Four pillars that support change

Community mental health centers across the nation have faced numerous challenges in the past decade: an unstable and shifting revenue base for public services, increased demand for public services, increased reliance on Medicaid, and higher expectations for quality outcomes. Washtenaw County in Southeastern Michigan has shared these challenges, but we have been fortunate to have a group of visionary leaders who are transforming healthcare in our community.

We believe that now, more than ever, organizations need systems to transform to respond to both external challenges and to proactively meet their own internal goals. In Washtenaw County, our goal is to create a community where behavioral healthcare is recognized as both a right of all citizens and integral to the well-being of both individuals and communities. We hope that some of the lessons we have learned will benefit other communities as well.

The Four Pillars

As Washtenaw County transitioned to managed behavioral healthcare, a regional approach, and options for integrated care, leaders struggled to create a culture of commitment to excellence, fiscal and clinical accountability, and a willingness at every level to implement evidence-based practices. While the system was not broken, it was mired in complacency, and leaders knew we were not fully prepared for the challenges ahead.

In our journey we have identified four “pillars” that have become the foundation for our system's transformation:

• Change Leadership

• Information Management

• Integrated Healthcare

• Evidence-Based Practices (EBPs)

Change Leadership and Information Management provide the essential structure needed to deliver EBPs and Integrated Healthcare. These powerful tools are transforming our system and changing lives.

A shared vision produces results that can't be bought. Through Change Leadership we have created a vision of recovery and integrated healthcare. The stakeholders in the vision include public officials, policy boards, major health systems, providers, payers, consumers, and families. While creating a vision for a community in which every citizen experiences the best possible health and well-being, we also have articulated the necessary components of a system that will support the vision.

To enable this future, leaders have exhibited the courage to redesign and restructure the organizations they lead. In May 2000 this led to the creation of the Washtenaw Community Health Organization. The WCHO replaced the community mental health board and created a new policy board with broader responsibilities. Through this transformation, oversight of publicly funded behavioral healthcare, substance abuse treatment, and primary care for indigent and Medicaid populations was integrated into a single administrative unit. The WCHO is a joint venture between the Washtenaw County Board of Commissioners and the University of Michigan Health System. The WCHO also operates in close partnership with the county's Public Health Department, the Washtenaw Health Plan (a county-based health plan for adults who are indigent, are uninsured, or have low incomes and who do not qualify for state or federal programs), and Community Support and Treatment Services, the primary provider of community mental health services.

The WCHO and its partners are transforming the system from a culture of compliance to a culture of commitment, in which staff members at every level are committed to a common, yet personal, vision. We have learned to apply the principles and practices of leadership, management, and coaching across multiple systems to create quantifiable results for consumers and the community. As a result, both consumer and staff satisfaction levels have continued to rise during a decade that has included massive restructuring, multiple budget cuts, and heightened expectations from all sources. For example, consumer satisfaction has increased from the 85 to 90% range to the 90 to 96% range, depending on the program and the satisfaction element. Through simple but powerful leadership tools based on a commitment to the success of each individual and each partner, we have unleashed unexpected reserves of talent, creativity, and energy.

Well-managed information reduces costs and leads to unexpected insights. Information Management is the second pillar and provides the infrastructure for transformation. We decided to create our own information technology system, called Encompass. Prior to the new system, our IT systems were disjointed and inadequate. We used separate systems for billing, basic data collection, and authorization processes. Our clinical record was entirely paper-based with only billing information and basic demographics captured electronically. We surveyed a number of off-the-shelf and customizable products but did not find one that would comprehensively meet our needs.

Our new system is a Web-based electronic medical record and information management system that lays the technologic foundation for implementing Integrated Healthcare and EBPs. The WCHO, provider network, Public Health Department, and Washtenaw Health Plan all migrated to the IT system to meet the needs of public-sector managers, providers, and consumers. The IT system's benefits are seen from the highest policy level to the individual clinician and consumer.

At the broad systems level, a data warehouse integrates information from multiple sources, providing the necessary information for data-based decision making. After implementing the IT system, we have been able to compare utilization and cost data across behavioral health, substance abuse, and primary and specialty care at the community level. This has led to the implementation of programs that target critical health issues, such as diabetes management for persons with serious mental illness.

