Big Changes in Big Sky Country
By Barbara Kriskovich, Organizational Consultant
The Rural Institute
"Who are you?" said the caterpillar.
This was not an encouraging opening for a conversation. Alice replied rather shyly, "I hardly know, sir, just at present—at least I knew who I was when I got up this morning, but I think I must have changed several times since then."
Lewis Carroll, Alice's Adventures in Wonderland
Montana is always interesting in the spring, but for those of us who are involved in services for people with mental illness, this spring brought about big changes in Big Sky Country so that we, like Alice in Wonderland, hardly know who we are. The big changes were the result of events that finally brought to an abrupt end the State's experiment with privatizing the public mental health managed care system.
By April, the 1999 Montana Legislature passed Senate Bill 534 as the vehicle to define a new mental health managed care system. Senate Bill 534, introduced by Senator Bob Keenan of Big Fork, generally revised the laws regarding public mental health delivery, requiring the Department of Public Health and Human Services (DPHHS) to incrementally implement a mental health managed care system. Incremental implementation allowed for time—time to find the system that would work for consumers, their families, the state, and service providers.
On June 30, 1999, the DPHHS and Magellan Health Services terminated their existing contract to provide public mental health managed care. This left Montana with no payment system for public mental health services and forced DPHHS to piece together an interim system.
Local mental health service providers, feeling a money crunch, laid off staff.
This was a system in change, with real people's
health care on the line. It was against this backdrop that the
Rural Institute's Montana Rural Mental Health Employment Initiative
(funded by the Substance Abuse and Mental Health Services Administration—SAMHSA)
took place. The Rural Institute staff took advantage of the changes
being made to work with state officials, the Legislature, local
community mental health service providers, and individuals with
mental illness to help shape a new managed care system that emphasized
employment of people with disabilities. Our philosophy is simple:
a job is the best
social program.
The Montana Rural Mental Health Employment Initiative's (MRMHEI)
goal was to expand the supported employment capacity of public
mental health services in four small rural Montana communities.
Each community's mental health provider received an annual subcontract
of $10,000 to build local employment capacity in replicable ways.
The project focused on consumer self-determination, policy refinement,
and staff training. Rural Institute staff worked in partnership
with the four regional mental health centers and provided intensive
and recurrent on-site training and technical consultation focused
upon employment, alternative funding, and supports for individuals
with psychiatric disabilities because a job is the best social
program.
The State Level
The Montana Psychiatric Association hosted a retreat that was facilitated by Dr. Robert Cole, whose specific skills in strategic planning and policy formation helped to guide the group. The retreat included psychiatrists, providers, consumers, legislators, DPHHS personnel, family members, and advocates. This retreat helped to slow down the process of replacing Magellan Health Services's managed care system and to take a closer look at the process. At these meetings, the Rural Institute was represented and emphasized the importance of employment. The mission statement of the group was "the Coalition for Montana Communities of Care propose and support a system involving bottom-up organization, which is open to efforts to incorporate the wisdom of successful programs from other areas, which changes incrementally, starts pilot projects, and contains a sophisticated purchasing agency."
Following this retreat, the Department of Public Health and Human Services held a series of town meetings. More than 400 people participated in twelve meetings. Attendance was diverse. A variety of topics were discussed, including the need for local managed care representation, and a simple, responsive grievance and appeals process for health care claims. The Rural Institute attended these meetings to discuss employment. Other items mentioned were the payment of claims, number of people being served, consumer information, and availability of services.
DPHHS also held a public hearing to discuss the proposed rules for the interim mental health program, which took effect July 1, 1999. The rules include proposed reimbursement rates for providers. At this hearing, the Rural Institute once again stated the need for employment services and supports to be a part of the mental health care system. Another key concern that consistently surfaced was the need for crisis intervention services. Case management and caseloads were discussed.
DPHHS sought input from people who were interested
in serving on the new Mental Health Oversight Advisory Council.
