Practice Change

How to Accomplish
Practice Change in
Behavioral Healthcare in
Less Than One Year

Submitted by:

Natalie S. Berger, Ph.D.
Director, Adult Network
Pikes Peak Mental Health, Colorado Springs, CO

Submitted to:

2004 Timothy J. Coakley Leadership Award
American College of Mental Health Administration
Foundation

HONORABLE MENTION

3/11/04

HOW TO ACCOMPLISH PRACTICE
CHANGE IN BEHAVIORAL HEALTHCARE
IN LESS THAN ONE YEAR

ABSTRACT :
This a challenging time in the field of public mental health. State and federal funding for public
behavioral healthcare is declining in a time when the demand for services is increasing.
Philosophical changes in mental health care service delivery, underscored by the tenants from the
President’s New Freedom Commission on Mental Health, are creating additional challenges for
practitioners. The Adult Network of Pikes Peak Mental Health (PPMH) has developed a model
for providing behavioral healthcare that meets these challenges while providing greater access to
care, holistic care delivered in natural settings and, at the same time, maintaining the quality
clinical outcomes at reduced costs.

HOW TO ACCOMPLISH PRACTICE CHANGE IN BEHAVIORAL
HEALTHCARE IN LESS THAN ONE YEAR
Background

For more than six years this community mental health center in Colorado Springs tried to convert
its traditional behavioral healthcare system to a Recovery oriented system. Three different
directors had tried and failed to accomplish this. Like many mental health centers, staff knew the
language of recovery, they could talk the talk, but the elements of practice that would define a
Recovery oriented system of care were never implemented. As Jacobson and Curtis (2000) point
out: Some states simply rename their existing programs, failing to acknowledge the necessity for
a fundamental shift toward sharing both power and responsibility 1 . The stakes for
accomplishing this change were increasing exponentially. Soon, incentives would be based upon
the recovery oriented performance measures for community mental health; funding for the
severe and persistently mentally ill (SPMI) was decreased 30% over a two year period with
further cuts expected; and accountability expectations were facing the public mental health field
across the nation, with numerous centers closing or being privatized or outsourced 2 . Time was
running short.

Our task was:

1. To define, develop and implement a service delivery model congruent with recovery
principles;
2. To improve access to care from 40 days (time to first appointment) to within 7 days;

1 Jacobson and Curtis. (2000) Psychiatric Rehabilitation Journal p. 335
2 David Lloyd (2002). How to Deliver Accountable Care

Timothy J. Coakley Leadership Award – Honorable Mention Page 1

3. To increase staff productivity from 46% to 60%;
4. To reduce the no show rate from 30% to 10%;
5. To serve more consumers with fewer dollars without a reduction in the quality of
outcomes; and
6. To improve staff job satisfaction from 2.1 to 3.0 on a 4.0 scale.

We achieved these results as identified in the table below. T tests and chi square tests of selected
data found the changes to be statistically significant at p<.01 levels. The story that follows is how
we accomplished all of this in less than one year.

COMPARISON 2002 AND 2003 PERFORMANCE METRICS
Metric 2002 2003
Ave. time to 1 st appt 40 days 2 days
Consumers active in consumer driven
15 people 92 people
services
Cost to serve individuals with severe 74% received >$500 of 61% received >$500 of
and persistent mental illness (SPMI) services/year services/year
Clinical productivity 48% 65%
Staff satisfaction 2.3 on a 4.0 scale 3.5 on a 4.0 scale
Average length of stay 1936 days 1840 days
Average cost of services/year $385 $237
No show rate for ongoing appts. 33% 13%

The Transformation Process

New management was brought in with competency in change management. The Network
Director spearheaded sweeping changes in accountability, service delivery systems, philosophy
of care and team cohesion. One of the key principles in this change process was the belief that
the staff who had been serving individuals with severe and persistent mental illness for 10-20
years had deep expertise regarding the needs of this population. Their expertise w valued,
as
respected and integral to determining both what needed to be done and how it could be
accomplished given the corporate culture. Thus, the first steps in bringing this organization to a
new level of performance was to form focus groups of consumers and staff to identify what was
working and what was not, and to generate ideas regarding what needed to be done in order to
improve care, improve morale and be more productive and cost efficient.

This project had unwavering support from the Change Champions, our CEO and COO, and
followed the change management best practices as defined by Daryl Connor (1995). Connor
defines seven elements as critical in order to orchestrate a change initiative that achieves the
desired outcomes:

? Burning Platform
? Project Champion


? Stakeholder Buy In
? Expectation Setting
? Incentivizing Change

? Marketing and Communication
? Project Planning

These elements guided the change process and provided the leadership team the vision they
needed to stay on course during the change process.

The focus groups produced a well-defined model for the needs of consumers at various stages in
their recovery based upon the Ohio Department of Mental Health (ODMH) consumer outcomes
initiative 3 The research from ODMH identified the stages of recovery, the needs of consumers
and the roles of providers during these different stages. While this model was widely publicized,
there was no known model identifying what programming should look like based upon the
ODMH research. The Adult Network designed our continuum of care based upon dose response
studies in traditional care settings and redefined these for application to a stepped care model of
treatment based upon Recovery Model principles.

