PROS Provider Handbook
Introduction
Purpose of the Handbook

The New York State Office of Mental Health (OMH) has established a new category of licensed programs known as Personalized Recovery Oriented Services (PROS). The development of this initiative included significant input from local government, recipients, family members and provider organizations.

The purpose of this Handbook is multi-faceted, including the following goals:

• to assist providers in understanding the intent of the PROS initiative;
• to assist providers in converting their existing mental health program model to a PROS model;
• to assist providers in obtaining PROS certification; and
• to provide guidelines and advice regarding the ongoing operation of a PROS program.

The Table of Contents of this Handbook provides an overview of the intended components. However, it should be noted that not all components will be released at the time of the Handbook's initial issuance. In accordance with need and availability, additional components will be distributed in the future. Revisions and updates to the original components will also be provided as necessary.

While the primary audience for this document is providers that will be converting to a PROS model, it may also serve as an informational resource for recipients, local governments, family members and other interested parties. This Handbook may also be found on OMH's website at www.omh.state.ny.us/pros. That website also includes frequently asked questions.

Background of PROS Initiative

The purpose of PROS programs is to assist individuals in recovering from the disabling effects of serious mental illness through the coordinated delivery of a customized array of rehabilitation, treatment and support services. The PROS program structure combines under one license: basic rehabilitation services, which assist individuals in managing their illness and restoring those skills and supports necessary to live in the community; time-limited, goal-focused intensive rehabilitation, which an individual can access at various points in the recovery process; ongoing rehabilitation and support, which allows a provider to offer continued assistance to an individual who has secured a job; and an optional clinical treatment component, which allows treatment services to be fully integrated into rehabilitation planning and service provision. These service components are coordinated using an Individualized Recovery Plan (IRP).

The PROS initiative utilizes the flexibility offered through the Rehabilitation Option of the Federal Medicaid Program, and will give service providers the ability to support individuals as they progress with their recovery. This approach gives local government and providers the ability to integrate multiple programs into a comprehensive rehabilitation service. Specifically, providers may combine clubhouses, employment services, intensive psychiatric rehabilitation treatment (IPRT) programs and other rehabilitation program categories, thereby reducing fragmentation, and increasing continuity of care and accountability for achieving recovery goals. Providers also have the option of converting continuing day treatment programs and integrating clinical treatment services into a PROS license.

PROS services are intended to be available in both traditional program settings and in off-site locations where such individuals live, learn, work or socialize. Providers are expected to create a therapeutic environment which fosters awareness, hopefulness and motivation for recovery, and which supports a harm reduction philosophy. Providers will be asked to collect outcome data over time in the areas of psychiatric hospitalization, emergency room use, contact with the criminal justice system, consumer satisfaction, employment, education, housing stability, and other indicators identified at the county level. These data will be used to help determine program effectiveness and each provider will be asked to develop an ongoing quality improvement process using the data.

National Context

The Institute of Medicine, National Academy of Sciences issued a report in 2001 entitled Crossing the Quality Chasm: A New Health System for the 21st Century. This report indicates that chronic conditions are now the leading cause of illness in the United States. While there are effective practices to treat many of these conditions, such practices are not generally available on the front lines of medicine; that is, knowledge does not readily move into general practice. Furthermore, the delivery system is fragmented and care is often not coordinated, leading to poor quality outcomes for healthcare consumers.

As with physical healthcare, scientifically proven effective treatment and rehabilitation practices for psychiatric conditions are not being incorporated into treatment settings. The 1998 Schizophrenia Patient Outcome Research Team (PORT) report found that, in many cases, only a small percentage of people with schizophrenia were receiving services that had been proven effective. For example, only nine percent received family education and support, and only 29 percent received the appropriate dose of medication on an ongoing basis.

A major National project is now underway to test approaches to move six science-based practices into the front lines of mental health treatment settings. These practices include: wellness self-management (also known as illness management and recovery); supported employment; family psychoeducation; assertive community treatment; integrated treatment for co-occurring mental health and substance abuse disorders; and evidence-based medication. Although such scientifically validated practices are known, individually, to produce positive outcomes, researchers have shown that when such practices are offered in combination, even more positive clinical outcomes result. For example, Dr. Ian Falloon demonstrated that if family education, problem solving and social skills training are added to medication therapy and case management, one year relapse rates can be reduced from 54 percent to as low as 14 percent.

In April of 2002, President Bush announced the New Freedom Commission on Mental Health. The final report of this Commission was submitted to the President in July 2003. The report indicated that the current system, in many cases, is fragmented and not recovery oriented. Referencing the 1999 Surgeon General's Report on Mental Health, the New Freedom Commission pointed out that scientific advances in treatment approaches for mental illness are often not readily available to Americans in need of mental health services. To address these issues nationally, the New Freedom Commission recommended:

• the development of new service delivery patterns and incentives to ensure easy and continuous access to the most current treatments and best support services;
• the use of individualized plans of care for managing illness;
• the modification of incentives to encourage continuous improvement in care; and
• increased accountability and flexibility to expand the range of services and foster creativity.

New York State Context

The challenges described above can also be found in the mental health system in New York State. Many of the current services, programs and licensing requirements have their roots in the Community Support Program (CSP) movement of the 1980s and 1990s. Although CSP approaches to managing symptoms, providing support and accepting long term disability were considered "state of the art" at the time, these CSP services now need to be updated to reflect current science-based approaches to treatment and rehabilitation, and to embrace a recovery focus and culture of hope.

New York's program and licensing categories, as currently configured, perpetuate fragmentation, lack of continuity, and do not promote accountability for sustained progress toward recovery. For example, an IPRT Program must close a case when an individual achieves the stated goal even if the person needs ongoing support to maintain that goal. People are often lost in the system as they move from one program or service to another.

The design of the PROS initiative is intended to address many of the care delivery system challenges identified by national reports and studies. Access to the range of services needed to facilitate recovery will be increased due to the comprehensive nature of the license. The Individualized Recovery Plan will promote individual and provider collaboration toward recovery, and will foster the integration of rehabilitation, support and treatment, thereby reducing fragmentation while preserving recipient choice of service providers. The flexibility of the PROS license is intended to stimulate creative development of recovery-oriented services. This design encourages a provider to work with an individual throughout his or her recovery process, thus enhancing accountability for outcomes.

The PROS license will be used to advance the adoption, on the front lines of care, of several scientifically proven practices that have produced superior outcomes for individuals with severe and persistent psychiatric conditions. These practices include wellness self-management, family psychoeducation, supported employment, integrated treatment for co-occurring mental illness and substance abuse, and evidence-based medication practices. By using the comprehensive nature of the PROS license and the Individualized Recovery Plan, these practices will be able to be provided in combination, offering the potential to amplify recovery outcomes. By collecting outcome data and using it to help improve individual and program effectiveness, a data based continuous quality improvement process is introduced. The various aspects of the PROS license, when viewed as a whole, support and encourage a recovery-focused culture and service delivery system.