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JSM Levels of Care

                                                 QUALITY OF SERVICES IN
                     PUBLIC MENTAL HEALTH /HUMAN SERVICES AGENCIES
 
 
We can ask the question, “What are the values of public agencies who provide mental health services and other kinds of human service programs?”, and we can add a second question, “What should these values be?”  This first question refers to what is, and the second refers to what is the ideal that we want to pursue.  Let’s take this distinction a little further.
 
Ten to fifteen years ago human service agencies devoted much time and effort to developing mission statements and vision statements.  In individual agencies, committees met and some kind of summary was created consisting of  high flying prose meant to be inspiring to employees and comforting to the people they served.  These statements were then posted on the wall for everybody to see.  Surely, these statements represented the ideals of the agency, put in words, but oftentimes these words were lost in actual practice,  in the “real” world of human service work. 
 
Many think, the real world is for realists; idealism is for dreamers.  Realists are supposedly anchored.  They have their feet on the ground.  Idealists are somewhere up in the clouds, floating, detached from reality.  Put this way, you can see why many say that idealism in social work is not exactly flourishing today.  Idealism branded as unrealistic and impractical is likely to fare badly, as it has over the past 20 years, notwithstanding the mission and vision statements made by virtually every human service agency in the state.  Forget for a moment the views of individual social workers.  Administrators for certain had to be realists.  They had to guide the department, or the agency, through the rough and tumble, often grimy, terrain of a political reality.  Is it possible that these administrators were the first to ignore their own mission and vision statements? 
 
Or have they?  What about individual social workers?  How important is idealism to each of these employee classes in public human services?   If you listen closely to the words of social workers, mental health therapists, and other employees of public agencies you often hear references to ideals being implemented in practice, value judgments about right and wrong approaches in providing care, passionate commitments to people they serve, and inspiring examples of responding to human needs.  On the other hand, in human service departments, you also hear the deadened sounds of rote speech, repetitious phrases, and empty aphorisms emanating from the hallways and meeting rooms.  Attachment to meaningless terminology is widespread in human service departments.  One is immediately struck by the proliferation of labels and categories applied to roles and functions, to services and programs, and to the clients themselves, labels and categories that often have little meaning, and worse yet are misleading.  One also sees  rules and regulations blindly and mechanically followed, as though compliance and obedience is naturally a good thing, and governing by policies no one really understands,  or really believes in much at all.  So which side does your agency show to the world?  Both of these?  One of them?  Which one?
 
Must we chose?  Or can we have both?  Does one narrative defeat the other?  How would we know which side we are showing to the public, and to each other, in our myriad conversations with clients, schools, police, and the common citizen?  Do we dare ask the question:  “What do we ourselves really believe in as public employees?”     
 
Is realism simply following custom and habit, even if these are bad habits?  Listen to the oft repeated refrain uttered by people working in human service agencies:  “That’s the way we’ve always done it.”  When we talk about the real world of social work and mental health practice, is that as far as we can go?  Is that what we meant when we wrote our mission statements and vision statements?  Another way of putting this question is to ask, “Can we maintain a commitment to better services in public agencies, keeping to the ideals while obedient to the persistent and immediate demands of daily labor?”  What do we need to do to put these principles into practice?  Should we dust off our mission and vision statements written long ago, and have never looked at since?  How can we return to basic values, while limiting the stifling influence of our own bad habits?
 
To answer these questions, let’s consider some of the issues that affect day-to-day practice in human services.  Let’s go to the place where social workers and mental health practitioners work “on the ground”. 
 
