Doughnuts. The
doughnuts smell good and I feel guilty.
At 10, I was sexually assualted. At 11, I turned to drugs and
alcohol, and in my teens, I used psychedelics and cocaine,
which led to more sexual abuse. I got through it with a loving
relationship and work that fulfilled me. While I had only a few
friends, I had many four-legged companions and I was happy for
many years.
At age 30, however, the trauma came rushing back and I fell into
self-harm to punish myself and escape the emotional agony.
My first diagnosis was posttraumatic stress and I endured many
hospitalizations over the next 23 years. While hospitalized in
1989, a staff member tried a shaming tactic on me. I ran out of
RECOVERY STORY
Chris Cavaliere, CPST
As a certified peer specialist trainer
(CPST), Chris Cavaliere is trained in
WRAP (Wellness Recovery Action
Plan), WHAM (Whole Health Action
Management), and DBT (Dialectical
Behavioral Therapy). She is a motivational
speaker on recovery practices, trauma-
informed communities, and service
systems. Chris is a member of the Fairfax-
Falls Church CPS Trainers and WRAP
Teams. As an advocate, Chris works
to influence hospitals to implement
peer support as a way of reducing
hospitalizations. Chris created Facing
Forward©, a peer-facilitated trauma
recovery workshop program. You can
reach Chris at ccavaliere0623@gmail.
com.
What About Me? I Am a Person, Not a “Case”
By Chris Cavaliere, CPST
6
the room and down the hall, where five psych techs
jumped me and proceeded to restrain me in a room
for eight hours. Another time, I was put in seclusion
after reporting an urge to harm myself. I screamed
through the tiny window: “Don’t leave me!”
When institutions
hinder recovery in
these ways, who are
they helping?
These are just a
couple of my early
experiences of being
in a mental hospital.
They illustrate how
hospitals can retraumatize people with impersonal
protocols and policies. This is what we are attempting
to change through a recovery-orientation to care.
Person-centered care begins with the question “What
happened to you?” Do not expect to know the
answer, but do try to understand the answer.
Progress in person-centered hospital care is slowly
coming around. This type of change must occur
at every level from programmatic changes to the
individual interactions that can shape recovery.
The two examples I share here demonstrate my
experience as a person seeking services and an
advocate. At the suggestion of my primary care
physician, I trained one of my dogs, Pip, as a
psychiatric service animal to cue me to practice
my DBT skills (my former career was dog training
and canine behavior consulting). DBT is a cognitive
behavioral treatment that applies mindfulness,
interpersonal effectiveness, emotional regulation, and
distress tolerance skills.
INOVA Fairfax
Hospital accepted
Pip as my therapy
dog and allowed
me to keep her
with me during
my hospitalization.
Once, I began to
disassociate and
felt overwhelming
urges to self-harm.
Intuitively, Pip ran to the nurse’s station and started
barking, alerting staff who followed her to me. They
were able to bring me back to the present. After that
episode, the head nurse instructed staff to watch Pip
for cues to best support me.
In 2011, while working as an advocate, I helped a
person who was experiencing irritability and psychosis
while hospitalized. Because I was listed as a supporter
on her crisis plan, I was able to notify staff of her
extreme sensitivity to the medications they were
prescribing. They listened to me and immediately
adjusted her medication. She soon stabilized.
When we ask to see a person’s pictures, we see the
person, not a “case” file.  l
Person-centered care begins with the
question “What happened to you?” Do
not expect to know the answer, but
do try to understand the answer.
7
Remarkable advancements paired with profound
policy and system failures characterize the current
healthcare environment. The healthcare system
continues to base psychiatric care on long-standing
beliefs that mental health conditions are both long-
term and permanently disabling. A fundamental
element of any plan to improve psychiatric care
must challenge healthcare practitioners’ current
understanding and role in obtaining successful
treatment outcomes.
The experience and evidence of recovery from
psychiatric illnesses challenges many professionals’
understanding of these conditions and existing
healthcare models. While a number of programs for
recovery training exist, few are available to the 90,000
hospital psychiatric nursing staff who work daily with
people in acute crisis.
To promote long-term change in psychiatric care,
the endowment for the Psychiatric-Mental Health
Nursing Program at the University of Colorado
began sponsoring the American Psychiatric Nurses
Association (APNA) Recovery to Practice (RTP)
curriculum across Colorado. In collaboration with
the Colorado-APNA chapter, regional and statewide
training began in 2014 with a facilitator-training
program.
PROGRAM SPOTLIGHT
Statewide Initiative to Train Practitioners in
Recovery Practices
By Michael J. Rice, PhD, APRN-BC, FAAN, and Kerry Bastian, BSN, RN
Michael J. Rice,
PhD, APRN-BC,
FAAN, Endowed
Chair and Professor,
College of Nursing
Anshutz Medical
Center, University of
Colorado
Kerry Bastian,
BSN, RN, Assistant
Director of Nursing
and Director of Staff
Development, Fort
Logan Mental Health
Institute of Colorado
8
Two staff from the Colorado Mental Health Institute
at Fort Logan attended the APNA RTP facilitator
training offered in May 2014. The program fit with the
Institute’s ongoing
training and helped
raise the level of
sophistication
of the existing
trauma-informed
care program. With
hospital administration
support, facilitators
have now integrated
the RTP materials
into new employee
orientation. All
clinical disciplines—
including nurses,
psychologists, and
new psychiatrists—must take the class. As experience
and studies indicate, the workforce is often resistant
to new training. Often by the end of this eight-hour
class, however, attitudes have changed and some
people report it as being the most important class
they have taken at the hospital.
