RTP: Opportunities in WHAM and ACA

Featured Practice

Whole Health Action Management, by Larry Fricks. Whole Health Action Management (WHAM) is being implemented by more than 1,000 peer providers in 18 states to achieve whole health and resiliency goals.

Rolled out in 2012, WHAM training was designed for the peer workforce by the SAMHSA–Health Resources and Services Administration (HRSA) Center for Integrated Health Solutions (CIHS). The program teaches skills to implement self-managed whole health and resiliency at Medicaid-billable service sites and in health homes and Veterans Administration programs. CIHS promotes integration of primary and behavioral health services and created WHAM to impart better self-management of chronic physical health conditions, mental illnesses, and addictions.

Peer support is a foundation of self-management in WHAM. In the United States, peer support traces back to as early as 1772, when Native Americans began forming mutual support groups to share experiences of hope and strength for recovery from alcohol abuse. WHAM participants engage in a person-centered planning process focused on 10 science-based health and resiliency factors to create concise whole health goals and weekly action plans supported by peers in WHAM groups and in one-on-one sessions.

The WHAM process also focuses on developing 10 mind–body resiliency skills to promote whole health and prevent relapse of addiction and mental illness. The health and resiliency factors included in the training are recommended by the Benson–Henry Institute for Mind Body Medicine at Massachusetts General Hospital, renowned for decades of research on promoting resiliency through the Relaxation Response—a stress-reduction skill taught by peers in WHAM. Mind–body resiliency skills and engagement in the healing relationships of peer support are also essential because of growing awareness of the impact of trauma, especially childhood trauma, on all dimensions of health. The 10 whole health and resiliency factors are

• Stress Management
• Healthy Eating
• Physical Activity
• Restful Sleep
• Service to Others
• Support Network
• Optimism Based on Positive Expectations
• Cognitive Skills to Avoid Negative Thinking
• Spiritual Beliefs and Practices
• A Sense of Meaning and Purpose

For financial sustainability, WHAM is also designed to teach participants how to write a whole health goal in a concise format using a six-step formula that positions the goal for weekly action plans and peer support. Recently, Peer Support Whole Health and Wellness, a new billable service delivered by peer specialists trained in WHAM, was approved in Georgia by the Centers for Medicare & Medicaid Services (CMS). Dr. Judith Cook of the University of Illinois at Chicago is conducting a federally funded 2-year randomized controlled study on the impact of WHAM–trained Peer Support Whole Health and Wellness coaches delivering the new CMS–approved service.

WHAM participants learn the following whole health and resiliency self-management skills:

• Engage in person-centered planning to identify strengths and supports in 10 science-based whole health and resiliency factors.
• Write an achievable whole health goal and weekly action plans.
• Participate in one-on-one sessions and peer support groups to create new health habits.
• Elicit the Relaxation Response to manage stress.
• Engage in cognitive skills to avoid negative thinking.
• Know basic whole health prevention screenings and how to prepare for them.
• Use shared decision-making skills for more engaging meetings with doctors.
• Implement the WHAM process at local sites.

Who can attend the training?

The training is designed for the peer workforce, but others are welcome to attend as long as they participate in the WHAM process and support local implementation.

What is included in the training?

• Training Participant Guide
• Weekly Action Plan Pocket Guide
• Peer Provider Implementation Guide
• Pedometers
• Training posters
• Training handouts
• National listserv for online peer support network and tips and tools for success

Larry is a Senior Consultant at the National Council for Behavioral Health, developer of the WHAM curriculum, and Deputy Director of the SAMHSA–HRSA CIHS. For information on booking a WHAM training delivered by National Council trainers, contact Hannah Mason at hannahm@thenationalcouncil.org.

Training and Technical Assistance

Training. RTP’s 10 Webinars support practitioners implementing recovery-oriented practice throughout the country. Recordings and slides are available to download.

2013

August: Peer Support in Behavioral Health and Its Emerging Practice Standards

May: The Affordable Care Act and Implications for Recovery-Oriented Practice

January: The Use of Medication in Recovery-Oriented Practice

2012

January: Assessing for and Addressing Trauma in Recovery-Oriented Practice

April: Understanding and Building on Culture and Spirituality in Recovery-Oriented Practice

2011

April: Person-Centered Care Planning

July: Promoting Recovery Through Psychological and Social Means

October: Graduation

2010

June: Emerging Trends in Program and Workforce Development

September: What Recovery Means in Acute Care

December: Outreach and Engagement

In August, RTP conducted a Webinar on peer support in behavioral health and emerging practice standards, where we introduced the idea of standards for the peer support profession, described the process for developing initial practice guidelines, provided a brief overview of key standard areas, and offered a first-person account of peer support’s impact. On November 7, we will discuss how these standards will affect practice by providing guidance on what peer support is (coaching, mentoring, disclosing, empowering, etc.) and what it is not (coercing, not disclosing, etc.) for peers and agencies. Presenters will address the uniqueness of peer support, how it complements other services, and its niche among the array of services available to persons with mental health and substance use disorders. Finally, a personal account of lessons learned from developing peer support programs within a state system will be provided.

