About SAPT Recovery

SAPT Background

What is the Self-Assessment/Planning Tool for Implementing Recovery-Oriented Mental Health Services (SAPT)?

The Self- Assessment/Planning Tool for Implementing Recovery-Oriented Mental Health Services (SAPT) was developed by a team of faculty, consumers, and service providers at the University of South Florida’s Florida Mental Health Institute (FMHI) under contract to Florida’s Medicaid Authority, the Agency for Health Care Administration (AHCA).  The SAPT helps mental health service provider agencies translate the recovery vision to effective policies and practices.  It provides a survey to track agency performance in recovery-oriented services implementation and a planning/implementation guide to suggest options for enhancing service delivery.

SAPT Background Topics


Domains

SAPT domains are organized under the categories of Administration, Treatment, and Community Integration, and provide the structure for both the self-assessment and planning/implementations sections of the tool:

Administration

1.      Philosophy
2.      Continuous Quality Improvement
3.      Outcome Assessment
4.      Staff Support
5.      Consumer and Family Support

Treatment

1.      Validation of the Person
2.      Person-Centered Decision Making
3.      Self Care – Wellness
4.      Advance Directives
5.      Alternatives to Coercive Treatment

Community Integration

1.      Access
2.      Basic Life Resources
3.      Meaningful Activities and Roles
4.      Peer Leadership

For each recovery domain the SAPT provides a four-point scale to help determine the agency’s level of capability in critical areas, describes important characteristics of services, and suggests strategies/activities for improving implementation.  The domains correspond to outcomes described in the Recovery Oriented Systems Indicators (ROSI), a consumer-based outcome measure (Dumont, et. al., 2006).  The SAPT may be used independently or together with the ROSI.  The SAPT helps agencies establish policies and practices that result in positive recovery-oriented services outcomes.  The ROSI informs agencies about the degree to which they have achieved those outcomes.  Applied together, the SAPT and ROSI may be used to support processes for policy development, program planning, staff development, and outcome evaluation.

The Recovery Vision is Critical to Delivering Effective Mental Health Services

The vision of recovery for people living with serious mental illnesses is fundamentally one of hope: hope that disturbing symptoms can be overcome; hope to become a meaningful participant in community; hope in the possibility of a life fully lived.  In the recovery vision, the integrity of the person is paramount; mental illnesses and the symptoms associated with them pose challenges to the person but they do not define the person (Anthony, 1991; Degan, 1988; New Freedom Commission on Mental Health, 2003).

The hopeful and empowering vision of recovery is contrary to assumptions that have shaped mental health policy and practice for the past half century.  Traditional beliefs viewed mental illnesses as following a course of long-term deterioration in symptoms and functioning that will necessarily limit meaningful participation in community life.  Mental health systems and programs offered little hope that persons with mental illness could ever achieve a vital and satisfying life.  Consumers of mental health services often felt diminished and demoralized by the very system designed to help them (Clay, 2005; Degan, 1988).

The vision of recovery is important because it reflects our most current understanding about the nature and course of mental illnesses and because it allows us to develop policies and practices with the potential of being truly helpful (Harding, Zubin, & Strauss, 1987; Harding et. al., 1987a;).   At its heart, the vision of recovery is about consumers having full participation at all levels of the mental health system, working as partners, and sharing both power and responsibility (Jacobson and Curtis, 2000; Mercer, 2006; Onken, Dumont, Ridgway, Dornan, & Ralph, 2002).

Recovery is Now the Lynchpin of Federal Mental Health Policy

The publication of Achieving the Promise, the report from President Bush’s New Freedom Commission, recommended a transformation of the nation’s mental health system of care.  It is the most important mental health policy document of the last 25 years and has been the catalyst for systems improvement activities throughout the country. The commission assessed our mental health system as “fragmented and in disarray leading to unnecessary and costly disability, homelessness, school failures and incarceration” and recommended fundamentally transforming service delivery based on a vision of recovery (New Freedom Commission on Mental health, 2003). The Commission’s Report and the documents of its subcommittees provide valuable guidance for translating the vision of recovery into policies and practices.

The shift to a recovery orientation in mental health systems and programs are the result of advances in our understanding of the course and treatment of psychiatric disorders.  Longitudinal research has demonstrated that recovery is a reality for as many as two-thirds of individuals with serious mental illnesses (Harding, Zubin, & Strauss, 1987; Harding, Brooks, Ashikaga, Strauss, & Breier, 1987).

Florida Medicaid Studies Identified the Need for Tools to Support Recovery-Oriented Mental Health Services

The SAPT was developed at the University of South Florida’s Florida Mental Health Institute (FMHI) under contract to Florida’s Medicaid Authority, the Agency for Health Care Administration (AHCA), in response to a two-part study entitled, Recovery-Oriented Medicaid Services for Adults with Severe Mental Illness – Parts I and II (Winarski, Thomas, Dhont, & Ort, 2006; Winarski, Thomas, & DeLuca, 2007).  The studies examined the implementation of new Medicaid services intended to promote the recovery and rehabilitation of adults with severe mental illnesses. These services were described in the Community Behavioral Health Services Coverage and Limitations Handbook (AHCA Handbook) and were designed to replace other, less rehabilitative approaches (Agency for Health Care Administration, 2004).

