A Story to Live

Recently I heard a very interesting presentation by Antonio Damasio http://www.usc.edu/programs/neuroscience/faculty/profile.php?fid=27 , a behavioral neurologist from the University of Southern California and author of the upcoming book Self Comes to Mind.  Damasio talks about how each of us imagines what the story of our life will be.  We then proceed, through education, work and/or personal relationships  to make that “story”  happen.  Damasio also tells us that we may be forced or choose to re-write our story as circumstances overtake us.   He says, "You are constantly rearranging the narrative of your life, …and  you're rearranging is a function of the experiences that you have had and as what you imagine your experiences in the future ought to be."

Let me give you an example of a life story and the “rearranging [of] the narrative” that you may be familiar with.   Patrick "Pat" Tillman (November 6, 1976 – April 22, 2004) was a football player who left his professional NFL sports career and enlisted in the US Army in June 2002, in the aftermath of the September 11, 2001 attacks on the World Trade Center.  He joined the Army Rangers and served multiple tours in combat before he died in the mountains of Afghanistan.   I am sure that Pat Tillman had spent much of his high school and college years imagining and writing the story of  a professional football career in the NFL.  He undoubtedly spent much of his life pursuing that story.   Then 9-11 happened and that circumstance caused him to choose to re-write his story.   From a NFL All-Pro Defensive Back to a US Army Ranger - Pat Tillman chose to re-write his life story with unfortunately tragic results- Pat Tillman was killed in combat.

Developmental psychology tells us that as young adults many of us have identified the professional and personal paths we intend to follow.  From Damasio’s perspective we have imagined and written our life story.  For some of us the story of our life proceeds just as we wrote it.  For others some circumstance that was never planned on, perhaps a marriage, the birth of a child, a divorce, a death or other life changing circumstance has caused the story to be re-written in a way we may never have imagined.  Sometimes that “re-arranging of the narrative” provides opportunities we may never have dreamed of, other times we find an inner strength that would have gone undiscovered, and sometimes tragedy results.  But none the less the life-story does continue on.

As I thought about Damasio’s ideas and how it might related to the work we do every day, I considered the concept of “recovery” and what is we do to help the clients we serve.  Although there are many perceptions and definitions of recovery, William Anthony, Director of the Boston Center for Psychiatric Rehabilitation http://www.bu.edu/cpr/ seems to have developed the cornerstone definition of mental health recovery. Anthony (1993) identifies recovery as " a deeply personal, unique process of changing one’s attitudes, values, feelings, goals, skills and/or roles.  It is a way of living a satisfying, hopeful, and contributing life even with limitations caused by the illness. Recovery involves the development of new meaning and purpose in one’s life as one grows beyond the catastrophic effects of mental illness."   

Until I came across Damasio’s work I am not sure I could have clearly and simply articulated exactly how “recovery” manifests itself.  Damasio’s  work suggests that while we are unable to change the circumstance of mental illness that has overtaken their lives  we can help our clients to re-imagine and re-write the story of their lives.  We can help our clients to develop the skills necessary to live in the community and to manage their own illness.  Each “story” is a personal and unique process and each person writes his/her own definition of recovery.  So  for me this is the take-away-  as I work with  clients I will now give  more time to understanding the story and, now that the client has embarked on recovery, how he/she is “re-arranging the narrative” how  I might be able to help with the re-imagining and the re-writing of the story.

Be Well!

Down Memory Lane

Robin Egger is the founder and president of the DC Central Kitchen – he is known for many things in the nonprofit world but I find him at his most interesting when he is championing the cause of innovation. Egger writes, "It is not enough to see the future coming – you have to go out to meet it, confront it, challenge it and [most importantly] change it when necessary.

I started off by asking what is it that Sound Community Services does better than anyone else in Connecticut and, to some extent, almost better than many other behavioral health agencies nationwide. While we do many things well, an area for which we are getting much recognition is our innovative use of technology. Let me give you an example – just last week 11 staff members from a Michigan behavioral health organization that serves more than 10,000 clients annually, delivering 350,000 distinct services to those clients, employing 1400 staff and with an annual budget of $82 million visited our agency to see just how we do things here. These colleagues spent part of one evening and entire day with us shadowing staff in our fiscal and reception offices,  listening to detailed presentations by Emily Reynolds and Jessica DeFlumer about several of the components of our state-of-the-art ECR including our treatment plan, clinical documentation protocols, E-prescribing etc. In addition to looking at our  electronic client record they also reviewed the way in which we do staff development, support the use of technology across the agency and how we use Google apps as the base architecture for our agency intranet.  They were particularly impressed with our "Help Page."  They really did think that we "had it together" as regards leveraging technology to support our staff and enhance client services.

