Recovery Marker Inventory (RMI) - Indiana Institute on Disability and

Annual Organizational
Change Forum
System Transformation to
Recovery Focused Services
Roy Starks-Mental Health Center
of Denver
• Creating a Recovery Focused System
• Measuring Recovery
• Creating a Culture which Promotes
Recovery Focused Work
What is Recovery?
• “Recovery refers to the process in which people
are able to live, work, learn and participate fully
in their communities. For some individuals,
recovery is the ability to live a fulfilling and
productive life despite a disability. For others,
recovery implies the reduction or complete
remission of symptoms. Science has shown that
having hope plays an integral role in an
individuals recovery.” William Anthony
• Achieving the Promise—The President’s New
Freedom Commission on Mental Health 2003
Vision Statement
New Freedom Commission
• “We envision a future when everyone with
a mental illness will recover, a future when
mental illnesses can be prevented or
cured, a future when mental illnesses are
detected early, and a future when
everyone with a mental illness at any
stage of life has access to effective
treatment and supports-essentials for
living, working, learning, and participating
fully in the community.”
Recovery focused System
• 1989—MHCD formed by City of Denver in
response to Robert Woods Johnson
Foundation—Requirement for one mental health
• Denver combined four existing mental health
centers to form MHCD
(small SE program, no consumer employment,
no drop-in or clubhouse program, no strengths
based case management, mission statement of
quality mental health, no value of recovery—ie.
Business as usual)
Recovery Focused System
1989-1993—Stabilize creation of new center
1993-2000—Implementation of Lawsuit
2000—Article on “Denver Approach”
2000—New CEO with Recovery Commitment
2001—Formation of Recovery Committee
2001—Creation of RNL
2003—Completion of Logic Model
2003—Commitment to “Center of Excellence”
2004—Adoption of new mission statement
Recovery Focused System
• Enriching Lives and Minds by Focusing on
Strengths and Recovery
• 2003 to 2007-Development of Markers
and Measures
• 2007—Use of REE and conversion to
• 2006—MHCD receives award of
Excellence from National Council for 2005
for work in recovery focused system
Recovery Focused System
• Outreach and engagement
– Outreach workers in homeless shelters
– Recovery Connections
– Housing First project with CCH
– Denver’s Road Home-1) Project for Homeless
Women 2) Project for Denver’s most difficult
to house
Recovery Focused System
• Housing with Appropriate Supports
– Extensive system of Group homes,
congregate apartments, section 8 apartments
• Partnerships with Colorado Coalition for the
Homeless, Denver Housing, Colorado Housing
and Homeless program, REDI corporation, Senior
Housing Options
Recovery Focused System
• Intensive Case Management
– Ratio of 1 to 12
– Ratio of 1 to 25
– Ratio of 1 to 40
– Ratio of 1 to 80
Psychiatry only
Recovery Focused System
• Integrated Treatment for Co-occurring
– MHCD SURGE program High Fidelity use of
the Integrated Dual Diagnosis Treatment
(IDDT) as developed by Kenneth Minkoff,
– Partnerships with Arapahoe House and CCH
Recovery Focused System
• Involvement of Recovering Persons
– On MHCD Board
– Consumer/Staff Partnership Council
– Peer Mentors
– Extensive employment of recovering persons
• 40% in Rehabilitation program
• CMA, vocational counselor, residential counselors,
mail room, administration, nurses, case managers
• Survey teams; Office of Consumer Affairs
Recovery Focused System
• Supported Employment
– Use of IPS Evidence Based Practice—
Adherence to Fidelity Scale as developed by
Drake and Bond—Serves 500 annually—Part
of Mental Health Treatment Study
– In conjunction with Supported Education
program—Modified from Clubhouse model—
Part of Bridge to Community Integration
Why Evaluate Recovery?
• The Surgeon General Report on Mental
Health (DHHS, 1999), and Presidents New
Freedom Commission (DHHS, 2003)
suggested mental health providers engage
in system transformation to become more
recovery oriented.
• At MHCD, we believe that evaluation is a
critical component of system change.
– We have a constant feedback loop about client’s
recovery for clinicians, managers and directors,
thereby providing data to assist in system
Evaluating Recovery of the Person
• Development by MHCD of
Multidimensional approach to evaluating
recovery from different perspectives over
Four Measures of Recovery
(1) Recovery Marker Inventory
(Staff rating of member progress
in recovery on eight dimensions.
Used to inform clinical & program
decisions - every 2 mo.)
(4) Recovery Needs Level
(Suggests best
level of services
for stage of recovery)
To what degree is
w Multiple perspectives
w Multiple dimensions
w Change over time
(2) Promoting Recovery in Organizations
(Consumer evaluation of
how specific programs and
staff are promoting recovery
- random sample 1x per yr.)
