This document summarizes the agenda and discussions at a Tribal Leaders Summit on the Mental Health Transformation Project. The purpose was to approve the Comprehensive Mental Health Plan and address outstanding questions. Presentations were given on tribal reports, prevention strategies, and social marketing. The draft plan was reviewed and public comments summarized. Key decisions were sought from tribal leaders on accepting the plan's issues, outcomes, and next steps.

1. Mental Health Transformation Project American Indian Health Commission – Tribal Leaders Summit November 9, 2006

2. Introduction and Logistics Welcome Logistics The purpose of today’s meeting is to approve the Comprehensive Mental Health Plan for submittal to the Governor’s Office for final review The TWG will be asked to make specific decisions today regarding various questions still outstanding in the CMHP

3. Today’s Agenda 9:00 – 10:00 Coffee, registration 10:00 – 10:15 Welcome and Opening session 10:15 – 10:45 Tribal Report Presentation 10:45 – 11:10 Prevention Report Presentation 11:10 – 11:30 Social Marketing Plan Update 11:30 – 12:30 Lunch 12:30 – 2:30 Review and Comment on the Comprehensive Mental Health Plan 2:30 – 2:45 Next Steps/Wrap-up

4. OVERVIEW BACKGROUND

5. MHTP OVERVIEW You Are Here

6. Schedule Overview Schedule Overview Jan Feb March April May June Aug July Sept Public Input 21 Subcommittee sessions 20 Listening sessions Surveys distributed statewide TWG Reviews/ Approves Outcomes Subcommittees Prioritizes Outcomes Task groups prepare strategies TWG Reviews/ Prioritizes strategies Sterling prepares draft CMHP RDA conducts needs assessment and Resource Inventory CMHP DRAFT TWG reviews draft CMHP Submit CMHP to Governor Deliver CMHP to SAMHSA Task groups share strategies with subcommittees and modify if needed Jan Feb March April May June Aug July Sept Jan Feb March April May June Aug July Sept Public Input 21 Subcommittee sessions 24 Listening sessions Surveys distributed statewide TWG Reviews/ Approves Outcomes Subcommittees Prioritizes Outcomes Task groups prepare strategies TWG Reviews/ Prioritizes strategies Sterling prepares draft CMHP RDA conducts needs assessment and Resource Inventory CMHP DRAFT CMHP DRAFT TWG reviews draft CMHP Submit CMHP to Governor Deliver CMHP to SAMHSA Task groups share strategies with subcommittees and modify if needed

7. Mental Health Transformation in Indian Country Presentation Jim Roberts and Linda Bane Frizzell

8. In support of the Centennial Accord, the MHTP developed a process to define issues, outcomes and recommendations to transform mental health services. Included participants from the MHTP Project team, the AIHC, the DSHS IPAC and the NPAIHB Two public forums were conducted in May 2006. Information from the forums was analyzed and nine high-level issues and 12 prioritized outcomes were defined. These are detailed in the CMHP. Indian Country Report Summary

9. Issues and Outcomes Overall outcome: The MHTP activities will be developed and measured with a commitment to the Government-to-Government relationship of the Governor’s Office and the Federally Recognized Tribes of Washington State. Participation and inclusion in all facets of the development of the transformation plan and implementation will acknowledge this relationship, and seek mutual opportunities to address the mental health needs of the Native American Communities. Issue 1: There needs to be intensive efforts developed to address cultural competency issues and problems. There will be an improved understanding by State officials/employees and other local governments about tribal government legal status. There will be an increase in culturally competent mental health service providers. There will be an increase in culturally competent mental health service programs.

10. Issues and Outcomes Issue 2: There should be regular meaningful tribal consultation meetings established (annually, or biannually, or quarterly) to work with tribal representatives at the government to government level for: discussion of health issues, policy development, collaborations, seamless operations, assessment and evaluation of programs. Treaty and Executive Order Tribal Rights will be honored. There will be tribal representation on the State’s MHPAC, Ethnic Minority Advisory Committee, and Transformation Project’s committees. Issue 3: Mental Illness and co-occurring disorders are difficult to segregate (as is currently true in the current State system; but not in most tribal behavioral health programs) when the focus should be on the patient/client as a whole person who must be able to interact with multiple entities in their communities. There will be comprehensive services that are developed in a seamless system.

11. Issues and Outcomes Issue 4: The RSN system has not proved to be effective, accessible, or culturally competent for use by American Indian patients nor has there been effective participation with tribal providers. The State must acknowledge that it has a shared responsibility with the federal government to provide health services. This responsibility should not be delegated to RSNs, municipalities or other governmental entities. Issue 5: License/certification criteria needs to be changed to deem tribally certified professionals and facilities as eligible to be reimbursed for services, including where desired, direct State contracts. There will be an acknowledgement by certification bodies and payers of services to accept practices of cultural customs and traditional health practices by tribally certified providers and facilities.