Obviously it was very gratifying to me for our agency to be so recognized. It has taken much hard work by many people to get us where we are today. After these colleagues left I spent some time reflecting on where we were when we started our technology journey. So let's take a trip down memory lane and rewind the clock back to September, 2004. In September, 2004 First Step was housed almost entirely at 38 Green St. Integrated Behavioral Health occupied the second floor and 2 offices on the third floor of 165 State Street. At First Step only the most senior managers had access to e-mail or the Internet and while line staff did use a homegrown UNIX software product called Caminar to enter service notes, three or more staff often shared a single computer within cramped office space. Staff frequently didn't enter their notes until the very end of the month. So you can imagine how congested the staff office and the single available computer was as the end of the month approached. I never did quite figure out how a staff member could recall the nuances of the interaction he or she might have had with the client when that interaction had happened 10 or 15 or even more days before. The Caminar system was less than reliable and each morning when you came to work you checked the department bulletin board to see if the " Caminar is up and running" sign had been posted – otherwise Caminar was down- it did seem to me at the time that Caminar was more often down than up and running. Getting notes done on time was really "hit or miss!"

And while there was a computer database for notes, the client file was still paper based. Mike Reynolds, our indefatigable IT guy, would come in every Sunday afternoon to print off reams and reams of Caminar notes. Those reams and reams of notes were taken to SAP where third shift staff collated the notes by date and by client. Once that task was completed the notes were distributed back to the programs where they were manually placed into the client file. Client files were actually large three ring binders. Clients who had received services with us for many years had multiple binders that contained literally thousands of pages. You can imagine what it was like to find a single note – it might take you hours to do so!

At IBH, software was used to schedule client appointments, bill Medicare, Medicaid, or other insurers for the services provided. Staff did have personal computers and access to e-mail in their offices. However these computers were not particularly well used. I do remember a staff member who did not know where the on/off switch was for the computer on his desk because he used the computer so infrequently. While at First Step notes were entered electronically, at IBH all notes, both clinical and medical, were handwritten on carbon-less forms. One copy of the form went to the client record and the second copy of the note went to billing. As some of you may know a signed note is required to bill for the services provided to the client.  Tracking clinicians down to get signed notes became an almost full-time job for a member of the billing staff. And on one very terrible yet memorable occasion, Integrated Behavioral Health had to pay significant dollars back to Medicare largely due to unsigned notes.  So that's how it was in 2004- very few computers, lots of paper, no spellcheck, and I'm sure lots of frustration.

In 2005, in response to the need for more integrated client services, the Department of Mental Health and Addiction Services strongly encouraged and supported the merger of First Step and IBH. While mergers are always difficult and complex undertakings, one of the major barriers to the merger of First Step and IBH was the conflicting computer systems – neither system was capable of communicating with the other. For example, First Step case managers could not read the notes or even see the schedule of services for clients served by IBH staff. IBH clinicians and psychiatrists could not read the notes of First Step case managers. It was clear that if the goal of improved services and improved communication between and among service providers was to be realized it was necessary to address the issue of the disparate computer systems once the two agencies merged to become Sound Community Services. After much investigation our agency decided upon the Carelogic "software as a service"( http://en.wikipedia.org/wiki/Software_as_a_service) solution by Qualifacts. Sound Community Services was the very first agency in Connecticut to adopt the enterprise version of Carelogic and the rest as they say is history!

Fast forward now to 2010 – there are now 12 behavioral health agencies in Connecticut who have adopted the Carelogic solution. And among those 12, Sound Community Services is recognized as a leader and innovator! As an agency we have developed a variety of strategies that leverage Carelogic and allow us to improve services for our clients. We were the first agency nationally to use the Qualifacts reporting system to develop a file upload protocol to be used to make automated appointment reminder calls. We were also the first agency nationally to utilize the Wiley databases in our treatment planning documents. Samples of our Quick Reference training pamphlet solution to support ongoing Carelogic staff development have been requested by many agencies nationally and two of our staff members now sit on Qualifacts advisory boards providing ongoing input into product development and use. We have shared our expertise both regionally and nationally – we have presented at several regional and national conferences and we are often sought out by other agencies for guidance and advice.  We have come a long way since 2004!

What will the future bring – no one knows for sure. But I do know that Robin Egger was right – particularly in the case of behavioral health-care and in this era of reform – you must be prepared to meet the future, to challenge it and change it when necessary!  Our innovative use of technology is helping us to do just that.

Be well!