As one of the APNA RTP curriculum trainers, I find
that the participants’ review of their worst day and
best day at work makes them more receptive to a
presentation by a person in mental health recovery.
This perspective breaks down barriers that staff may
have built up, giving them an opportunity to reflect
on their own practices. Many staff report that they
had not previously viewed hospitalization through the
eyes of the person using these services. For veteran
staff, this perspective is
an awakening. Changing
our thoughts from “what
is wrong” with a person to
“what has happened” to
him or her evokes more
empathy and compassion,
increasing job satisfaction,
and helping staff recognize
that recovery is possible.
The curriculum review of
the Nursing Scope and
Standards also helps get
nurses back to basics. As
one nurse stated, “We’re
taking back our practice.” The curriculum validates
nurses’ responsibility to view the people they serve in
the best light and promote their healing. Developing
recovery-oriented treatment plans in collaboration
with an individual helps to reduce prejudice and
prepare the individual for a full life in recovery. The
peer recovery stories in the curriculum are especially
powerful for nursing staff who often see people only
at their worst.
As one staff member said, “This is what I’ve always
felt in my heart was how we should be caring for our
clients. It always felt like we could be more human.”
This is what psychiatric nursing is all about.  l
“This is what I’ve always felt in my
heart was how we should be caring
for our clients. It always felt like we
could be more human.”
… some people report [this class] as
being the most important class they
have taken at the hospital.
9
Five Tips for Adopting a Recovery Framework
Developing and implementing recovery-oriented systems of care can be a rewarding but difficult and
complex process. The shift to a recovery orientation requires training and a conscious effort to accept
a major philosophical change. Here are five recommendations from states, hospitals, organizations,
and communities that have begun this process.
Ground what you do in what science tells us works. Train practitioners not just in recovery
orientation, but also in evidence-based techniques, such as cognitive therapy and trauma-informed
care. The city of Philadelphia, for example, has trained hundreds of providers to use cognitive therapy
and its principles in inpatient and outpatient settings, with children and adults, and for mental health
and substance use conditions.
3
4
Commit to peer recovery support services. People who have firsthand experience with mental health
and substance use conditions are very effective at engaging people, keeping them connected to
services, and helping them maneuver their own personal recoveries.
Redefine roles. A recovery orientation encourages people to drive the process of their own recovery,
redefining the role of the person in recovery from “patient” to full partner in the recovery process. The
role of the professional shifts from “expert who treats behavioral health disorders” to consultant and
ally. While these changes challenge the way clinicians see themselves, their roles, and people with
behavioral health conditions, they may come to see their professional roles enhanced. While helping a
person learn how to manage symptoms is important, it is more complex to help a person see a life path
that goes beyond treatment goals. When the practitioner is a partner in the process and there to help
the individual, this partnership becomes the cornerstone of the recovery orientation and reflects the
strengths-based approach advocated by researchers in the mental health field.
5
2
Shift the service emphasis from an acute care model to longitudinal recovery self-management.
In substance use treatment, this means moving from treatment models that focus primarily on brief,
episodic modalities that help people to achieve abstinence or “get clean” to services that go beyond
crisis stabilization. In mental health treatment, this means expanding the focus beyond symptom
reduction and working collaboratively with people to help them learn how to manage their conditions
and draw on support beyond the healthcare system to achieve high levels of personal wellness and
connection with their communities.
Develop core values and principles based on input from people in recovery and use this feedback
to revamp programs and policies and retrain your workforce. The state of Connecticut put this
philosophy into practice by creating a program in hospital emergency departments that used peer
support specialists in crisis intervention units to provide support and practical assistance to others with
behavioral health conditions.
1
5 TIPS
Changing attitudes is a process that takes time, and persuading traditional providers to embrace a recovery
orientation is not always easy. Those who are on this path report that they believe that their efforts toward
systems change will ultimately benefit service providers, practitioners, communities—and most importantly—
the individuals with behavioral health conditions and their families.  l
Sources: “Embracing Recovery” by Rebecca A. Clay in Monitor on Psychology, October 2013; and Provider Approaches to Recovery-
Oriented Systems of Care: Four Case Studies (2009) by A. Halvorson, J. Skinner, and M. Whitter.
10
Upcoming RTP Webinars
Creating Environments of Hope and Wellness: Recovery in Hospital Settings
The popular RTP webinars are back, beginning in early January 2016, with a presentation focused on recovery-
oriented approaches in hospital settings. Expanding on the themes covered in this issue of Practicing
Recovery, this webinar will explore guiding principles and concrete steps for transforming hospital-based
services to promote and support recovery and wellness.
