WRAP Inclusion and Training: The community feedback period for this idea began on 6/10/2019 and ended on 8/9/2019

What is the problem that needs to be addressed? Please describe how it is related to mental health.
Mental health consumers are encouraged to develop a Wellness Recovery Action Plan (WRAP https://mentalhealthrecovery.com/wrap-is/) to help understand their experience of a mental illness diagnosis and also manage their life when the situation devolves towards crisis. There is no evidence that healthcare providers, specifically Doctors (MD and DO), are trained on WRAP. WRAP is not mentioned on any material associated with the Psychiatry Resident in Training Exam (https://www.acpsych.org/prite) nor on any Psychiatric Residency Training Program website this submitter has encountered nor experienced. WRAP is not mentioned on any medical insurance documentation. It is unclear if licensed healthcare providers will comply with a client’s WRAP nor if insurance companies will fund any part of a client’s WRAP. Anecdotal evidence suggests that the County of Orange Behavioral Healthcare Agency does not follow a consumer’s WRAP pre-crisis plan/crisis plan. WRAP plans are not assessed for ethics, unhealthy behaviors, case-based trends by diagnosis, best practices, case-based deviations from the WRAP formula that may be helpful, etc. WRAP plans are also not assessed for completeness, coherence, disambiguation, etc. Thus it may be difficult for a provider to understand the true intentions of a WRAP during a crisis. It is hypothesized that a private payor vs. public payor healthcare disparity/inequity exists based upon the use of WRAP.

Why is this a concern for Orange County? What can Orange County and other counties learn from this project?
Wellness Recovery Action Plan (WRAP) is a required component of many behavioral health contracts in Orange County. Mental health consumers may be at different levels of recovery and different levels of sophistication with their WRAP. At this time the many other concerns on this issue are not known but anticipated to be many.

What is currently being done to resolve this problem in our county and throughout the United States? If applicable: Is it working; why or why not?

What is new or different about this project idea? Please describe how this differs from what is already being done (Question 6). Please list any research that was done on this topic.
The novel approach for this proposal involves taking a few tools from healthcare and utilizing them together. These tools include 1) The Wellness Recovery Action Plan; 2) The Institutional Review Board for Human Subject Research; 3) (Epidemiology) The ability to find aggregated trends associated with better outcomes; 4) (Epidemiology) The ability to find exceptions to diagnostic criteria by outcome (conduct patient selection); 5) Utilize a recovery mindset to drive behavior change (i.e. stop smoking/substance use, achieve better sleep hygiene, achieve a better diet) via behavior change theory; 6) An orientation tool to maintain a connection to reality during a crisis/prevent delirium; 7) Other tools and methodologies yet to be identified.

What is the project idea? Please describe how this project will operate.
Utilize an Institutional Review Board (IRB) for Human Subject Research methodology for mental health consumers to submit a WRAP for approval to be included as part of the medical record that follows a patient into progressively more invasive care/levels of restraint. The project would have a few separate components/tasks: 1) Pre-Crisis Client Engagement for WRAP approval/feedback based upon ethics and other criteria to eventually be included in the client’s medical record; 2) Epidemiology analytics to asses trends and exceptions which can possibly lead to better care; 3) Client engagement during crisis to maintain orientation/prevent delirium; 4) Cross-agency collaboration to refer the consumer to existing behavior change platforms (i.e. 12-step, New Lung, Independent Living Training) when the client is ready; 5) Contract review to include this project into the workflows of existing healthcare resources; 6) Training for healthcare providers that did not receive WRAP as part of their professional training/licensure exam; 7) Sharing of how mental health consumers may have tailored their WRAP or augmented the WRAP process to include thought processes not previously documented; 8) Other tasks identified during the public comment period/INN review process.


Additional Information:

May 24, 2019


Innovations Team

Thank you for your submission. The Innovation team needs additional information, please elaborate on your response as best as possible so that we may work through our review process.

•This idea has many components. Please describe how a project utilizing these components would operate on a daily basis.

Via the innovations approach of the County of Orange I anticipate the day to day operations of such a project would likely be compliant with whatever contract is put in place between the County of Orange and the Contractor. It is anticipated that the Contractor will have policies and procedures utilized by employees. It is anticipated that the County of Orange will have a Contract administrator/overseer that will monitor key performance indicators agreed upon between the County of Orange and the Contractor. This submitter identifies only one entity in Orange County with the ability, interest and infrastructure likely to be successful with such a project.

I am open to advocating for this Innovation in another County within the State of California that may be a better fit for the nature of the innovation and with the ability to have more competition among bidders with anticipated ability to execute the project. Los Angeles has at least three entities likely to have the ability, interest and infrastructure likely to be successful with such a project. Ideally, I would bid this proposal out to all academic medical centers in the State of California to bring the best to the table. Unfortunately, the Proposition 63 structure partitions potential contract bidders into monopoly positions for a given community. Any monopoly bid for this project is expected to bring mediocrity.

I am open to waiting, perhaps a lengthy amount of time, for the right people with high integrity to take on this project. There is no rush to implement this project as a significant portion of this project enables professionals to suspend the rules as they are currently understood. Many rules exist for very good reasons.

Comparing and contrasting the policy strategies between mental illness and cancer is interesting. I was asked “How do we treat cancer?” in medical school. My answer was that we divide up the cancer cases into regional research networks to test different interventions. Based upon the success or failure of those interventions we change the treatment protocol for specific cancers. I was told that was the best answer the attending physician ever heard. In retrospect, I would add that we utilize a multi-factorial approach to cancer that includes traditional chemotherapy, radiation therapy, surgical excision, treating the underlying insult/cause of the cancer (i.e. limiting asbestos exposure, HPV vaccination), immuno-therapy, etc. At the best medical facilities these different specialists meet together in regularly scheduled tumor board meetings to discuss specific cases.

Obviously, we don’t have such an approach to mental illness and I am not advocating for any invasive nor expensive interventions to mental illness. So, looking at the history of Cancer policy can be interesting (https://www.nih.gov/about-nih/what-we-do/nih-almanac/national-cancer-institute-nci). In looking through that history, I am guessing that the National Cancer Institute Community Oncology Research Program (https://ncorp.cancer.gov/) was the program that enabled the cancer strategy core my answering the question “How do we treat cancer?” The NCI COPR has a description (https://ncorp.cancer.gov/about/) about what it does and some infographics (https://ncorp.cancer.gov/about/infographics.html).

I don’t want to single out any specific mental health effort in a comparison to cancer. The general strategy currently used is case based recovery model interventions (no aggregation to see which strategies are more successful to hard outcome metrics such as life expectancy, income, suicide rate nor soft outcomes such as higher level of care utilization).

See Inclusive Data Gathering (Vital Development Statistics) for specific issues that are open questions.

I would equate this proposal to a National Institutes of Health R1/P1 research grant (https://grants.nih.gov/grants/funding/funding_program.htm).

It would be appreciated if the Community Forum submission forms would remain open for repository of comments until a specific project idea meets a hard endpoint within Orange County (i.e. OC INN Team decides to not pursue, OC MHSA committee decides to not pursue, or OC Board of Supervisors votes down, comment collection moves outside the Orange County jurisdiction). The rules changes/jurisdictional changes for comment submission on a specific INN project are expected to be a pain that this submitter will likely abstain from. Having one repository to track an INN project from start to finish would be nice.

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