Philosophical Changes

The Recovery Model: Tighter financial constraints occurred with capitated funding for mental
health in the 1980’s. This began a period of increasing accountability for monies spent in
community mental health care service delivery. Not long after this, the best practice guidelines
for treatment of SPMI began to recognize some changes in basic tenants away from a medical
model of treatment to a recovery model 4 .

1. Mental illness was no longer considered a terminal life sentence.

2. The provider was now viewed as a partner in care, not as directing treatment.
3. The treatment goal needed to be to help consumers develop meaningful roles in their
communities, not to develop a long-term therapeutic relationship with the therapist.
4. Consumers would play a more active role in decision-making and responsibility for their
recovery.
5. Delivering in-vivo care became the ideal, rather that treatment rendered within the
mental health center
6. The importance of support systems, to include family, peers and community, became
more and more central to attaining and maintaining recovery
All of these changes required a shift in philosophy and service delivery model for the Adult
Network. How could we change an institution that had built its operational systems and
business processes to support an office-based treatment delivery model to something that was
much more dynamic?

3 ODMH
4 www.mh.state.oh.us/initiatives/outcomes/resrecovprinc.html


PHILOSOPHY CHANGES REQUIRED

RECOVERY PRINCIPLES MEDICAL MODEL
Strength based illness focused

doing with doing for

integrated team individual provider

graduated disengagement long term therapy relationship

case management 50 minute hours

community based clinic based

present focused focus on past traumas

The Service Delivery Model

The ODMH four-stage model of recovery - engagement / motivation / commitment / recovery
& rehabilitation - became the philosophical basis for our programming. Four different types of
service systems based upon evidenced-based treatment protocols were designed to be congruent
with the differing needs of consumers at each stage. These treatment options were aligned with
the four stages of recovery defined by ODMH.

1. Engagement: The CORE program (Community Outreach Recovery and Engagement)
was designed around the needs of consumers at this bottoming-out stage of recovery.
The assertive community treatment model was identified as the most appropriate for this
level of care. Intensive case management of individuals who did not acknowledge their
mental illness or who were resistive to treatment in a traditional setting were served by
the CORE team.
2. Motivation: The Discovery team created a psychosocial rehabilitation model for
consumers at this level of care. Consumers served by this team did not yet have the
support systems in place to help them buffer routine life challenges and did not yet have
confidence in the providers or themselves in terms of the ability or commitment to
setting and attaining realistic goals. Therefore, community-based case management and
psychoeducational groups became the model for treatment at this stage.
3. Commitment: The Passages team was designed to support the recovery process for
consumers at this stage. Individuals served through this team received more standard
in-clinic treatment such as cognitive behavioral therapy and dialectical behavioral group
therapy. Individuals at this stage of recovery were not expected to require a significant
amount of case management and would be able to keep regularly scheduled
appointments.
4. Recovery and rehabilitation (medication-only treatment status): Individuals at this stage
are fairly well integrated into the community and have adopted a life-long approach to
wellness. They receive medication evaluations and may participate in the consumer
driven clubhouse or drop-in groups at the mental health center.


Community Integration

We developed a task force to seek out opportunities for our staff to work with consumers in their
communities and ways to create liaisons with other community agencies. We received great
corporate support from our community which is helping to break down stigma about mental
illness.

We designed a new intake model that allowed consumers to be scheduled within two days. We
implemented an electronic transfer system that created more fluidity for consumers to move
within the different levels of care, and we increased our available group programs to provide
more options for skill building, developing support systems and problem solving. Consumers
were encouraged to take our core curriculum, Recovery 101, to help understand illness
management and recovery principles and their role in the recovery process.

All of these service changes required new performance-based job descriptions so that staff would
know what their expectations were within this new system of care and so that we could identify
any new skill sets that we would need to develop to accomplish this new service model.

Facing the Hardest Challenges

Internal resistance: The new model was presented to the executive team of the mental health
center. The reaction was: “This is a great model, but we can’t do it because it would change the
whole way we do business.” In response to this, the CEO exercised his Change Champion role
by responding: “We will implement this model, and it i the role of the business systems to
s
support the service delivery model, not to drive it.” And so we proceeded to tackle the biggest
challenge of all: How to get a bifurcated system (clinical versus operational) to align with a new
service delivery structure.

Infrastructure Changes

A year-long focus group at the Colorado State Mental Health Services division examined best
practice in providing evidenced-based care concluded: “We don’t know how to execute practice
change.” Well, at PPMH we do; and we have done it; and it works. Our challenges were:

CHALLENGES
System Existing State Desired State
Admissions Individually scheduled appts. Intake clinic model with 2
with 50% no show rate and 40 days to first appointment
days out
Medical records Request charts only two times Records available on demand
per day
Appointment scheduling Set by central scheduling Dynamically set by providers
Groups Only preassigned Drop-in groups to meet
dynamic needs of consumers
Reports Standardized reports for Tailored reports with targets
measuring all clinical for each different type of
performance metrics service delivery system
Human Resources Standardized job descriptions New performance-based job
for all clinicians descriptions built upon
different competencies
required in each program

System Existing State Desired State
Information Systems Programmed to support 8 Reprogrammed to delineate 4
teams, individual primary teams and a therapeutic team
therapist model treatment concept
Transfers of clinical A manual system with Electronic transfer systems
responsibilities for cases centralized control that takes managed at the local level that
between teams or between weeks takes minutes
clinicians

Change Model:

According to best practice guidelines for change management, the following principles need to be
kept in mind:

? The #1 contributor to project success is strong, visible and effective sponsorship.
? The top obstacle to successful change is employee resistance at all levels: frontline, middle
managers, and senior managers.