Three-Part Webinar Series:
Crisis and Recovery: Opportunities for Healing and Growth
In January, RTP will also offer a three-part series examining ways to integrate recovery-oriented approaches
into response and support services that help individuals experiencing emotional or psychiatric crisis. It will
present models and approaches that exemplify the value of a recovery orientation in these crucial periods.
Topics will include
•	 Supporting recovery in acute care and emergency settings
•	 Recovery-oriented, community-focused responses to behavioral health crises
•	 Hospital diversion and alternatives in crisis response
Watch your email for dates, times, and registration information.
RTP PRESENTATIONS
more weight and certainty than current knowledge
justifies. Together, these influences can silence, mute,
or marginalize the creative efforts of the person at the
center of concern (AKA “the patient”). If we overvalue
the power of neuroscience, personal crises that
may have importance and meaning can be reduced
to misfiring neurotransmitters, or we may miss the
significance of a psychiatric crisis in the effort to stifle
symptoms, a process akin to removing the battery
from a beeping smoke detector.
I have come to embrace a radical humility about
my medical training and what my clinical skills can
offer. I must speak carefully, listen deeply, appreciate
strengths and capacities at least as much as identify
problems, offer ideas and treatments tentatively, be
open meaningfully to shared decision making, and
engage fully as a human being in relationships with
the people and families I serve.
These positive actions and tempering practices guide
us on our journey toward being a recovery-oriented
agency.  l
A Note from the Field
Continued from page 11
11
RTP Training Curricula
Like Cone Health and the Fort Logan Mental Health Institute of Colorado, organizations can use the Recovery
to Practice curricula to help train the workforce. SAMHSA supported six membership associations as they
developed curricula to promote recovery principles and practices among behavioral health practitioners. The
intent was to transform the concepts of recovery from a set of beliefs to recovery-oriented practices. Here is a
brief description and link to each curriculum. We invite readers to explore the curricula and learn more about
the participating professional organizations.
Addiction Specialists Curriculum from the Association for Addiction Professionals
The RTP Addiction Specialists Curriculum educates addiction professionals about the recovery-
oriented model of care, addiction recovery, addiction professionals’ specific role in promoting it, and
the competencies needed to integrate addiction recovery concepts into practice.
Peer Specialists Curriculum from the InterNational Association of Peer Supporters (iNAPS)
iNAPS designed and developed the RTP Peer Specialists Curriculum with input from peer support
practitioners nationwide. Throughout the development process, leading content experts in the
recovery and peer support movements reviewed and helped shape the curriculum.
Psychiatric Nursing Curriculum from the American Psychiatric Nurses Association (APNA)
APNA developed its RTP Psychiatric Nursing Curriculum in collaboration with people with lived
experience and psychiatric-mental health nursing leaders. The curriculum and related training materials
aim to increase nursing knowledge of recovery-oriented care and how it translates into nursing practice.
Psychiatry Curriculum from the American Psychiatric Association (APA) and the American
Association of Community Psychiatrists (AACP)
APA and AACP designed a nine-module RTP Psychiatry Curriculum to provide a basic understanding
of recovery from mental health and substance use conditions and recovery-oriented care. The intent
of the training materials is to bring recovery-oriented practice into the mainstream of professional
psychiatric practice.
Psychology Curriculum from the American Psychological Association (APA)
APA’s RTP Psychology Curriculum provides psychologists and other mental health professionals
with information about issues facing people with serious mental health conditions. Based on current
scientific literature, the curriculum provides training in the latest assessment and intervention
approaches with the intent of assisting individuals with severe mental illnesses to achieve their full
functional capability.
Social Work Curriculum from the Council on Social Work Education (CSWE)
The RTP Social Work Curriculum aims to introduce social workers to the recovery model. It focuses on
defining mental health recovery, tracking its origins and development over time, and discussing the
alignment of the recovery model to social work practice. CSWE offers web-based events and webinars,
supports a virtual recovery learning network, and provides social workers with a number of recovery-
oriented training resources.
RESOURCES
12
February is American Heart Month
American Heart Month increases awareness
about heart disease and how people can prevent
it. Download a toolkit of resources and tips for
planning an observance, and visit Million Hearts
Initiative for the latest research, proven tools,
and best practices for preventing heart disease
and stroke.
SAMHSA’s 12th Prevention Day
The Power of Prevention!
National Harbor, Maryland
Visit the site to learn more or
register to attend.
Community Anti-Drug Coalitions of
America 26th National Leadership
Forum
Forum 2016: Coalitions –
Monumental Impact!
National Harbor, Maryland
Visit the site to learn more or
register to attend.
National Council for Behavioral Health
Conference
Las Vegas, Nevada
Visit the site to learn more or
register to attend.
29th Annual Research  Policy
Conference on Child,
Adolescent  Young Adult
Behavioral Health
Tampa, Florida
Visit the site to learn more or register to attend.
6th Anniversary of the
Affordable Care Act
MAR
7 – 9
MAR
13 – 16
CONFERENCES  EVENTS
FEB
1
FEB
1 – 4
This product was developed [in part] under contract number HHSS283201200038I/ HHSS28342001T (Reference No. 283-12-3801) from
the Substance Abuse and Mental Health Services Administration (SAMHSA), U.S. Department of Health and Human Services (HHS). The
views, policies, and opinions expressed are those of the authors and do not necessarily reflect those of SAMHSA or HHS.
