Case Examples

Behavioral Health Challenges in the General Hospital Practical Help for Hospital Leaders l Table of Contents Introduction

The case examples in this booklet were developed to Recommendation 1 ...... 2 accompany the AHA Behavioral Health Task Force’s Hospital leaders should ensure that assessments of the health needs and recommendations, most of which are listed to the resources in their community include specific attention to behavioral illness. left. See page 37 for a complete listing. Please refer to the “Recommendations” booklet for a comprehensive discussion of the task force’s work. The Recommendation 2 ...... 5 Case Examples, Recommendations and a Hospital leaders should review and evaluate the organization’s behavioral health TrendWatch issue brief are components of the AHA’s plan in light of identified community needs, the behavioral health needs of their resource Behavioral Health Challenges in the patients, and available community resources. General Hospital: Practical Help for Hospital Leaders, available at www.aha.org Recommendation 2a ...... 10 Hospital leaders should use a comprehensive financial and operational assessment to evaluate the benefits and economic value of behavioral health services to all operational components of the hospital.

Recommendation 3 ...... 13 Hospital leaders should encourage and actively participate in (1) developing a community-wide and/or regional plan for persons with behavioral health disorders and (2) coordinating community agencies addressing behavioral health needs.

Recommendation 3a ...... 18 Hospital leaders should work with community agencies and support services and with state and local governmental authorities to ensure that all patients are treated in the most appropriate setting so that the hospital’s backstop role is appropriately limited.

Recommendation 3b ...... 22 Hospital leaders should create a formal plan that clearly defines its role and its established relationships for behavioral health with other providers, practitioners, and governmental and community agencies.

Recommendation 4 ...... 28 Hospital leaders should clearly communicate to public and private payers the costs required to care for behavioral health patients, especially those with chronic and severe conditions, and the costs to society of not treating those patients.

Recommendation 4b ...... 32 Hospital leaders and their associations should become advocates for the public mental health system and its adequate funding.

Recommendations Summary ...... 37

Practical Help for Hospital Leaders 1 Case Examples

Recommendation 1 Hospital leaders should ensure that assessments of the health needs and resources in their community include specific attention to behavioral illness.

Collaborating with Community Partners for a Community Health Assessment Edward Hospital & Health Services, Naperville, IL

Summary The Behavioral Risk Factor Survey is a randomized Edward Hospital & Health Services collaborated with phone survey of the health and behaviors of adult and the local United Way and the county health department child residents of Naperville. Secondary data from pub- to conduct a comprehensive, multimodal needs assess- lic health data sources and statewide risk assessments ment for their community. The results of the assess- complete the survey process and provide a benchmark ment assisted Edward Hospital in allocating resources to against which certain results of the survey can be com- meet the behavioral health needs identified. pared. A supplemental survey questionnaire sent to all households in Naperville asks respondents to identify Community and Hospital specific human care service needs and to evaluate the The city of Naperville, IL, located 28 miles west of level of satisfaction with these services. downtown Chicago in DuPage County, is one of the fastest growing cities in the country. As of 2005, the To supplement the survey results, focus groups involv- population was estimated at 147,779 with a median ing individuals who are leaders of or have special insight income of $93,338 per household. Approximately 2.5 into different segments of the population are conducted. percent of the population lives below the Federal The focus group participants identify primary concerns Poverty Level. Naperville has been ranked as one of the of the populations they represent and of the community top 100 best places to live in the U.S. overall.

Edward Hospital & Health Services consists of a 236- Results of the Edward Community Health & Human bed, not-for-profit, acute care hospital Needs Assessment of 1995 identified untreated mental (Edward Hospital); a 110-bed psychiatric hospital illness and depression as key community concerns. The (Linden Oaks Hospital) that provides a wide range of assessment also demonstrated the need to focus on the inpatient and outpatient behavioral health services; two quality and availability of both psychiatric and substance health and fitness centers; and a variety of related health abuse services, particularly outpatient services. The 2000 services. survey indicated that these issues are still concerns.