 
 
      
 
                        Program Model                       Standards of Care                   Quality Rating                                               
Level 1.           Conventional*                         Minimalist                               Fair
 
Level 2.           Quasi-integrated**                 Enhanced                                Fair to Good
 
Level 3.           Fully integrated***                 High                                        Excellent
 
 
*Conventional model
 
This model emphasizes categories of services.  The programs and staff are divided according to specialty.  Labels and categories are made concrete and fixed, as if they referred to real objects, rather than referring to processes.  Clients are labeled and put into the program that handles people with that label.  Often the labels are wrong, and the categories don’t fit, so the individual is moved around from one category to another, or is given several categories of service at the same time, with minimal attention to meaning and purpose in referral activities.  Many clients fail as a result of movement around the system.  Meaning and purpose is usually defined by program category, as opposed to needs of the client.  As long as these services have staff with the right credentials and fill out paperwork correctly these programs will pass state certification reviews.  The biggest failing of these programs is that the emphasis is on following procedures with minimal attention to clarifying the foundational theory behind decision making throughout the episode, whether it be short or long.  Persons with multiple and complex needs are served least well because the division of labor is scattered between several “experts” or specialists.  Often staff who sense risk make a referral to another provider to manage that risk, resulting in a program culture in which responsibilities are frequently transferred from one provider to another.    
 
 
**Quasi-integrated model
 
The link and refer model characterizing the conventional approach is modified for many of the clients, such that integrated programming occurs at least a portion of the time.  Integrated programming works best with people having multiple and complex needs.  One part of the agency is developed to provide integrated services, perhaps to one target group, while the remainder of the agency works more or less in the conventional ways.  Better use of integrated services across several target groups allows better care for that portion of the target group having the most complex needs.  Some clients will do quite well with conventional services, but many will not do well at all, and for these the integrated approach is most likely to be effective.  However, one of the weaknesses of a situation with a mixed level of services is getting the right person to the right type of care.  This process is referred to as triage.  Another weakness is that integrated services programs may be isolated from other programs and other staff.  However, in the mixed system there is a conscientious effort to integrate services for at least some of the clients needing care from the agency.
 
 
***Integrated services model
 
In the integrated agency all target groups have the option of integrated services, meaning that there is a mix of conventional and integrated services for each of the target groups.  Conventional programs and agency staff are familiar and comfortable with both kinds of services.  The triage process in the agency allows a differentiation of clients into those who need more conventional approaches and those who need more integrated approaches.  Clients needing services that are more integrated are typically those with multiple and complex needs.  These individuals are vulnerable to being passed around within the agency, from person to person, or program to program.  The link and refer culture is minimized in integrated services.  Integrated services programs emphasize the power of social connections.  A primary theme is that social relationships are central to healing and transforming someone.  Integrated services builds the social connections with teams consisting of formal and informal support persons.  Each person enrolled has a team.  These teams expect providers to be a regular member of the team, and family and extended family, and other support persons become key team members.  Team members assume primary responsibility for the care of the individual.  Teams are organized around processes that enhance communication and development of the theory (story) that guides decision making.  The narrative developed by the team focuses on improving the life of the person receiving services.  These programs are not exclusively focused on managing symptoms of illness.  Integrated services uses a developmental framework for understanding client needs.  In integrated services, process is placed front and center.  Process is visible to all team members; they are both influenced by it and contribute to it.  The team finds an anchor through story, the story of the person’s life.  All members of the team can relate to this story.  Conventional categories and labels are minimized in this approach.  Service coordination is a key function in integrated services programming.  Usually, one person is assigned as the service coordinator and that person pursues active outreach into the community to establish communication pathways with everyone involved.  The service coordinator develops and maintains connections for all members of the team, often performing this role in situ, moment by moment.  Planning by the team is anchored in process.  The process encourages the interpretation of events and actions through the lenses of meaning and purpose.  Only a person exposed to the context and who is knowledgeable of the time-frames can properly attribute meaning and purpose to an event or to an action.  That advantage allows the proper response to complex problems.  Team members put themselves in a position to relate to issues in this way.  Agencies with this kind of programming employ highly skilled generalists who can identify and promote a process orientation in the agency for all target groups.  These persons, using triage, minimize the barriers and traps inherent in conventional programming.  


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