MAR
23
13

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Recovery to Practice Newsletter 5 dec_2015

  • 1. Practicing Recovery: Incorporating a Recovery Orientation in Hospital Settings I s s u e 5 : J a n u a r y 2 0 1 6 In This Issue A Note from the Project Director���������� 2 Putting Individuals at the Center of Care.......................... 2 A Note from the Field: Becoming a Recovery-oriented Agency............................................................................... 3 Thought Leader: Implementing Recovery-oriented Practices at Cone Health.................................................... 4 Recovery Story: What About Me? I Am a Person, Not a “Case”................................................................................ 6 Program Spotlight: Statewide Initiative to Train Practitioners in Recovery Practices.................................... 8 5 Tips: Five Tips for Adopting a Recovery Framework.... 10 RTP Presentations��������������� 11 Resources������������������� 12 Conferences Events�������������� 13
  • 2. RTP@ahpnet.com www.samhsa.gov/recoverytopractice Laurie Curtis, MA, CPRP Project Director, Recovery to Practice People who work in behavioral health organizations have daily opportunities to promote wellness and recovery through their approaches to treatment and support and their many interactions with the people they serve. In her 2009 article, “A Wellness and Recovery Model for State Psychiatric Hospitals,”1 Dr. Peggy Swarbrick offers a framework to help hospitals shift toward more recovery-oriented environments and services. She makes an important point that wellness and recovery should infuse all aspects of hospital-based services, from the environment itself to staff attitudes and language to person- centered treatment; discharge planning; and assumptions about individual strengths, capacity, and resiliency. In this issue of Practicing Recovery, we look at concrete steps undertaken by several organizations to help transform their systems to promote and support recovery and wellness. Two psychiatric nurses report on how they have used the American Psychiatric Nurses Association (APNA) Recovery to Practice curriculum to help build knowledge and understanding within their workforces. A psychiatrist reflects on his organization’s journey of transformation toward recovery-oriented services, and a certified peer specialist shares her thoughts about how hospitals can both help and hinder the personal process of recovery. While this issue offers the perspectives of three distinct types of healthcare employees, a recurring theme is woven through each of their articles: recovery-oriented practice incorporates attention to individuals’ overall wellness, rather than spotlighting only problems and diagnoses.  l 1. Swarbrick, M. A Wellness and Recovery Model for State Psychiatric Hospitals. Occupational Therapy in Mental Health, July 2009, pp. 343-351. A NOTE FROM THE PROJECT DIRECTOR Putting Individuals at the Center of Care The Centers for Medicare Medicaid Services (CMS) proposed to revise the discharge planning requirements that hospitals must meet to participate in the Medicare and Medicaid programs. The proposed rule puts the person using services and their caregivers at the center of care delivery, and prioritizes the goals and treatment preferences of the person using services during the discharge planning process. These improvements should better prepare people seeking services and their caregivers to be active partners in planning for their needs during the next step in their care. Published in the Federal Register on November 3, 2015, the proposed rule is available online at http:// federalregister.gov/a/2015-27840. We invite Practicing Recovery readers to review the proposed rule change and comment during the 60-day comment period. For more information, visit https://s3.amazonaws.com/ public-inspection.federalregister.gov/2015-27840.pdf. 2
  • 3. Christopher Gordon, MD, Senior Vice President, Clinical Services, Medical Director, Advocates, Inc Christopher Gordon, MD, is senior vice president of clinical services and medical director of Advocates, Inc., in Framingham, Massachusetts. In this capacity, Chris is responsible for all clinical programs, including residential services, outpatient, emergency services, employment, and other supports for people with psychiatric and development disabilities, brain injury, and substance use disorders. He is also an associate professor of psychiatry at Harvard Medical School (part-time), where he has taught on faculty since 1976. Chris is a member of SAMHSA’s Recovery to Practice Steering Committee, which provides input and guidance on all RTP activities, events, and products. You can reach him at chrisgordon@advocatesinc.org. Becoming a Recovery-oriented Agency Iwas honored by the invitation to write an introduction to this issue on recovery-oriented practice. While I am happy to share a few thoughts about our journey here at Advocates, I do not want to overstate our accomplishments. Advocates, Inc., is a nonprofit, human services agency providing services to people with a range of challenges, including psychiatric conditions, developmental and cognitive disabilities, brain injuries, and other behavioral health conditions. We have come a great distance, but we have further to go to become the recovery-oriented agency we aspire to be. In my experience, transitioning to a recovery-oriented practice involves both positive actions that promote recovery in addition to softening, avoiding, or tempering factors that may hamper recovery. One critical positive action that an organization should take is clarifying the organization’s values. At Advocates, this is an ongoing process of exploring our values and philosophy through a task force including people receiving services, staff providing direct care, and administrators. This group created a document and companion video, The Advocates Way, to serve as a guide to our practice approach. We use these materials to orient new staff members and empower the people we serve to hold us accountable to our ideals. Fundamental to these values is creating authentic relationships with the people we serve. In this authentic relationship, the person has a substantial voice in