The studies included a series of interviews and focus groups with consumers, service provider administrators and clinicians, and representatives from managed care organizations.  They described a period of transition in programs implemented by mental service provider agencies, with both consumers and staff engaged in a process of defining new roles and responsibilities in the delivery of recovery-oriented services.   The studies also identified the lack conceptual frameworks and service implementation tools needed to support this transition, with no systematic way to ensure that the services described in the AHCA Handbook were delivered at an acceptable level.

Major response themes from the studies were organized across five areas:

Consumer Engagement

  • Consumers did not always experience program activities as relevant to achieving life goals.
  • Consumers had varying levels of participation in agency operations and there was little evidence of equal working partnerships.
  • Consumers often experienced treatment planning as a bureaucratic rather than an interpersonal process, in contrast to staff perceptions of treatment planning as being highly person centered.
  • Consumers generally expressed high levels of satisfaction with agency services but expressed more critical views when asked to provide specific details of experience.

Recovery-Oriented Service Delivery

  • Staff perspectives on recovery principles and practices vary considerably across individuals, with some actively integrating a recovery orientation into practice , while others expressed little knowledge/understanding of recovery as it relates to mental health services, and viewed recovery as an unrealistic expectation.
  • Services placed a greater emphasis on skills teaching in the clinical setting and less on real life application of skills.
  • Both consumers and staff are in a process of transition in roles and responsibilities as it relates to recovery.  Both consumers and staff expressed struggles with the emphasis on greater consumer self-direction that is central to the implementation of recovery-oriented services.

Community Integration

  • Many consumers experience loneliness and isolation.  This was expressed even among consumers living in group settings (e.g., Assisted Living Facilities, also known as ALF’s).
  • In addition to accessing treatment, mental health services were described as an important way to maintain social connections.
  • The lack of affordable housing and employment opportunities and lack of transportation creates a significant barrier to achieving full community integration.

Work Force Issues

  • Staff turnover was a described as a concern by consumers in each of the programs studied. Program staff also identified lack of staffing as a barrier to effective service delivery.
  • Most staff did not express a strong need for technical assistance or training. Only one person identified the need to learn about rehabilitative recovery-oriented services. This lack of interest in training may be indicative of an incomplete awareness of the knowledge and skills required to effectively implement rehabilitative recovery-oriented programs.

Finance Mechanisms

  • The studies concluded that the shift in some AHCA areas from fee-for-service financing to capitated systems, represented by managed care organizations, has important implications for the delivery of rehabilitative recovery-oriented services.  Fee-for-service financing focuses on discrete units of care defined by medical necessity.  Capitated financing, on the other hand, can provide more flexibility while also being more compatible with the holistic approaches of recovery-oriented services.
  • The definition of rehabilitative recovery-oriented services in HMO contracts is a critical determinant for how these services are delivered.

Pilot Studies of the Self-Assessment/Planning Tool for Implementing Recovery-Oriented Mental Health Services (SAPT)

In response to these findings, AHCA approved a project to support the development of a tool to assist Florida agencies with the planning and implementation of recovery-oriented services (Winarski, Dow, Hendry, Robinson, and Peters, 2009). The Self-Assessment/Planning Tool for Implementing Recovery-Oriented Mental Health Services (SAPT) was tested as part of a pilot program in which seven Florida mental health service provider agencies completed a self-assessment survey to establish a baseline of recovery service capability and developed program strategies to enhance recovery service implementation. Processes and procedures for implementing the SAPT on the internet using the Qualtrics software program were also developed.  In addition, the findings informed revisions made to the survey and planning/implementation guide.

The second phase of the pilot implemented both the SAPT and ROSI surveys at five Florida mental health service provider agencies.  We applied statistical analysis to findings and determined a strong linear relationship between the SAPT and the ROSI; agencies with a high a SAPT score tend to have a high ROSI score.  We further tested the web-based method of data collection for both the SAPT and ROSI surveys and found it to be a viable/preferred method for data collection.

Applied together, the SAPT and ROSI provided information from an agency and consumer perspective that can be used to support recovery-oriented policy development, program planning, staff development, and outcome evaluation.

James Winarski, M.S.W.
University of South Florida

College of Behavioral & Community Sciences
Dept. of Mental Health Law & Policy,
Louis De La Parte Florida Mental Health Institute
13301 Bruce B. Downs Blvd.
Tampa, FL 33612-3807

(813) 974-6490
FAX (813) 974-9327

jwinarski@fmhi.usf.edu