(3) Recovery Measure by Consumer
(Consumer’s rating
of their own recovery on
five dimensions – all
members every 3 months)
Recovery Marker Inventory (RMI)
Recovery Marker Inventory
• Indicators usually associated with individual’s
– But they are not necessary for Recovery. For
example, a person may struggle to find a job because
of their level of Recovery OR because the economy is
• Collected every other month on every consumer
in high case management teams, according to a
predetermined criterion on outpatient consumers
Recovery Marker Inventory
Active/Growth orientation,
Symptom interference,
Engagement/role with service provider,
Jail episodes/days, Hospital episodes/days due to
psychiatric reasons, Hospital episodes/days due to
physical reasons,
• Substance abuse (level of use)
• Substance abuse (stages of change).
Reliability of the RMI V2.1
• Reliability- how consistently we will get the
same score for individuals with the same
level of indicators of recovery (we want high
reliability, meaning high constancy in scoring).
– Mathematically, it is hard to get a high reliability with only 6
– RM V1.0 has a CTT reliability of .67
• IRT reliability: Person = .75, Item =
• CTT reliability = .78
Item difficulty for the Recovery
Marker Inventory V2.1
Interference (.83)
Active Growth (.63)
Participation (-.10)
Housing (-.22)
Employment (-.35)
Education (-.79)
• The easiest marker is reduction in symptom interference. In traditional
treatment this will be primary goal.
• As the markers increase in difficulty that means that the number of
consumers that get a high score in this marker decreases,
•For example, if a consumer has a high score in
engagement/participation, they will also have a high score in active
growth and symptom interference because these markers are easier to
achieve for our consumers.
• The hardest marker of recovery for our consumers to achieve is education.
This means that most consumers who score high on education will score
high on all other markers of recovery.
Promoting Recovery in Mental
Health Organizations (PRO)
Recovery Enhancement
• Developed by Patricia Ridgeway
• People rate the importance of several elements
(such as hope, sense of meaning, and wellness)
to their personal recovery, and rate the
performance of their mental health program on
three activities associated with each of these
• They also rate the program on factors in the
program climate that promote resilience or
rebound from adversity
Promoting Recovery in MH
Organizations (PRO)
• Developed by MHCD to address our
special needs
• Sections for each type of staff that
interacts with our consumers (front-desk
clinical, medical, case managers,
• Currently is being piloted at MHCD
The Reaching Recovery Program is the intellectual property of the Mental Health Center of Denver. By [viewing
this presentation; receiving these materials, etc.] you agree not to infringe on or make any unauthorized use of the
information you will receive.
Recovery Measure by Consumer (RMC)
Recovery Measure by Consumer
• Intended to measure the consumer’s
perception of their Recovery
– Very useful to understand whether what we
observe matches how the consumer is feeling
• For example, a person may stay at home because
they have an introverted personality, OR because they
might have paranoia symptoms
– Sometimes, the consumer fills it out with the
help of the clinician, thus sparking new areas to
explore together
Recovery Measure by
Consumer Dimensions
Active/growth orientation
Symptom’s interference
Social network
Social Networks (-.48)
Hope (-.32)
Active Growth
Safety (.08)
Symptom Interference
The easiest domain of recovery is an increase in social networks and hope
• As the domains increase in difficulty that means that the number of consumers that
get a high score in this domain decreases,
• For example, if a consumer has a high score in safety they will also have a high
score in active growth, hope and social networks because these markers are easier
to endorse for our consumers.
• The hardest recovery domain for our consumers to achieve is symptom interference.
This means that most consumers who score high on symptom interference will score
high on all other domains of recovery.
Recovery Needs Level (RNL)
Recovery Needs Level
• Helps to assign the right level of service
to the consumers
• The basic assumption being that
consumers recover and their needs
change over time.
• Used at MHCD every 6 months in
combination with their Individual
Service Plan (ISP)
Recovery Needs Level
• Measures criteria for service needs in 17
areas such as:
• Hospitalizations
• Lethality
• Co-Occurring Substance Abuse
• Case Management Needs
Recovery Needs Level
• Completed by Primary Clinician in Electronic
• Scored Electronically According to Algorithm
• Five Levels of Service:
High intensity case management
Medium intensity case management
Outpatient service
Psychiatry only
Lessons Learned
• On average, individuals coming into
MHCD who are homeless and have a
severe mental illness, move from ACT to
Intensive case management in 18 months
• In a five year period 21% moved to more
intensive services and 64% moved to less
intensive services
Lessons Learned
• As people move to less intensive services,
they do not fall apart—In fact their
recovery markers and measures both
continue to increase.
• People at all five levels access supported
employment services.
• As people move into employment, all of
the recovery markers increase
Lessons Learned
• The first year the RNL was implemented,
25% of people in ACT moved to less
intensive services
• Following the first year, 16% move from
ACT to less intensive
• The cost for 400 openings to intensive
services the first year would have cost the
state an additional 5 million dollars.