12. Issues and Outcomes Issue 6: The law enforcement workforce and the court system need to be changed to adequately protect communities and become a collaborator in the mental illness service delivery system. There will be an increase in the overall number of law enforcement professionals, and an increase in capacity for improving outcomes for people who are mentally ill. The State and local governments will recognize tribal court orders with full faith and credit and accept tribal assessments. Issue 7: The state Medicaid plan needs to be changed to include more reimbursable services for prevention and for patients with mental illness and co-occurring disorders. Current programs are over burdened and consequently do not have the ability to cost-shift expenses to maintain programs and services without reimbursement. The state Medicaid plan will be enhanced to include more reimbursable services for prevention and for patients with mental illness and co-occurring disorders.

13. Issues and Outcomes Issue 8: There is not enough emphasis on the impact of the K-12 educational system and its role in mental health. This relates to the issues associated with school personnel to respond to mental health issues and administrative issues on how they operate educational programs. There will be increased support for the educational system to develop programs to increase their ability to deal with mental health issues, including allowance for the increasing numbers of drug abuse affected children. Issue 9: Resources need to be allocated to enable system changes needed to participate in the transformation project. There will be a commitment by the State to begin a process that brings together tribal service providers, higher education, Portland Area Indian Health Board, SAMSHA (including the Center for Substance Abuse Prevention and the Center for Substance Abuse Treatment), and other collaborators.

14. The following decisions are needed by the TWG. Does the TWG accept the issues and outcomes proposed in Chapter 3, Mental Health Transformation in Indian Country ? Are there any outcomes that the TWG cannot accept? Are there other outcomes that should be included? Indian Country Decision Points

15. Prevention Report Presentation David Brenna

16. The Prevention Advisory Group was formed to review and document prevention-related issues as part of the MHTP process The Advisory Group included 38 members representing multiple disciplines Discussions with agency leaders further clarified the need to include prevention activities as part of transformation. Focused on five areas/populations Infant mental health School-aged children/families 18-31 year olds at risk for serious mental health issues Preventing re-hospitalization Mental health problems for older adults Prevention Summary

17. Broad Representation on the Advisory Group Prevention Advisory Group Representation

18. Social Marketing Update Chair: Heidi Keller Department of Health Review of the CMHP

19. Current Status Update Public Comments Overview CMHP Review Process: BRIEF overview of document In-depth discussion of major themes Opportunity to discuss/resolve critical issues, concerns TWG will be asked to adopt the CMHP Review of the CMHP

20. Public Review and Comment The draft CMHP was available for public review and comment from August 1 to August 15. During this period, the website received almost 8,000 hits (the site typically receives approximately 3,000 hits per week.) The draft CMHP, in whole or in part, was downloaded just under 2,000 times.

21. Public Review and Comment 52 respondents provided on-line feedback through an electronic survey. Survey contained two types of fields Rating scale (strongly agree, agree, neither agree nor disagree, disagree and strongly disagree) Free-form feedback Survey sought feedback on each chapter and section, and overall satisfaction See handout for complete section-by-section results.

22. Public Review and Comment Ratings for all components of the CMHP were positive. Favorable responses (agree/strongly agree) ranged from 51.2% to 80%. Unfavorable responses (disagree/strongly disagree) ranged from 0% to 22%. Responses to sections on Washington-specific goals related to housing and employment were particularly favorable (~80% agreed or strongly agreed the sections identified issues the respondent feels strongly about.) Overall satisfaction with the CMHP recorded the highest unfavorable response (22.7% [10 individuals] disagreed or strongly disagreed that they were satisfied overall.)

23. Public Review and Comment Respondents generally agreed or strongly agreed that the CMHP identified the important issues and offers strategies to achieve transformation in Washington.

24. Public Review and Comment Comments were wide-ranging…both positive and negative (see handout for additional comments.) I feel the introduction was well written, clear and concise. I think it was a comprehensive WISH LIST for all past, present and future consumers and providers. It felt very energizing to even read what others were considering and realizing there was a state infrastructure developing to support realization of these goals. I honestly do not think there ever will be sufficient funds to provide housing, dx. and treatment for the ever increasing numbers of individuals who are needing intensive MH treatment. DD issues are not sufficiently addressed or highlighted in the plan. I hope this is not just another excuse to gather more information. I would like to see some RESULTS for a change. Get off it and get to work.