Please mark November 7, 2013, on your calendars for Peer Practice and Context: Developing Quality Standards, where peer supporters and people with lived experience will describe how national standards can translate to appropriate roles in the workplace. Register today.

Technical Assistance. RTP Technical Assistance (TA) provides valuable resources that support strategies for implementing recovery-oriented care in practical and sustainable ways.

RTP’s video products can be very useful in sharing a recovery message with colleagues, friends, and practitioners. Recovery-Oriented Practice Is a Multidisciplinary Practice is a recording of the RTP presentation that was first conducted at the 2012 National Alliance for Mental Illness National Convention and at SAMHSA’s headquarters in November 2012. The video demonstrates how recovery-oriented practice can be an integrative principle among multidisciplinary teams in the field and how multidisciplinary collaboration translates to sustainable recovery practice across professional settings.

Another video, Certified Peer Specialist Story—Gina Calhoun and Scott Heller, captures an interview describing how peer support can significantly contribute to the fundamental structure and process of a treatment team meeting at an inpatient facility.

TA inquiries over the past few months have spanned the recovery spectrum, with requests for information on peer support specialist training, establishing recovery-oriented treatment approaches at behavioral health centers, and preparing recovery-oriented conference presentations.

Although behavioral health practitioners are RTP’s primary audience, anyone interested in promoting recovery transformation is welcome to access RTP training and TA. We have an extensive library of recovery-oriented articles, personal stories and anecdotes, curricula, videos, and links to relevant publications and professional sources. To access TA, contact RTP staff Monday through Friday from 9 a.m. to 5:30 p.m. at 877.584.8535, or email requests to recoverytopractice@dsgonline.com. We will respond to each request within 48 hours and make arrangements for longer consultations on a case-by-case basis. You can also access most of these resources on our Web site.

Project Update

More than 8,000 practitioners, consumers, family members, and others dedicated to improving the behavioral health care system subscribe to the RTP listserv—a reflection of the support for moving recovery into professional practice. We receive regular emails from subscribers who are interested in every component of recovery, from education, training, and implementation to workplace transformation and institutionalizing recovery principles and practices. Subscribers receive all RTP communications, including our biweekly Highlights, quarterly eNewsletters, Webinar announcements and materials, calendar events, Special Features, and Web site updates. Please remind your colleagues, family members, and friends how easy it is to join our listserv. All of these resources, including archived editions of our publications and products, are available at no cost.

Have you visited our Resources Library lately? Among the more than 1,000 multimedia items are research articles, personal stories, videos, training programs and tools, and links to valuable Web sites. We continually add new materials and welcome resources you’ve identified as helpful for advancing recovery. If you have a resource that could benefit RTP’s readers, please complete our brief Contribution Form. Our focus is on mental health, addictions and substance use, and co-occurring disorders, and our primary target audience is professional practitioners.

As the new fiscal year kicks off, the six professional disciplines—psychiatry, psychiatric nursing, psychology, social work, addiction counseling, and peer support, represented by national organizations—are marketing and launching curricula designed to train their respective practitioners in implementing recovery-oriented practice. To learn more about a particular discipline’s curriculum, read Professional Discipline Training Awards.

As always, we value your feedback and appreciate your suggestions. Our Webinars, eNewsletters, and RTP Highlights are based on your input and contributions. Please send us your stories and continue to inspire the people who are making recovery a reality every day.

Resource Spotlight

AARP’s fact sheets cover every aspect of the ACA for people over and under 65, as well as those with limited or moderate incomes and those living in rural areas. There is information on funding for suicide prevention programs and better access to health care services for minority populations, and many of the guides are available in Spanish, Chinese, Korean, Vietnamese, and Tagalog. The Health Law Answers tool generates a custom report explaining what the ACA means for individuals and families. AARP also produces a series of Webinars on navigating the ACA (past Webinars are archived).