Program Overview Program Impact Edward Hospital has had a strong focus on mental As a result of the 1995 assessment, Edward targeted health since 1995 when it was identified as one of the behavioral health as one of its top three priorities, with top issues in Edward’s Community Health & Human the following objectives: Needs Assessment Survey. Conducted again in 2000, • Increase access to inpatient and outpatient behavioral the survey is a collaborative effort between Edward health services in Edward’s community. Hospital and Naperville United Way. The results of the • Expand awareness of behavioral health issues and assessment assist Edward Hospital in allocating resources treatment options available at Edward. to address the health care needs of Naperville residents • Focus on providing comprehensive, high quality and assist the Naperville United Way in identifying new behavioral health treatment options for patients across agencies and programs to support and in allocating the continuum of care. funds to its affiliated agencies. In the past year, Edward completed the following initia- There are four components to the needs assessment: the tives to meet these objectives: Behavioral Risk Factor Survey (conducted in conjunc- • Strengthened and expanded Linden Oaks’ Resource & tion with the DuPage County Health Department); Referral services to meet a growing community need. supportive data obtained from secondary sources; a sup- • Expanded child and adolescent services available with- plemental survey (mailed with the assistance of the City in the community with the opening of the Linden of Naperville); and community focus groups. Oaks Child & Adolescent Center.

2 Case Examples • Developed intensive outpatient and traditional outpa- collaborative initiatives with other community organiza- tient services to treat patients suffering from anxiety tions. One of their management team is on the board disorders. of the Naperville United Way. • Redesigned the child/adolescent inpatient program to better serve patients and families. Lessons Learned and Advice to Others • Strengthened relationships with schools, professional The hospital’s mission to serve the community can best providers, and the faith community. be met when services are designed to meet identified needs of the local market. Working collaboratively with Program Funding local community government and agencies ensures the Funding for the assessment is shared primarily between appropriate delivery of needed services. The benefits of Edward Hospital and the United Way of Naperville. collaboration extended well beyond the scope of this The City of Naperville pays the cost of mailing the sup- project to the wider organizations. Tremendous feelings plemental survey questionnaires. The hospital takes a of accomplishment, good will, and collegiality resulted lead role in data collection and analysis. from the project.

Obstacles or Challenges Contact: Because of the hospital’s strong position in the communi- Mary Lou Mastro ty, there are no obstacles to the collaborative assessment. President Linden Oaks Hospital at Edward Success Factors Naperville, IL This type of broad community assessment can only be [email protected] successful with collaboration. Edward has a strong pres- 630-527-3017 ence in the community and ongoing involvement in • • •

Discovering What the Community Believes Is Lacking in Mental Health Services Stormont-Vail Regional Health Center, Topeka, KS

Summary needs assessment. The purpose of the assessment is to Partnering with the local United Way and other health gather information from residents and community lead- care providers in a community needs assessment, ers related to health and social welfare conditions. Stormont-Vail Regional Health Center identified com- Stormont-Vail uses findings from the survey to help munity needs related to behavioral health services in the identify key health care needs and set priorities as part area and developed goals to meet these needs as part of of their strategic planning process. the system’s strategic planning process. Among the top issues identified in a recent community Community and Hospital needs assessment were concerns about the availability of Topeka is the capital of Kansas and the fourth largest quality mental health services in the Topeka area. city in the state. As of 2005, the population of Topeka Leaders from organizations involved in behavioral health was estimated at 117,326. The median income is – including Stormont-Vail – came together to determine $35,726 per household. Approximately 14.6 percent of whether these concerns were valid, and if they were, to the county lives below the Federal Poverty Level. develop strategies to meet the needs.