all decisions affecting that person. To the greatest extent possible, we afford the person the respect and dignity to make all critical decisions about his or her own life. Even when we must act unilaterally or in direct contrast to the person’s wishes—for example, committing an individual to a hospital for their own or others’ safety—The Advocates Way provides guidance for how to protect the individual’s rights and dignity, while doing all that we can to mitigate the trauma of these events. For us, nothing has been more powerful than heeding and honoring the voices of people receiving services and their support networks. Peer specialists and peer advocates are the true paradigm shifters, helping us appreciate the many paths people may take to leading fulfilling lives. The concept “nothing about us without us” is a powerful mantra. Including the people we serve in clinical meetings, operational planning, and quality improvement changes everything. For me as a psychiatrist, becoming more recovery-oriented has involved appreciating that my medical training, which can be of such great service to many people, holds unintentional risks to recovery. The very language of illness and disease conveys ideas of irredeemable damage, diagnoses can feel like life sentences, and medical assertions often carry Continued on page 11 A NOTE FROM THE FIELD 3
  • 4. My 40 years’ practice as a psychiatric nurse in mental health and substance use is rooted in the fundamental value that all people deserve dignity and respect. In 2012, I completed the APNA (American Psychiatric Nurses Association) RTP course on integrating recovery-oriented practices into the care provided to people with behavioral health conditions. As Cone Health’s nursing professional development specialist, it was my job to get the word out and incorporate this evidence-based practice throughout our six-hospital system. This article presents some of the ways in which we have launched those changes at Cone Health. The need to embrace hope for a better future and deliver person-centered, trauma-informed, culturally sensitive care to people seeking services drove changes to the clinical culture at Cone Health. The administration charged my colleagues and me with ensuring that recovery-oriented values would drive Cone Health’s cultural transformation. Our approach to operationalizing this transformation was first to form a team that was inclusive, collaborative, contagious, and inspiring. Key sponsors and stakeholders, including the hospital’s president, vice president, and supervisors; local mental health organizations; psychiatrists; counselors; and people who receive services and their families joined us in this Implementing Recovery-oriented Practices at Cone Health By Barbara Akins, RN, BSN, FCN Barbara Akins, RN, BSN, FCN, Accreditation/Quality Patient Safety Coordinator and Professional Nursing Development Specialist, Cone Behavioral Health Hospital Barbara “B” Akins is a registered nurse with Cone Behavioral Health Hospital in Greensboro, North Carolina. In 2012, she completed the American Psychiatric Nurses Association (APNA) Recovery to Practice curriculum, Acute Care Psychiatric-Mental Health Nurses: Preparing for Recovery-oriented Practice, which aligns with SAMHSA’s national initiative and The Joint Commission’s standard on patient-centered communication. You can reach B at Barbara.Akins@conehealth.com. THOUGHT LEADER 4
  • 5. effort. Everyone was enthusiastic about making these changes across our large regional healthcare system. In 2013, we launched a hospital- wide project, “Recovering Recovery in Mental Health, Substance Abuse, and Chronic Illness,” which emphasized serving the whole person while also acknowledging that we cannot split a person into pieces as they navigate their mental health, substance use, and medical conditions. Since many of those we serve are admitted with chronic illness diagnoses, we recognized the need to educate staff throughout the hospital system. To meet this need, we developed print materials and posters and conducted in-service training for staff during lunch sessions at all six hospitals. Simultaneously, staff developed and conducted psychoeducational group sessions for psychiatric nurses and mental health technicians across Cone Health’s nursing units. These group learning sessions covered topics such as support systems, wellness, recovery, personal development, leisure and lifestyle changes, relapse prevention, and healthy coping skills. This training required significant resources: meeting rooms, refreshments, registration and coordination capacity, and trainers. In 2013, we conducted our first Psychiatric Nursing Academy, an annual program for RNs who recently graduated and passed their boards; the RTP training is part of the Academy curriculum. In addition, we trained certified substance abuse counselors within the community in SAMHSA’s 10 Guiding Principles of Recovery, including their application to chronic illness. Throughout the transformation, the hospital’s surveys of people seeking services have shown significant improvement. Our baseline 71 percent rate of satisfaction in April 2013 increased to 88 percent in September 2013. We continue to disseminate the RTP Program and now have 10 staff trainers. We also provide Handle with Care training, a crisis intervention system and verbal de-escalation program that incorporates recovery approaches in how we talk, listen, and engage with the people we serve. This practice is interwoven throughout our hospital, Cone Health System, and the community. Taking steps toward recovery requires great courage, self- acceptance, developing a positive and meaningful sense of identity, and regaining belief in one’s self. We know that it starts with speaking, and although breakdowns may occur, breakdowns create breakthroughs. Our journey continues.  l SAMHSA’s 10 Guiding Principles of Recovery Learn more about SAMHSA’s 10 Guiding Principles of Recovery. 5