Guest Columnist

The Affordable Care Act: An Opportunity to Embrace Trauma-Informed Care, by Cheryl S. Sharp, M.S.W., ALWF. What would it feel like to finally access health care after years of not having your basic health care needs fulfilled? Imagine going to your first appointment with a laundry list of health concerns, only to be met with impatience, insensitivity, and a lack of understanding of your experiences.

Among the discussions about the Affordable Care Act (ACA), one piece that is often lost is the potential impact on the individual’s experience with health care. Individual experience is what drives and defines trauma-informed approaches—looking at the way services are provided and the environment in which they are offered. When a client walks in, does he or she feel welcome or is the rushed experience of required screening forms and questions retraumatizing? Are we only focusing on what’s wrong with a person rather than what’s strong? People need to feel safe to come in for care and be treated in a trauma-sensitive manner.

When simplified, the ACA is about payment reform and access to services. These objectives may not seem like they relate to a changed environment, but they certainly have an opportunity to play a part. Here’s how.

The first change will be the increase in clients accessing care. Uninsured individuals who have experienced trauma will have access to health insurance options through the Medicaid and private insurance expansion. With 30 million more insured, these people will have the opportunity for preventive and coordinated care—an experience many may not have had in years. Again, providers will need to be prepared to address the unique needs and concerns of these clients in a manner that does not retraumatize, but welcomes.

Providers offering peer-delivered services have the best opportunity to enhance the client experience. Increased access means providers will soon face an even greater workforce shortage and will need to find new ways to expand their capacity. This introduces great options for states to increase their peer workforce. States with peer support services that are reimbursable under Medicaid are poised for this change.

When it comes to specific services, the ACA brings both opportunities and challenges. It does not prescribe one specific health care strategy—each state is setting its own benchmark plan and defining minimum service requirements separately. Although this means trauma-specific services may be covered (or not) differently from state to state, it establishes flexibility for providers to determine, through care management and other person-centered approaches, which services they will provide to clients. Changes in payment structures allow providers to acknowledge we are complex beings with health needs that vary over time, increasing their ability to make trauma-informed services and other person-centered approaches to care a reality.

People who have experienced trauma will benefit most from coordinated care. Adverse Childhood Experiences (ACEs) are the number one chronic health epidemic in the United States. As the ACE Study revealed, individuals who experience trauma in childhood face long-term health consequences across their lifespan, including increased likelihood of stroke, diabetes, cardiovascular disease, cancer, and early death. The exploration and encouragement of new models of care under the ACA, such as Accountable Care Organizations and Health Homes, offer an opportunity for those who have experienced trauma to receive coordinated or integrated primary and behavioral health care services.

Perhaps Robert Anda, M.D., co-principal investigator of the ACE Study, said it best by putting ACEs into perspective when considering trauma and its effect across the lifespan. “The impact of ACEs can now only be ignored as a matter of conscious choice. With this information comes the responsibility to use it.”

Integrated services provide an opportunity to increase partnerships between behavioral health and primary care to reduce retraumatization and provide assistance when past traumatic experiences are identified. It is imperative to include questions in preventive services, as well as in physical health screens, that address a person’s experience in mental health, and to be prepared to make appropriate referrals if the person has a desire to address those experiences. This is where partnerships between behavioral health and primary care can truly make a difference.

Regardless of the type of services provided, we must work together to be trauma informed. Safe and sensitive practices are not limited to a particular type of services. The principles of trauma-informed care make us consider how we provide support to those who cross our thresholds, and encourage us to create an atmosphere that helps people take control of their health and lives. There are many available tools for agencies to explore how they might address trauma and its impact in different settings.

The ACA’s long-term effects on trauma-informed services and delivery of care to people who have experienced trauma depend on the ability of providers to seize these opportunities and show their efficacy. A final parity regulation this year will solidify minimum services in requiring coverage for common trauma treatment. In 2015, the Department of Health and Human Services will reassess whether the state-based approach to reforms is working and which states have effective approaches in place.

The ACA is bringing sweeping changes to health care delivery and we have the opportunity to improve health care for those who have experienced trauma. Let’s take this opportunity and get to work.

Cheryl is the Senior Advisor for Trauma-Informed Services at the National Council for Behavioral Health. Contact her at cheryls@thenationalcouncil.org.

