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Game change or game over?
“Unprecedented change” has been the buzzword in Indiana for the past year, as the state's behavioral health authority and Medicaid program announced sweeping changes in their service delivery and reimbursement systems. Indiana's transformation initiative redefined consumer eligibility, service models, provider credentials, authorization procedures and reimbursement rates and rules-a “you name it, it's changing” scenario.
When almost every organizational process and system is affected by new requirements, how can a provider organization prevent a game-changing scenario from becoming a game-ending event? Staff and board members at Cummins Behavioral Health Systems had to ask ourselves that question as initial analyses of the impact of Indiana's transformation initiative pointed to a 27 percent reduction in consumers who could be served; a 28 percent reduction in staff; and a 31 percent reduction in Medicaid funding-the mainstay of behavioral health financing in Indiana.
If our leadership knew one thing, it was that we needed the engagement and brainpower of all our staff, a lesson learned as we implemented high performance team principles several years ago. (See the April 2008 article, “From top-down to team-based.”)
Our first step, which started a year ago, was “information streaming.” The planned changes were comprehensive and complex, so communications required special attention from day one. A big mistake, we believe, is to use training as the primary vehicle for implementing organizational change. To truly engage front-line staff in re-engineering, we need to involve them in re-imagining. To do that, they had to be as well informed as our managers.
Next, our data managers (the direct care and support staff from each team who are specially trained in data interpretation and analysis) assumed lead roles in carrying out an impact study. They used pivot table analysis to view caseloads (by county or program) and study them according to diagnosis, demographics, levels of need, services received, and other factors critical to qualifying individuals under the new service packages that Indiana planned to implement in July 2010.
Following this analysis, the data managers shared the results with their respective teams, who were invited to consider the findings. The results were sobering: Each team considered the potential loss of consumers, services, revenue-and jobs-within their business units. (See “Pivot table analyses show possible impacts of new system.”)
To avoid the threats of malaise and inertia that can come with such unprecedented changes, we took strong action, in the form of a comprehensive organizational reengineering plan. The plan reshaped our organizational structure, redefined staff roles, adapted electronic records and technology resources, reconstructed service delivery models, developed new staff training and supports, and revised organizational policies and procedures. A later plan addition called for the closure of two offices that lacked the clinical foundation or service volume they would need to survive in the new environment. (Affected employees were offered the opportunity to transfer to other Cummins locations.)
Each team within Cummins’ six-county service area developed its own strategies for carrying out the organizational plans according to its program and constituent needs. The following describes the efforts of one such team, the staff who deliver care in Indianapolis-Marion County.
Transforming an outpatient center into a recovery-resiliency center
The new service and reimbursement model in Indiana called for a shift from traditional outpatient care to systems that promote recovery and resiliency for individuals experiencing the most acute behavioral health disorders. Service packages would be based upon two key elements: clinical assessment and level of need demonstrated.
The model proposed major reimbursement changes. Rates for group services would be cut by almost two thirds, while reimbursements for individual skill-building services would rise significantly. Payments for traditional outpatient services-rates unchanged for more than 20 years-remained the same, leaving providers little choice but to manage these services very carefully.
The new rate structure, along with new provider credentialing requirements, rendered many traditional services (partial hospitalization, for example) unfeasible, so each county team had to shift its service array to one that could accommodate consumer needs under the new reimbursement mechanism.
To transform traditional outpatient-driven care to recovery-driven care, we focused on re-engineering service systems to:
Promote consumer access to rehabilitation-recovery services throughout the service process;
Deliver solution-focused brief care; and
Ensure clinical efficacy and efficiency to the greatest degree possible.
Redefining our organizational model of care first required us to frame clinical services in terms of best-practice recovery and resiliency models within every discipline. Most critically, Cummins developed the position of life skills specialist, a position designed to meet payer changes by providing services focused on consumer choice, wellness, and autonomy within the community (see figure 1). Each new life skills specialist attended a dedicated training program that highlighted treatment approaches and strategies that follow the recovery-resiliency framework.
Relying upon systems theory as a framework, our local teams reorganized in a manner that reflected the realignment of functions within the larger organization. Previously, like disciplines had been grouped into subsystems that interacted with one another (i.e., therapists comprised one subsystem, life skills specialists another).