In addition, the IT system can track and manage data for more than 130 quality indicators, including the HEDIS measures for physical health; state-required indicators for mental health, developmental disabilities, and substance abuse; and locally defined indicators. Subsequently, accreditation and corporate compliance activities have improved, as evidenced by positive results on multiple audits by external bodies.

The IT system has laid the foundation for timely, efficient, and consistent documentation of service delivery, allowing for enhanced utilization and performance analysis at the provider level. For example, by using the IT system, one partner agency had a 78% increase in Medicare and commercial insurance collections. Data entry at the point of service has eliminated redundancies and reduced errors. This has created cost savings in administrative support, which allowed dollars to be shifted to clinical services during budget reductions.

The Web-based IT system is coupled with mobile technology to enhance service delivery in consumers' homes, in partner agencies' facilities, and in outreach settings in the community. The IT system supports standardized clinical protocols based on EBPs, which help guide clinicians in decision making.

Care improves by holistically focusing on the mind and body. The third pillar is Integrated Healthcare. We know that people with mental illness have a higher incidence of major chronic health disorders, including diabetes, hypertension, cardiovascular disease, COPD, asthma, and substance abuse. We also know that individuals with medical/surgical diagnoses often have co-occurring mental health conditions, typically anxiety or depression.

Integrating our system's governance, finance, and information management created the opportunity for care integration. We first established integrated health services access for behavioral health, substance abuse, public health, and physical healthcare services for Medicaid and indigent consumers. A single phone call can result in an assessment for all services.

Integrating direct services was the next step. Using the data warehouse, the partners have integrated behavioral health and primary care services in clinics. Based on the concept of a medical home, in which each individual receives complete care in the setting of his/her choice, we have placed primary care services within the public mental health system and behavioral health services within the primary care setting. There are now six such settings in our community. These partnerships also have established a mechanism for community mental health consumers in recovery to transition to primary care settings for ongoing support. Early data from our integrated healthcare sites demonstrate increased access to services and a high level of consumer satisfaction.

Treatments based on facts improve consistency and quality of care. The close alliance between physical healthcare and behavioral healthcare has supported the adoption of EBPs, the fourth pillar. In determining what care would be delivered in an integrated, recovery-based system, we placed a high value on EBPs. In line with the priorities of the Substance Abuse and Mental Health Services Administration, our local community mental health system provides Assertive Community Treatment, family psychoeducation, integrated dual disorder treatment, and supported employment, as well as monitors prescribing practices. Each of these programs has been evaluated for fidelity to its model, and programs and teams challenge themselves to continue to improve fidelity over time. Staff members' enthusiasm for EBPs has led to layering multiple EBPs within programs. Our commitment to EBPs has included the development and implementation of promising practices for homeless outreach and treatment and jail diversion services.

Many who have attempted EBP implementation understand the challenges and resistance to changing clinical practices. In fact, our early experience with EBP implementation showed us the need for change leadership and infrastructure development. Our early EBP adopters generated data confirming the improved outcomes demonstrated in other communities, but they needed the support of a systematic, yet inspirational, approach to change leadership, coupled with ongoing access to resources and data. Today staff members at all levels generate ideas for using evidence-based models.

Conclusion

Many communities face a long road toward economic recovery. Public services and public funding will continue to face resource constraints and ever-increasing levels of accountability. In Washtenaw County, we firmly believe that the way forward lies not in doing more with less, or even in doing less with less. We believe that through system transformation based on Change Leadership, Information Management, Integrated Healthcare, and EBPs, we will continue to improve quality, expand access to care, and offer consumers a path to recovery.

Donna Sabourin, MA, LLP, is the Executive Director of Washtenaw County Community Support and Treatment Services, a department of the Wash-tenaw County, Michigan, government, providing community mental health services under contract with the Washtenaw Community Health Organization. She has worked for Washtenaw County for 15 years and in community mental health settings for 30 years.

To contact the author, please e-mail sabourid@ewashtenaw.org.