Professional Discipline Training Awards

The six RTP professional disciplines met in September to share results from pilot tests conducted over the past year, discuss system changes that have occurred within their specialty areas, and brainstorm ways to collaborate across training programs. The momentum gained so far, especially following the pilots, has generated great excitement among the professions and in the field—a sentiment evidenced by the numerous people and organizations throughout the country that have expressed interest in delivering the training. As one meeting participant remarked, “This used to be a movement about people with lived experience. Now that the disciplines are part of the movement, the experience is much deeper and much more diverse.”

As the associations prepare their curricula for final dissemination and delivery in 2014, each organization—the American Psychiatric Association (ApA), American Psychological Association (APA), American Psychiatric Nurses Association (APNA), international Association of Peer Supporters (iNAPS), Council on Social Work Education (CSWE), and Association for Addiction Professionals (NAADAC)—has worked diligently to first identify the unique training needs of their respective target audiences, document findings in a Situational Analysis, design and test a curriculum that reflects those findings, and develop and implement marketing strategies to disseminate and deliver their programs.

The six curricula consistently cover the recovery principles and priority concepts of SAMHSA’s 10 Components of Recovery. However, the programs’ structure varies according to the delivery methods and venues each target audience finds most effective. Staff at the disciplines’ organizations possess decades of experience developing innovative learning experiences for their colleagues, and in some cases (APNA, CSWE, and NAADAC) represent the recognized authority to design and certify training programs for the profession. Each discipline awards continuing education credit for completing training in accordance with the profession’s certification requirements.

If you are interested in delivering the RTP curriculum to your organization or staff, the professional associations welcome you to become familiar with their curricula and learn how to register and attend the training, deliver the training, or both. They also invite you to help disseminate information about the trainings through your Web sites, listservs, publications, and other existing communication channels. Specific updates and invitations follow.

The RTP curriculum developed by ApA and its partner, the American Association of Community Psychiatrists, comprises 10 modules. A total of 179 participants—including psychiatrists, medical students, residents, other mental health professionals, peers, and family members—attended the 10 pilot sessions. Participants represented personnel in various settings, including outpatient clinics, inpatient facilities, emergency rooms, and private practices, among others. As a result of the pilots, 95 percent of participating psychiatrists reported they would be likely or very likely to incorporate what they learned during training into their practice. Facilitator training is being planned for December, at which point psychiatrists and people with lived experience will learn about delivering the program online and in person. For more information on attending or co-presenting, contact Deborah Cohen.

APA is disseminating its curriculum through training councils to reach its target audience: training directors and trainees in APA–accredited doctoral, internship, and postdoctoral programs. RTP Advisory Committee members and the Committee on Assessment and Training have collaborated on the development of 15 90-minute modules, and intend for delivery to occur through public and private mental health clinics, university settings, and Veterans Administration Psychosocial Rehabilitation facilities. They are interested in discussing opportunities for people with lived experience to co-present with psychologists at upcoming trainings. Please contact Urmi Chakrabarti for more information.

APNA’s RTP staff have piloted six modules in person and recently converted the content to an online format. Delivery will include a combination of PowerPoint presentations and interaction among group participants and facilitators. During APNA’s annual conference in early October, 89 participants attended the full-day Facilitator Training. In addition to providing an overview of the program and orientation on delivery methods, the session generated interest among those who want to launch the training for inpatient psychiatric nurses and other staff within their hospitals. For more information, contact Deborah Hobbs.

CSWE plans to disseminate information about its RTP curriculum, including how to attend training and deliver it, at the Annual Program Meeting in November. The curriculum contains three modules that are broadcast via Webinar. Preparatory reading familiarizes participants with background material while post-session learning networks aim to continue facilitated conversations. For more information about how to access the training, contact Erin Bascug.

NAADAC RTP staff presented their curriculum to some 54 state affiliates and executive committee members at its annual conference in mid-October. Members throughout the country learned how to participate in the training and to facilitate delivery of the nine Webinars, each of which is presented and supported by at least one leader in the addictions recovery field (a person with lived experience). This training allows participants to learn about implementation of recovery-oriented tools translated from principles and concepts. NAADAC is enthusiastic about sharing its curriculum and has made a concerted effort to promote training materials through educational event announcements, magazine articles, and partnerships with like-minded organizations. They ask that you circulate their announcements, trainings, and magazine articles to audiences of interest, and invite you to learn how to participate and facilitate the program. Contact Cynthia Moreno Tuohy or Misti Storie for more information.

iNAPS completed its innovative delivery of pilot trainings and has significantly modified the curriculum over the past year, with content shifting to respond to participant feedback. The curriculum can be delivered in a weeklong format, span multiple weeks, or over two to three weekends in a retreat fashion. Facilitators are taught to deliver the training work from a Facilitator Guide, and all participants receive a Participant Guide. The curriculum reflects the newly emerging national practice guidelines and will be modified as core competencies and standards are developed. For more information, contact Steve Harrington.