  • 6. They say a picture tells a thousand stories. Before we look at the bigger picture of person-centered hospital care, use your imagination and suppose that I am sharing snapshots with you: photos of my dogs swimming in the Shenandoah River; camping with friends; me riding my bike; trees, animals, and sailboats on the Potomac River. Now, imagine that we are watching an old movie. I am seven years old, sitting in a neighbor’s window. My mom is inside our house next door. I have not seen her or my brother and sisters, or been in our house for so long it seems like years. I last saw my dad lying in the street. I wanted to lie down beside him; I do not know what “died” means. The neighbor’s kids are excited; their mom just brought home hot Krispy Kreme Doughnuts. The doughnuts smell good and I feel guilty. At 10, I was sexually assualted. At 11, I turned to drugs and alcohol, and in my teens, I used psychedelics and cocaine, which led to more sexual abuse. I got through it with a loving relationship and work that fulfilled me. While I had only a few friends, I had many four-legged companions and I was happy for many years. At age 30, however, the trauma came rushing back and I fell into self-harm to punish myself and escape the emotional agony. My first diagnosis was posttraumatic stress and I endured many hospitalizations over the next 23 years. While hospitalized in 1989, a staff member tried a shaming tactic on me. I ran out of RECOVERY STORY Chris Cavaliere, CPST As a certified peer specialist trainer (CPST), Chris Cavaliere is trained in WRAP (Wellness Recovery Action Plan), WHAM (Whole Health Action Management), and DBT (Dialectical Behavioral Therapy). She is a motivational speaker on recovery practices, trauma- informed communities, and service systems. Chris is a member of the Fairfax- Falls Church CPS Trainers and WRAP Teams. As an advocate, Chris works to influence hospitals to implement peer support as a way of reducing hospitalizations. Chris created Facing Forward©, a peer-facilitated trauma recovery workshop program. You can reach Chris at ccavaliere0623@gmail. com. What About Me? I Am a Person, Not a “Case” By Chris Cavaliere, CPST 6
  • 7. the room and down the hall, where five psych techs jumped me and proceeded to restrain me in a room for eight hours. Another time, I was put in seclusion after reporting an urge to harm myself. I screamed through the tiny window: “Don’t leave me!” When institutions hinder recovery in these ways, who are they helping? These are just a couple of my early experiences of being in a mental hospital. They illustrate how hospitals can retraumatize people with impersonal protocols and policies. This is what we are attempting to change through a recovery-orientation to care. Person-centered care begins with the question “What happened to you?” Do not expect to know the answer, but do try to understand the answer. Progress in person-centered hospital care is slowly coming around. This type of change must occur at every level from programmatic changes to the individual interactions that can shape recovery. The two examples I share here demonstrate my experience as a person seeking services and an advocate. At the suggestion of my primary care physician, I trained one of my dogs, Pip, as a psychiatric service animal to cue me to practice my DBT skills (my former career was dog training and canine behavior consulting). DBT is a cognitive behavioral treatment that applies mindfulness, interpersonal effectiveness, emotional regulation, and distress tolerance skills. INOVA Fairfax Hospital accepted Pip as my therapy dog and allowed me to keep her with me during my hospitalization. Once, I began to disassociate and felt overwhelming urges to self-harm. Intuitively, Pip ran to the nurse’s station and started barking, alerting staff who followed her to me. They were able to bring me back to the present. After that episode, the head nurse instructed staff to watch Pip for cues to best support me. In 2011, while working as an advocate, I helped a person who was experiencing irritability and psychosis while hospitalized. Because I was listed as a supporter on her crisis plan, I was able to notify staff of her extreme sensitivity to the medications they were prescribing. They listened to me and immediately adjusted her medication. She soon stabilized. When we ask to see a person’s pictures, we see the person, not a “case” file.  l Person-centered care begins with the question “What happened to you?” Do not expect to know the answer, but do try to understand the answer. 7
  • 8. Remarkable advancements paired with profound policy and system failures characterize the current healthcare environment. The healthcare system continues to base psychiatric care on long-standing beliefs that mental health conditions are both long- term and permanently disabling. A fundamental element of any plan to improve psychiatric care must challenge healthcare practitioners’ current understanding and role in obtaining successful treatment outcomes. The experience and evidence of recovery from psychiatric illnesses challenges many professionals’ understanding of these conditions and existing healthcare models. While a number of programs for recovery training exist, few are available to the 90,000 hospital psychiatric nursing staff who work daily with people in acute crisis. To promote long-term change in psychiatric care, the endowment for the Psychiatric-Mental Health Nursing Program at the University of Colorado began sponsoring the American Psychiatric Nurses Association (APNA) Recovery to Practice (RTP) curriculum across Colorado. In collaboration with the Colorado-APNA chapter, regional and statewide training began in 2014 with a facilitator-training program. PROGRAM SPOTLIGHT Statewide Initiative to Train Practitioners in Recovery Practices By Michael J. Rice, PhD, APRN-BC, FAAN, and Kerry Bastian, BSN, RN Michael J. Rice, PhD, APRN-BC, FAAN, Endowed Chair and Professor, College of Nursing Anshutz Medical Center, University of Colorado Kerry Bastian, BSN, RN, Assistant Director of Nursing and Director of Staff Development, Fort Logan Mental Health Institute of Colorado 8