? Employees want to hear messages about change from two people: the CEO or their
immediate supervisor (and these messages are not the same).
? When asked what they would do differently next time, most teams would begin their change
management activities earlier in their next project, instead of viewing it as an add-on or
afterthought.

? The top reasons for employee resistance are a lack of awareness about the change, comfort
with the ways things are and fear of the unknown. Middle managers resist change because of
fear of losing control and overload of current tasks and responsibilities 5 .
Key to success in accomplishing change at PPMH was recognizing the importance of the
executive champion, involving stakeholders from the grass roots level, developing a common
language about the changes and putting into place systems to reinforce the changes. It is also
important to provide an incentive system to ensure that changes implemented take root, thus, we
developed a variety of additional tools to help maintain the changes implemented.

Maintaining Change

Performance-based job descriptions: Performance management requires clear communication about
job role expectations. We invested time with our staff to define those skill sets that were essential
to being effective in our new team structure and service delivery model. Frontline staff
participated in defining those traits that they wanted in their teammates, and management
developed the performance targets and required skill sets for each service delivery type. All of
these were incorporated into performance-based job descriptions that are tailored for each
position. Supervisors use these as a tool in individual supervision sessions, and managers view
aggregated data on a monthly basis to ensure that each service delivery unit with fidelity to the
treatment model.

Performance data reporting: In an organization that had only measured productivity based upon
self-reported numbers of clients seen, we realized we needed reliable, valid measures of the
impact of our changes on both productivity and clinical outcomes. We had to develop new
reports and generate buy-in for management by data. Accountable care was an unfamiliar

5 http://www.prosci.com/benchmark.htm


concept to staff and one that was quite scary at first. It took nine months of working with our
report writers and having staff scrub the data until we developed reports that were accurate and
useful to staff. They now clearly can view their own performance compared to goals. These
reports help staff stay on target for caseload management, which is critical to providing quality
care.

Developing staff incentives on a shoestring budget: One of the basic tenants in performance
management is to reward those behaviors you wish to see maintained. Doing that on the typical
community mental health budget has always been challenging, and this last fiscal year even more
so. Our staff generated a list of low budget rewards that helped to bond us as a community and
recognize individuals who met performance targets.

INCENTIVES ON A SHOESTRING
Incentive Program Eligibility
Pancake breakfast served by management Everyone could attend
Training dollars awarded to those who met
Meeting 100% of performance targets
performance metrics
A special office supply product Meeting minimum performance standards
Two highest scorers on annual performance
Day off with pay to top two performers
evaluations
Summer perk of time off: four 9 hour days and
Meeting 100% of performance targets
every other Friday off
Breakfast brought to your door by the boss Meeting minimum performance standards

Such efforts generated levity while at the same time underscoring the value of staying true to our
performance goals. The most privileged benefits, i.e., time off and professional development
funding, were reserved for those who demonstrated the strongest commitment to the goals of the
organization in serving consumers. The community celebrations shared by all helped builds
cohesiveness and a stronger sense of shared joy and spirit.

Outcomes

While budget cuts have required us to cut staff and some services, such as transportation, we
have seen morale rise and consumer satisfaction increase. This is a testimony to believing in the
wisdom of those on the frontline and providing them with the support and resources they need
to do their job. There are three statements that capture the heart of what we have accomplished
here: one from a consumer, one from clinical staff and one from support staff. These are a
testament to our success.

On the day of the launch of our Recovery Model, one of the consumers who was beginning her
first day with the Discovery Team sat in the waiting room and said:

“I feel so important now; look at all the things I can choose
from.”

One of our veteran clinical staff said recently:

“These are the good times now.”

One support staff that had been with the network nine years said:

“This is the most fun I have had in my nine years with the
Center.”

Change can revitalize us even in these trying times.


References

Beer, M., & Nohra, N., (2000). Cracking the Code of Change. Harvard Business Review 78(3),
32-144.
Connor, D.R., (1992). Managing at the Speed of Change. New York: Villard Books.
http://www.mhrecovery.com/ (Ohio Dept of Mental Health)
http://www.prosci.com/benchmark.htm
http://www.state.h.us/initiatives/outcomes/resrecovprinc.html
Jacobson, N & Curtis L (2000). Recovery as a Policy in Mental Health Services: Strategies
Emerging Form the States. Psychiatric Rehabilitation Journal 23(4), 333-341.
Lloyd, D. How to Deliver Accountable Care. (2002)


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