Some ninety people applied to serve on the new council. The new
council met for the first time in August 1999. The council consists
of nineteen members, including State Senator Bob Keenan who served
as chair. Consumer representation on the council is fifty percent.
The council will:
- assist in the development of Request for Proposals for mental health services,
- assist in evaluating the proposals,
- recommend planning priorities and review and comment on the state plans for mental health services,
- review and comment on administrative rules
- identify and recommend performance and outcome measures
- report to the Legislative Finance Committee
- identify desirable statutory changes
- monitor, review, and evaluate the adequacy and allocation of services
- act as a conduit for direct community input to the Department.
Also on the state level, Governor Marc Racicot appointed Bonnie Addee as the Mental Health Care System Ombudsman, a position that was created by Senate Bill 534. The Ombudsman will represent the interests of consumers and families involved in the public mental health system.
The Community Level
During the months of February and March, the Rural Institute Training Department hosted Open Space Meetings in Livingston, Hamilton, Miles City, and Conrad, the four community sites in the Montana Rural Mental Health Employment Initiative. The meetings reflected both the feel of Montana and the individuality of each community. The purpose of the meetings was to increase the capacity for employment of people with mental illness. The meetings were well attended with an interesting mix of consumers, service providers, and business people. The meetings were held in the late afternoon from 5:00PM to 7:00PM with desserts and beverages offered after the meeting.
It seems only natural that in Montana's Big Sky Country Open Space Technology would be used for town meetings. Open Space Technology works where conflict and confusion are present. It is effective when a diverse group of people must deal with complex and potentially conflicting information in innovative and productive ways. It is particularly powerful when nobody knows the answer and the ongoing participation of a number of people is required to deal with the questions. The Open Space environment encourages people to be creative, synergistic, and self-motivated. Any size group can use Open Space Technology. The local mental health centers and the organizational consultant from the Rural Institute compiled a mailing list of people in the community to invite. This list included consumers, family members, business people, agency staff, community leaders, and interested people. The invitation did not include a prepared agenda, but an invitation to be a part of a creative meeting. People were told that every issue and concern would be addressed and that they should "be prepared to be surprised." These interactive meetings initiated a substantial community consensus building process.
When participants arrived for the meeting, they
were greeted with colorful posters. The posters explained:
- The Theme - Employment of People with Mental Illness
- The Four Principles:
- Whoever comes are the right people.
- Whatever happens is the only thing that could have.
- Whenever it starts is the right time.
- When it's over, it's over.
- The One Law -The Law of Mobility, which says that if, during the course of the gathering, any person is in a situation where they are neither learning nor contributing, they must move to another small group to discuss a different piece of the puzzle.
- Be Prepared to be Surprised.
Chairs were placed in a circle, as a circle encourages communication and openness. When everyone was seated in the circle, the purpose/theme of the meeting was stated. Participants were asked to write their concern/issue on a piece of paper and post it on a wall. Every issue of concern to anyone was raised and each person took responsibility for that issue. All issues were discussed in detail in small groups. A full report of issues and discussions was made available to all participants. Action plans and priorities were written. Passion and responsibility drive successful Open Space Meetings.
The meetings provided a forum for open communication without agendas. Because of the openness, many wonderful ideas were expressed. One participant expressed the need for more assistance finding employment and getting needed supports after becoming employed. Several participants talked of concerns about returning to work and its impact on their Social Security benefits. One consumer expressed the importance of finding an employer who will understand your disability and treat you well. The issue of transportation was a universal theme in all the meetings. It was noted that the community could be educated about mental illness when consumers involve themselves in the community through service clubs and organizations. The fear of disclosure was an issue for many consumers. Some people feel comfortable disclosing and other people prefer not to disclose their illness. Small business and self employment ideas were brain stormed. One participant stated that everyone has skills that are useful in business. Someone noted that being employed is important for self worth and money, but it is also important that people continue to explore talents and abilities. There was consensus in all the communities that people will continue to work together on the ideas generated by the meetings.