  • 9. Two staff from the Colorado Mental Health Institute at Fort Logan attended the APNA RTP facilitator training offered in May 2014. The program fit with the Institute’s ongoing training and helped raise the level of sophistication of the existing trauma-informed care program. With hospital administration support, facilitators have now integrated the RTP materials into new employee orientation. All clinical disciplines— including nurses, psychologists, and new psychiatrists—must take the class. As experience and studies indicate, the workforce is often resistant to new training. Often by the end of this eight-hour class, however, attitudes have changed and some people report it as being the most important class they have taken at the hospital. As one of the APNA RTP curriculum trainers, I find that the participants’ review of their worst day and best day at work makes them more receptive to a presentation by a person in mental health recovery. This perspective breaks down barriers that staff may have built up, giving them an opportunity to reflect on their own practices. Many staff report that they had not previously viewed hospitalization through the eyes of the person using these services. For veteran staff, this perspective is an awakening. Changing our thoughts from “what is wrong” with a person to “what has happened” to him or her evokes more empathy and compassion, increasing job satisfaction, and helping staff recognize that recovery is possible. The curriculum review of the Nursing Scope and Standards also helps get nurses back to basics. As one nurse stated, “We’re taking back our practice.” The curriculum validates nurses’ responsibility to view the people they serve in the best light and promote their healing. Developing recovery-oriented treatment plans in collaboration with an individual helps to reduce prejudice and prepare the individual for a full life in recovery. The peer recovery stories in the curriculum are especially powerful for nursing staff who often see people only at their worst. As one staff member said, “This is what I’ve always felt in my heart was how we should be caring for our clients. It always felt like we could be more human.” This is what psychiatric nursing is all about.  l “This is what I’ve always felt in my heart was how we should be caring for our clients. It always felt like we could be more human.” … some people report [this class] as being the most important class they have taken at the hospital. 9
  • 10. Five Tips for Adopting a Recovery Framework Developing and implementing recovery-oriented systems of care can be a rewarding but difficult and complex process. The shift to a recovery orientation requires training and a conscious effort to accept a major philosophical change. Here are five recommendations from states, hospitals, organizations, and communities that have begun this process. Ground what you do in what science tells us works. Train practitioners not just in recovery orientation, but also in evidence-based techniques, such as cognitive therapy and trauma-informed care. The city of Philadelphia, for example, has trained hundreds of providers to use cognitive therapy and its principles in inpatient and outpatient settings, with children and adults, and for mental health and substance use conditions. 3 4 Commit to peer recovery support services. People who have firsthand experience with mental health and substance use conditions are very effective at engaging people, keeping them connected to services, and helping them maneuver their own personal recoveries. Redefine roles. A recovery orientation encourages people to drive the process of their own recovery, redefining the role of the person in recovery from “patient” to full partner in the recovery process. The role of the professional shifts from “expert who treats behavioral health disorders” to consultant and ally. While these changes challenge the way clinicians see themselves, their roles, and people with behavioral health conditions, they may come to see their professional roles enhanced. While helping a person learn how to manage symptoms is important, it is more complex to help a person see a life path that goes beyond treatment goals. When the practitioner is a partner in the process and there to help the individual, this partnership becomes the cornerstone of the recovery orientation and reflects the strengths-based approach advocated by researchers in the mental health field. 5 2 Shift the service emphasis from an acute care model to longitudinal recovery self-management. In substance use treatment, this means moving from treatment models that focus primarily on brief, episodic modalities that help people to achieve abstinence or “get clean” to services that go beyond crisis stabilization. In mental health treatment, this means expanding the focus beyond symptom reduction and working collaboratively with people to help them learn how to manage their conditions and draw on support beyond the healthcare system to achieve high levels of personal wellness and connection with their communities. Develop core values and principles based on input from people in recovery and use this feedback to revamp programs and policies and retrain your workforce. The state of Connecticut put this philosophy into practice by creating a program in hospital emergency departments that used peer support specialists in crisis intervention units to provide support and practical assistance to others with behavioral health conditions. 1 5 TIPS Changing attitudes is a process that takes time, and persuading traditional providers to embrace a recovery orientation is not always easy. Those who are on this path report that they believe that their efforts toward systems change will ultimately benefit service providers, practitioners, communities—and most importantly— the individuals with behavioral health conditions and their families.  l Sources: “Embracing Recovery” by Rebecca A. Clay in Monitor on Psychology, October 2013; and Provider Approaches to Recovery- Oriented Systems of Care: Four Case Studies (2009) by A. Halvorson, J. Skinner, and M. Whitter. 10