Using Recovery
Information for Quality
Creating a Culture Which
Promotes Recovery Focused
MHCD Values
We, the staff, consumers, and governing board of MHCD, value:
• Consumer recovery and resiliency fueled by hope and
encouragement toward consumer goals
• Compassion and empathy
• Service excellence, efficiency, and effectiveness to meet the
needs of consumers and the community
• A wellness culture that recognizes, respects, and develops the
strengths of consumers, staff, and our partnerships in the
• Honesty, integrity, and ethical behavior in all our actions,
communication, and relationships;
• Diversity in our workplace, relationships, and community;
• Innovation, creativity, leadership, and flexibility
• Green sustainability to protect the environment and reduce waste
in all our valued resources.
MHCD Wellness Culture
• We intentionally bring out the best in ourselves and
others by:
• Seeing everyone’s strengths
• Supporting and encouraging one another
• Celebrating staff, accomplishments, and diversity
• Respecting ourselves and others
• Listening to each other
• Creating an environment of healthy and positive
relationships and community partnerships
• Believing everyone wants to be great
• Being passionate about our mission and having fun in
the process
• Believing anything is possible!
First Break All the Rules
Marcus Buckingham & Curt
• “The Measuring Stick
– Do I know what is expected of me at work
– Do I have the materials and equipment I need
to do my work right?
– At work, do I have the opportunity to do what I
do best every day?
– In the last seven days, have I received
recognition or praise for doing good work?
– Does my supervisor, or someone at work,
seem to care about me as a person?
– Is there someone at work who encourages my
– At work, do my opinions seem to count?
– Does the mission/purpose of my company
make me feel my job is important?
– Are my co-workers committed to doing quality
– Do I have a best friend at work?
– Is there someone at work who encourages my
– At work, do my opinions seem to count?
– Does the mission/purpose of my company
make me feel my job is important?
– Are my co-workers committed to doing quality
– Do I have a best friend at work?
– In the last six months, has someone at work
talked to me about my progress?
– This last year, have I had opportunities at
work to learn and grow?
These twelve questions are the simplest and
most accurate way to measure the strength of
the workplace.”
– In the last six months, has someone at work
talked to me about my progress?
– This last year, have I had opportunities at
work to learn and grow?
These twelve questions are the simplest and
most accurate way to measure the strength of
the workplace.”
Go Put Your Strengths to Work
Marcus Buckingham
• Set out format for how to maximize the
use of your strengths in the workplace
• Sets course for how to build on the
strengths of others and to maximize their
strengths in the workplace
Catalytic Coaching
Garold L. Markle
• Provides detailed alternative to traditional
performance evaluation which enables
people to create a course to maximize
strengths and accomplishments
– Employee input sheet
– Coaches perception
– Employee creates plan
Client Driven Treatment Planning
• Individual Service Plan (ISP)
• Asks consumers what they need and
• Elicits consumer’s strengths
• Actively uses consumer strengths in
objectives and methods
• Used and reviewed with the consumer
• Included in Peer Review
Service Planning
• The Individual Service Plan asks consumers:
– What do you need and want?
– What skills, interests, resources, and qualities do you
– What cultural/ethnic/racial/spiritual strengths do you have?
– What do you see as the areas you'd like to change?
– Other input from consumer about priorities
• Clinician input about priorities
• The Case Review is integrated with the ISP and
involves consumers
• Six Month Case Review
– Consumer Perception of Progress
– Clinician Perception of Progress
– Consumer-identified treatment focus for next six months
Role of the
Electronic Medical Record
• STAR / eCET integrated platform
• Helpful tool for Quality at the Source
• Service integration
– Service delivery coordinated with service plan
– Service integration among all staff
– Actively includes Rehab and Residential
• Peer Review
• Extensive staff training
• Integration with recovery instruments
Data Collection: Integration and Automation
• Automated and integrated processes
• Recovery Instruments:
Integrated with STAR electronic medical record
• Show rate reports
• Peer Review:
– Conducted electronically using STAR documentation
– Input into an MS Access database for analysis
• Goebel UM Review:
– All new admissions, identified in STAR database
– Outliers identified in STAR services database
– Services and documentation compared with RNL in
• PRO Survey (Promoting Recovery in MH Organizations)
– Scannable forms eliminate manual data entry
Benefits of Our Integrated Systems
• Performance and process feedback to
clinicians, managers, administration
– Peer review trend reports
– Clinician utilization reporting
– Consumer complaints data and reports
• Compliance with state and federal
Due dates
Benefits of Integrated System
• Systems for collaboration,
cooperation, involvement
– Accessible data
– Efficiency through automatic data capture
– Efficient and effective peer review
– Information to provide quality care
– Effective utilization of resources,
clinical and administrative
• Mentor, Measure, Motivate
– Engage clinicians in using recovery data
– Focus on what’s measured
– Identify best practices
– Watch trends for continuous improvement
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