Personal Story

Just in Time, by Joseph Maiorana. I was born in Puerto Rico in 1989. As a child, I was very friendly and giving—raised to always do the right thing. After being punished for my outgoing and outspoken behavior, however, I began to frown upon socializing. Eventually my parents broke up, which further pulled me down. My grades dropped from A’s and B’s to F’s and D’s. I stayed away from others, sitting in the corner of classrooms and hiding my head inside my backpack as I cried. I was constantly singled out and mocked, so I became the class clown—perhaps a plea for attention. High school was unbearable. I was unable to socialize and spent my lunch hour inside the kitchen hiding from bullies. Every time I said something, it would backfire and I would be ridiculed.

I dropped out of high school in my last year and locked myself in my room, going out only to see movies with my one friend. My mother would bring him to our home so we could socialize. After I left Puerto Rico and came to California, I felt even lonelier. I couldn’t reenter high school since I had recently turned 18. A counselor from a nearby college gave me the option of attending without a GED and I decided to take it. I did very well in most classes, but my social life was still dragging, along with my self-esteem and aspirations. In my last semester I was unable to afford my books and fell behind. For financial reasons I dropped all my classes and soon after started having suicidal thoughts. I searched for a job and for 5 years failed miserably. The competition was fierce and although I pursued every entry-level position you could think of, I was not that well-qualified. At some point, I gave up all hope. Turning to my mother, I cried and pleaded for help and said I would do anything, even take antidepressants, which I had resisted in the past.

A few weeks later, a therapist came to my home. She took a liking to me and offered treatment at Camino Nuevo, a mental health facility. I was very happy but a bit pessimistic since I had seen several therapists before. Talking about my problems did not seem to help, and it often made things worse. But this time was different. At the facility I met one of my heroes, Dr. Mojica. He diagnosed me with social anxiety and prescribed Paroxetine, an antidepressant. Social anxiety is more common than most people realize. For me, it was something slightly more severe than the anxiety you get when speaking in front of a classroom. It made my hands sweaty and my knees shake—and I would grow very pessimistic. Eventually I was matched with another hero, Imelda, a therapist from the same clinic who took over my case. Although I was getting a bit better, I still wasn’t going out as much as I should have. Imelda visited me at home until I was comfortable enough to go to the clinic again. She was a friendly, kind face, and I grew eager for the time we spent together.

After taking Paroxetine for some time, I couldn’t feel my heart pound in social situations like I used to. My hands stayed warm but did not sweat. It was as if I didn’t care anymore what people thought of me—I felt happy just going out and being myself. Imelda referred me to Employment Works, a branch of Goodwill, where I was matched with job coach Ryan Yowell, the next hero in my story. We hit it off right away and quickly developed what felt like a friendship, not just a coach-and-program-participant relationship. Ryan was like a mentor whom I could look up to, ask anything, and laugh with. Within 2 weeks, he helped me get a job at Goodwill. He geared me up and made me feel confident I would do well.

After working for 8 months, I have a car I bought with my own money, many friends, an exercise routine, and best of all, a promotion from Sales Associate to Peer Support Specialist. I sincerely thank the people who saved my life—those who helped me directly and from behind the scenes. Now an Associate Peer Specialist, I intend to save a life as well.

Joseph and Ryan recently helped launch a new program at Goodwill. As one of the top Peer Support Specialists and a shining example of self-confidence, Joseph has made several presentations to large and small groups over the last 3 months, smiling and having fun throughout the experience.

Related Links

The Affordable Care Act toolkit provided by Mental Health America highlights key ACA facts and resources for everything from enrollment and navigation to peer services, essential health benefits, and advocacy.

The Department of Veterans Affairs (VA) believes roughly 1.3 million veterans and nearly 1 million spouses and children of veterans are uninsured. The ACA’s Health Insurance Marketplace is a new platform where uninsured individuals can shop for policies. Veterans will find answers to their questions about benefits, enrollment, and more at http://www.va.gov/health/aca/FAQ.asp.

Only 2.5 million of the some 23.1 million people who needed substance abuse treatment in 2012 actually received it. The reasons? A lack of health coverage and high treatment costs. As one of the 10 essential health benefits, treatment for substance abuse and addiction has new options under the ACA.