25. Public Review and Comment And comments provided valuable feedback and insights…. I would like to encourage the use of stronger language that addresses the need for coordinated prevention activities that are school-based. The Transformation Project presents a unique opportunity for Washington State to leverage the critical role that K-12 education can play in the development of foundational prevention skills. Accountability for social and emotional development as an integral part of preparing healthy, competent, citizens needs to be part of any comprehensive mental health plan. Outcomes are often reflective of outlooks…They [available services and supports] are designed primarily to reduce the most obvious symptoms, minimizing the need for expensive hospitalization but promising little more. it is great that you included this historical summary I would like to see a little more discussion and clarity around the current state of the RSNs.

26. OVERVIEW OF CMHP Introduction: Brief overview of process, introduces some of the key players and activities in Washington’s transformation process Chpt 1: Sets forth the state’s outcomes*, strategies*, current efforts (state agency strategic plans) and brief gap analysis Chpt 2: Governance and Organizational Structure Chpt 3: Transformation in Indian Country** Chpt 4: Prevention** Chpt 5: Evaluating the Transformation* Chpt 6: Next steps -- presents emerging themes in Washington's transformation * Previously adopted by TWG ** Decision points discussed/adopted by TWG earlier today Review of the CMHP

27. Summary The community process had little focus on this goal but did mention stigma reduction and suicide prevention. State agencies have identified a variety of activities related to stigma reduction and these activities will be pursued in Year 2 along with the Social Marketing Campaign. Treating mental health with the the same urgency as physical health was not well-defined in our community process, nor was it addressed in agency strategic plans. Next Steps Washington is pressing for a link between physical and mental health in state policy and will also pursue treating mental health with the same urgency as physical health as part of the Year 2 plan. State executives and leaders acknowledge that a transformed system will need to systemically move away from being illness focused toward one that is health focused. Federal Goal #1 Americans Understand that Mental Health is Essential to Overall Health.

28. Summary Three major themes emerged during the MHTP planning processes that will need to be considered when transforming the mental health system. Clear processes are needed to describe how consumers and families will be involved with the development and delivery of services, Models of self-directed care need to be implemented, and Funding be available for consumer- and family-run organizations. More detail is needed in each state agency strategic plan to determine how each agency is honoring the subcommittee recommendations. Next Steps State agencies need to develop detailed implementation plans describing how this goal will be achieved in their agency. The MHTP office will work with stakeholders to facilitate increased consumer, youth and family participation in agency planning processes. Federal Goal #2 Mental Health Care is Consumer and Family Driven.

29. Summary Several primary themes were raised in the community process including training providers to be culturally competent, ensuring equal access to services regardless of population group or geographic areas, broadening types of services available including alternative or non-traditional services, and eliminating disparities. Each state agency is pursuing these objectives independent of others . Next Steps State agencies need to document, with more specificity, what disparities exist in the state so strategic plans can address them. Federal Goal #3 Disparities in Mental Health Services are Eliminated.

30. Summary Coordinated, uniform approaches are needed across agencies to improve consumer and family access to appropriate services. Particularly with children, common diagnostic standards, common treatment approaches and training for consumers and professionals regarding screening, assessment and treatment referral would significantly improve outcomes. Next Steps During Years 2 through 5, the Transformation Project will promote expansion of standardized early screening, assessment, and referral with particular emphasis on children, school, and early learning programs and older adults. Federal Goal #4 Early Mental Health Screening, Assessment and Referral to Services are Common Practice.

31. Summary Many of the Subcommittees recommendations proposed that new practices be implemented, in some cases to extend existing services, and in some cases to supplant existing services. Many of the practices requested do not meet objective criteria as being “evidence-based,” and the EBPEP Task Group expanded its scope to include a number of promising and emerging practices consistent with subcommittee recommendations . Little crossover has traditionally existed between the research coming out of the academic community and the policies and practices pursued by policymakers, service providers, and consumer and family advocates. Federal Goal #5 Excellent Mental Health Care Is Delivered and Research Is Accelerated.

32. Next Steps Future planning efforts need to be more specific and concise, and engage multiple agencies working in unison to achieve tangible progress regarding many of the recommendations of the subcommittees. TWG agencies need to engage the research community to establish plans, develop core outcome measures, and pursue federal grants to conduct studies of effectiveness. The Transformation office will facilitate meetings between the TWG organizations and the research community. Federal Goal #5 (continued) Excellent Mental Health Care Is Delivered and Research Is Accelerated.

33. Summary The IT Task Group developed strategies that advance the TWG’s vision to: support linked and/or integrated data across systems; explore ways to make data available to individual consumers; and make those data available to the consumer’s multiple providers and case managers . Although the project is involved with multiple agencies in utilizing technology to document services and track outcomes, little has been done this first year to address telehealth strategies and electronic medical records. Next Steps In addition to developing integrated databases for monitoring system utilization and performance, Washington plans to pursue telehealth strategies in Year 2. We will follow the lead of the Health Care Authority on issues related to medical records. Federal Goal #6 Technology Is Used to Access Mental Health Care and Information.