The Open Space Meetings were important in bringing together a variety of people in the communities to focus on the idea of employment for people with mental illness. The meetings also empowered consumers to openly talk about issues that were of concern to them. Business people were eager to assist with ideas and suggestions. These meetings made everyone realize that we are all members of the community and want to be active and involved members of the community.
Business Advisory Councils are also being formed in the communities as a result of these Open Space Meetings. The councils have consumers, business people, and service providers as members. The Business Advisory Councils will expand as the implementation phase of this project gradually replaces the consensus building phase. The councils meet monthly to work on employment opportunities in the area for people with mental illness. The business people who have stepped forward are truly a gifted and energetic group.
The Individual Level
In each of the four MEMHEI communities, Rural Institute organizational consultants helped individuals with psychiatric disabilities to find work and helped their mental health care services to provide employment supports.
In Conrad, employment has become a reality instead of a dream for Coby. In July of 1999, Coby began working at the Conrad IGA grocery store three days a week from 10:00AM to 2:00PM. He starts his day by sweeping the entryway to the store, then bags groceries and stocks shelves. Coby's co-workers are supports. They taught him how to bag items separately and to know when a grocery bag is full enough. Coby learned to stock shelves and how to stack carts to get the most benefit from each trip.
After the first week of work, Coby was more relaxed and comfortable with customers. His personal appearance is clean and neat, and he purchased new clothes for work.
In August of 1999, Coby was given a chance to increase his hours and days and now he works four days a week from 10:00AM to 4:00PM. He did this just as the store was remodeling with new checkout counters and a lot of mess. His supervisor said that Coby handled it all with ease. Coby has done well and can be proud of the work he is doing and his success. Judy Buechler of the Golden Triangle Mental Health Center has been supporting Coby's learning his new job.
In Livingston, Elizabeth (who has had lots of work experience) is now working part-time as a rehabilitation aid. Elizabeth has worked on a volunteer basis for the Angel Line in Livingston. A Plan for Achieving Self-Support (Social Security PASS plan) was written for Elizabeth for transportation.
Lee has also started working as a clerk at a local deli. Other people are working on employment goals, including dog grooming, medical transcription, school for graphic arts degree. Claire Hendrickson, a case manager in Livingston, has taken the lead on work and job development. She has encouraged people to take a chance on work.
In Hamilton, Lawrence is working at Mountain Rose Pottery. A talented artist in a variety of media, including the use of computer graphics, Lawrence wanted a job in the town of Victor, which is close to home. His job at Mountain Rose Pottery is the result of Jean McDonald's (of Western Montana Mental Health Center) good job development practices. Lawrence, his family, and his employer are all thrilled with his employment.
In Miles City, a group of five consumers have joined together, with the help of Vocational Rehabilitation, the Job Training Partnership Act (JTPA), and Jeanne Vetch, the day treatment director, to start a small business. The Miles City High School does not have a school lunch program, so students go out for lunch—a ready market for the Lunch Express. Vocational Rehabilitation provided a catering trailer to use for their business and JTPA provided startup funding. Lots and lots of elbow grease was needed to clean the cook trailer completely and Jeanne added hand-tailored curtains. One of the consumers skillfully designed the eye-catching logo.
On October 1st, the Lunch Express began serving food from 11:30 AM to 1:00PM near the high school. As these new business owner/operators become more proficient with cooking and selling, they plan to branch out into other areas of retail trade.
Conclusion
Even though this year's project focused on building community consensus, employment has already become an option of choice. But convincing state government, local mental health service providers, and individuals with mental illness to embrace the idea that employment is key takes hard work on the state, local, and individual levels. MRMHEI expanded the supported employment capacity of the public mental health services in four small rural Montana communities during the project's first year. The project's success is largely due to the big changes Montana's mental health managed care system has undergone this last year. The atmosphere of change provided an opportunity to reshape and refocus an entire system on the idea that a job is the best social program. It's that simple.