  • 11. Upcoming RTP Webinars Creating Environments of Hope and Wellness: Recovery in Hospital Settings The popular RTP webinars are back, beginning in early January 2016, with a presentation focused on recovery- oriented approaches in hospital settings. Expanding on the themes covered in this issue of Practicing Recovery, this webinar will explore guiding principles and concrete steps for transforming hospital-based services to promote and support recovery and wellness. Three-Part Webinar Series: Crisis and Recovery: Opportunities for Healing and Growth In January, RTP will also offer a three-part series examining ways to integrate recovery-oriented approaches into response and support services that help individuals experiencing emotional or psychiatric crisis. It will present models and approaches that exemplify the value of a recovery orientation in these crucial periods. Topics will include • Supporting recovery in acute care and emergency settings • Recovery-oriented, community-focused responses to behavioral health crises • Hospital diversion and alternatives in crisis response Watch your email for dates, times, and registration information. RTP PRESENTATIONS more weight and certainty than current knowledge justifies. Together, these influences can silence, mute, or marginalize the creative efforts of the person at the center of concern (AKA “the patient”). If we overvalue the power of neuroscience, personal crises that may have importance and meaning can be reduced to misfiring neurotransmitters, or we may miss the significance of a psychiatric crisis in the effort to stifle symptoms, a process akin to removing the battery from a beeping smoke detector. I have come to embrace a radical humility about my medical training and what my clinical skills can offer. I must speak carefully, listen deeply, appreciate strengths and capacities at least as much as identify problems, offer ideas and treatments tentatively, be open meaningfully to shared decision making, and engage fully as a human being in relationships with the people and families I serve. These positive actions and tempering practices guide us on our journey toward being a recovery-oriented agency.  l A Note from the Field Continued from page 11 11
  • 12. RTP Training Curricula Like Cone Health and the Fort Logan Mental Health Institute of Colorado, organizations can use the Recovery to Practice curricula to help train the workforce. SAMHSA supported six membership associations as they developed curricula to promote recovery principles and practices among behavioral health practitioners. The intent was to transform the concepts of recovery from a set of beliefs to recovery-oriented practices. Here is a brief description and link to each curriculum. We invite readers to explore the curricula and learn more about the participating professional organizations. Addiction Specialists Curriculum from the Association for Addiction Professionals The RTP Addiction Specialists Curriculum educates addiction professionals about the recovery- oriented model of care, addiction recovery, addiction professionals’ specific role in promoting it, and the competencies needed to integrate addiction recovery concepts into practice. Peer Specialists Curriculum from the InterNational Association of Peer Supporters (iNAPS) iNAPS designed and developed the RTP Peer Specialists Curriculum with input from peer support practitioners nationwide. Throughout the development process, leading content experts in the recovery and peer support movements reviewed and helped shape the curriculum. Psychiatric Nursing Curriculum from the American Psychiatric Nurses Association (APNA) APNA developed its RTP Psychiatric Nursing Curriculum in collaboration with people with lived experience and psychiatric-mental health nursing leaders. The curriculum and related training materials aim to increase nursing knowledge of recovery-oriented care and how it translates into nursing practice. Psychiatry Curriculum from the American Psychiatric Association (APA) and the American Association of Community Psychiatrists (AACP) APA and AACP designed a nine-module RTP Psychiatry Curriculum to provide a basic understanding of recovery from mental health and substance use conditions and recovery-oriented care. The intent of the training materials is to bring recovery-oriented practice into the mainstream of professional psychiatric practice. Psychology Curriculum from the American Psychological Association (APA) APA’s RTP Psychology Curriculum provides psychologists and other mental health professionals with information about issues facing people with serious mental health conditions. Based on current scientific literature, the curriculum provides training in the latest assessment and intervention approaches with the intent of assisting individuals with severe mental illnesses to achieve their full functional capability. Social Work Curriculum from the Council on Social Work Education (CSWE) The RTP Social Work Curriculum aims to introduce social workers to the recovery model. It focuses on defining mental health recovery, tracking its origins and development over time, and discussing the alignment of the recovery model to social work practice. CSWE offers web-based events and webinars, supports a virtual recovery learning network, and provides social workers with a number of recovery- oriented training resources. RESOURCES 12
  • 13. February is American Heart Month American Heart Month increases awareness about heart disease and how people can prevent it. Download a toolkit of resources and tips for planning an observance, and visit Million Hearts Initiative for the latest research, proven tools, and best practices for preventing heart disease and stroke. SAMHSA’s 12th Prevention Day The Power of Prevention! National Harbor, Maryland Visit the site to learn more or register to attend. Community Anti-Drug Coalitions of America 26th National Leadership Forum Forum 2016: Coalitions – Monumental Impact! National Harbor, Maryland Visit the site to learn more or register to attend. National Council for Behavioral Health Conference Las Vegas, Nevada Visit the site to learn more or register to attend. 29th Annual Research Policy Conference on Child, Adolescent Young Adult Behavioral Health Tampa, Florida Visit the site to learn more or register to attend. 6th Anniversary of the Affordable Care Act MAR 7 – 9 MAR 13 – 16 CONFERENCES EVENTS FEB 1 FEB 1 – 4 This product was developed [in part] under contract number HHSS283201200038I/ HHSS28342001T (Reference No. 283-12-3801) from the Substance Abuse and Mental Health Services Administration (SAMHSA), U.S. Department of Health and Human Services (HHS). The views, policies, and opinions expressed are those of the authors and do not necessarily reflect those of SAMHSA or HHS. MAR 23 13