34. Summary Washington consumers identified housing as a key component to successfully managing their mental illness. The lack of stable housing, including the lack of support systems to maintain housing, was a key finding in Washington’s Resources Inventory and Needs Assessment . Housing issues are intimately tied to issues of employment and general health care, and need to be considered in tandem. Next Steps The Transformation Project has been in contact with several statewide homelessness and housing committees and will work toward creating collaborative strategies to address these shortcomings in Year 2 . A number of TWG agencies identified housing as an issue in their strategic plans, however these plans lack specific implementation details and show little cross-agency coordination. State Goal #7 Individuals with mental illnesses have stable housing in the communities where they live.

35. Summary Consumers and family members clearly articulated several concerns regarding opportunities to obtain and sustain employment. While many state agencies have identified stable employment as necessary for an individual to achieve recovery, few have delineated clear implementation strategies to address this goal. All efforts to increase employment opportunities need to be coordinated with all TWG partners. Next Steps The MHTP Project is already engaged in crafting a Workforce Development Plan in alignment with SAMHSA’s efforts. In Year 2, the MHTP will facilitate cross-agency discussions in an effort to develop more specific recommendations and strategies regarding employment services. State Goal #8 Employment is an expectation and a priority in Washington for people with mental illness.

36. Transformation Themes Year 1 was extremely active and many components of the transformation effort were being built — some in concert with others and some independently. As Year 1 was coming to a close, agency and project staff worked to align all these activities. For example, significant time was spent on aligning outcomes and strategies with state strategic plans. The project team then identified gaps in implementation plans. Key agency executives were consulted to assess implications to the agencies. Project Staff identified key themes and prepared them for submission in the draft plan. On the following pages, the TWG will be asked to answer a number of questions that could drive changes in the current DRAFT CMHP for submittal to Governor Gregoire. As a result of the Year 1 efforts, a broader vision of mental health transformation began to emerge.

37. Decision Point Does the TWG endorse Theme 1? Are TWG organizations committed to integrating these recommendations into their strategic plans, including detailed implementation strategies? Transformation Theme 1 State agencies, local government, providers, advocates, consumers, and families will make every effort to implement the specific recommendations of the subcommittees. Cross-system collaborations that focus not only on symptoms, but on citizens overall health, wellness and recovery must be paramount if the system is to improve, and we are to reduce negative consequences and improve the lives of our consumers, family members, and our communities.

38. Decision Point Does the TWG endorse Theme 2? Does the TWG support recommending to the Governor and the Legislature that a state policy be adopted (through proclamation, policy directive, and/or resolution) that implements this philosophical approach? Transformation Theme 2 The state of Washington views mental health as part of overall health.

39. Decision Point Does the TWG endorse Theme 3? Does the TWG support recommending to the Governor that she create an executive policy position to focus on prevention and early intervention? Transformation Theme 3 Mental health is incorporated into existing prevention and early intervention initiatives and more coordination occurs among these programs.

40. Decision Point Does the TWG endorse Theme 4? Does the TWG support the development of an annual report card that helps state agencies track their progress toward health status improvements against a set of agreed-upon common outcomes? Transformation Theme 4 Following the lead of the Washington Health Foundation, state agencies, with leadership from the Governor, Legislature and Superintendent of Public Instruction, will develop a core set of benchmarks (outcome measures) to track the health of Washington state residents.

41. Decision Point Does the TWG endorse Theme 5? Does the TWG concur that state agencies and their contractors should incorporate into their strategic planning process clearly defined ways for increasing consumer/family involvement in the planning and delivery of services ? Transformation Theme 5 State agencies will increase opportunities for their consumers/families/youth to establish agency priorities and direction.

42. Decision Point Does the TWG endorse Theme 6? Does the TWG want to recommend the IT Task Group focus its efforts in Year 2 on further developing strategies that improve cross-system data collection, analysis and reporting? Transformation Theme 6 State agencies will improve cross-system data collection, data analysis and data reporting systems that focus not only on outputs but report on actual outcomes-reductions in negative consequences and improvements in overall consumer/family/youth/ community health indicators.

43. CMHP ADOPTION Other critical policy issues/concerns? Does the TWG approve the Comprehensive Mental Health Plan for submittal to Governor Gregoire (with any modifications from the day’s discussion incorporated)?

44. Wrap Up Questions?

45. Next Steps/ Wrap Up Sterling Associates will work with the Project Team to revise the CMHP based on decisions made today September 1 : The CMHP will be delivered to the Governor’s Office for final review. September 30: The CMHP will be submitted to SAMHSA. TWG Year 2: Schedule Focus Proposed October work session

46. Wrap Up Final comments or questions Thank you!