The new environment required multi-disciplinary collaboration around the purpose of optimizing consumer treatment. Thus, six previous teams were reengineered into three: Adult Recovery, Family Resiliency, and Addiction Recovery (see figure 2). This new organization of teams co-located the members of a consumer's treatment team and scheduled collaboration times when team members could meet and interact with other systems/teams such as medical, intake, and addiction services.
Team reorganization strategy: Indianapolis-Marion County
Team structure and interaction
As we reorganized the direct service team structure, we also redefined the ways that we conveyed, processed, and put information into practice (see figure 3). The communication responsibilities of team members were clarified among the teams that specialize in youth and family services, addictions, and adult mental health services. A comprehensive redesign of clinical and medical staffing processes increased care planning and coordination time and made more clinical training opportunities available.
Information exchange during the interdisciplinary staff sessions reflected the principles of solution-focused brief therapy, wherein the team identifies a concrete list of strategies that each service provider will apply at the next clinical encounter. It also focused attention on the types and amounts of care provided, helping to ensure that service delivery was consistent with the new state requirements and service array.
Overall, these sessions give specific direction to each team member for service delivery while underscoring team accountability for the recovery outcome. Clinicians’ perspectives are shifted from “I serve this individual and communicate occasionally about progress” to “we have wrapped a team around this consumer and thus have ongoing discussions that provide better solutions, more timely interventions, and greater flexibility than before.”
A positive side effect of the new team structure and communications system is that unexpected crises are managed more capably as team members collaborate to mobilize resources and supports. In the past, emergency management was left up to the primary clinician.
Critical to the Marion County team's reorganization efforts was the data-driven, solution-focused high performance team approach employed throughout Cummins. We utilized this approach to involve staff in specific solution-focused collaborations related to key service delivery and redesign challenges. This approach provided a framework for sharing knowledge, mobilizing resources, and promoting innovation within and among the various office teams.
Organizational outcomes
Three months into our experience with Indiana's new service delivery system, we have been pleasantly surprised by the results. The initial impact analyses had predicted that if we did not make significant changes, we would lose consumers, staff, and revenue at a level of 20 to 25 percent. First quarter reports indicate that the number of persons served actually increased, no jobs were lost, and net service revenue increased by 15 percent over the previous year.
Pivot table analyses show possible impacts of new system
Process:
Data managers, trained in analytical techniques and integral to each of Cummins Behavioral Health Systems’ high-performance teams, used pivot table analysis to view entire caseloads and project the possible impacts of new funding and program changes within Indiana. The tables could be manipulated to show diagnoses, assessment scores, demographics, level of need, number and types of services provided and more.
These data were mined to determine:
How many clients would no longer be eligible for services because they had an excluded diagnosis?
How many were currently receiving more or fewer services than would be allowed in the future when new service package rules, based on assessed levels of need, were applied?
How many current assessments/level of care ratings appeared to be incorrect based on other data available?
How many client diagnoses might be incorrect?
Findings:
Analysis based on client diagnoses showed that 22 percent of current clients would be excluded from services. However, we estimated that 13.5 percent had diagnoses that could legitimately be changed to fit the new criteria.
Analysis based on client assessment scores showed that another 25 percent of clients could be excluded from services. Subsequent review found that assessments were incorrect for 17.9 percent of clients served and could appropriately be changed to meet the new requirements.
Overall, relative to the new service models being introduced, we found that individuals were significantly underserved. Based on data from assessments and treatment plans, our analysis showed that staff were having difficulty planning recovery-resiliency services.
Actions:
All staff received training on assessment, level of need determination, and diagnostic requirements for the new service delivery system.
Additional training highlighted service planning according to the new recovery-based model, emphasizing “the right services, in the right amount.”
Staff subsequently identified and modified assessments, diagnoses, and treatment plans in a manner that was clinically appropriate and in conformity with the new state rules.
Game plan changes, pre- and post-transformation
The changes affecting community mental health centers in Indiana have given Cummins the opportunity to enrich clinical services, develop solution-focused systems, examine current best practice models, and strengthen the resiliency of our organization. Although the score at the end of one quarter cannot predict the success of any game plan, we believe that the team approach to transformation is serving us well as we adapt to the new rules of the game.
Robb Enlow, LCSW, is Director of Marion County Operations for Cummins Behavioral Health Systems, Inc. His experience includes eight years as a therapist working with families, adolescents, children, and individuals diagnosed with personality disorders. Behavioral Healthcare 2010 November-December;30(10):14-18