The second oldest hospital in Kansas, Stormont-Vail As the group evaluated the survey results, it became evi- Regional Health Center, Topeka, is a 586-bed acute care dent that two issues needed be addressed. The first was referral center for northeast Kansas. The hospital is part a lack of public awareness of behavioral health care of Stormont-Vail HealthCare, an integrated health care options available in the community. The recent loss of system serving a 12-county area. two major mental health providers in the area contributed to a public perception of a significant loss in Program Overview inpatient services; however, Stormont-Vail had begun to For the past several years, Stormont-Vail Regional expand services to offset this loss as early as 2001, when Health Center, along with other health providers and they opened Stormont-Vail West as a freestanding community organizations in Topeka, has collaborated behavioral health center. They tripled the number of with the local United Way in conducting a community inpatient beds available within the organization and

Practical Help for Hospital Leaders 3 Case Examples

expanded services to include child and adolescent units. Program Funding Although the public’s perception regarding the availabil- Primary funding for the community needs assessment is ity and quality of inpatient services was not valid, supported by the United Way and its partners. Stormont-Vail viewed these observations as valuable feedback. As a result, the hospital intensified its efforts Obstacles or Challenges to increase public awareness of available services and to The major challenges in responding to the community communicate information on how these services can be needs assessment were operational in nature. The devel- accessed by those in the community. opment of additional services required additional space. Making programmatic and facility changes had impacts The second behavioral health care issue to emerge from on other services that had to be addressed. the needs assessment was a shortage of behavioral health outpatient services. Outpatient service providers were Success Factors turning patients away because they were unable to pro- The major factor for success was the high level of support vide the services needed. Stormont-Vail worked with for behavioral health services within the organization. local community mental health centers to revise policies that adversely affected access to outpatient care. At the Lessons Learned and Advice to Others same time, Stormont-Vail began to evaluate its own For others interested in being involved in similar pro- behavioral health plan in light of the community assess- grams, the Stormont-Vail Regional Health Center expe- ment findings and to explore viable options for expand- rience provides some helpful advice: ing outpatient services. • A community needs assessment is a key tool for identifying community needs that can help shape an orga- Program Impact nization’s behavioral health services. Because behavioral health is a core service of the organi- • Don’t discount the subjective feedback that is received zation, goals to advance the development of additional as part of a community assessment. Even if the pub- outpatient behavioral health services were incorporated lic’s perceptions are incorrect, they may provide into Stormont-Vail’s strategic plan. In the current year’s insights into the need for greater or more targeted plan, one of the goals is to analyze outpatient needs for marketing and communications efforts. specialized services such as dementia care and senior • Participation with other stakeholders in the needs partial hospitalization. assessment review process provides opportunities for increased communication and potential collaboration Additionally, the plan calls for the formalization of a among community behavioral health organizations. medical detoxification program as a base for future substance abuse services. The elements of the program Contact: include: providing formal education to nursing staff on Julie DeJean detoxification protocols, providing formal substance Administrative Director abuse education to all social work staff, adding detoxifi- Stormont-Vail West cation protocols to the nursing assessment tool, identify- Topeka, KS ing designated detoxification beds, and developing trau- [email protected] ma requirements for substance abuse screening. 785-270-4613 • • •

4 Case Examples Recommendation 2 Hospital leaders should review and evaluate the organization’s behavioral health plan in light of identified community needs, the behavioral health needs of their patients, and available community resources.

Leveraging Resources to Meet the Needs of Underserved Populations California Hospital Medical Center, Los Angeles, CA

Summary assessment in the greater Los Angeles metropolitan area. California Hospital Medical Center (CHMC) collaborat- The assessment identified a number of mental health con- ed with local hospitals to conduct a community assess- ditions in the community, including depressive disorders, ment. Findings from the assessment suggested a need past trauma, acculturation problems, marital difficulties, for increased capacity to provide more culturally sensitive parenting problems, domestic violence, stress, and pover- and competent mental health services in a timelier man- ty. Many adults with these types of mental health prob- ner. CHMC set strategic priorities that leverage hospital lems fail to receive treatment because of lack of health and community resources to meet these needs. insurance coverage or other funding. Findings from the assessment suggested a great and growing need for Community and Hospital increased capacity to provide more culturally sensitive and In 2005, Los Angeles County, CA, had an estimated competent mental health services in a timelier manner. population of 9,758,886 with a median income of $48,248 per household. Approximately 16.3 percent of In an effort to address this need, CHMC incorporated a the population lives below the Federal Poverty Level. focus on behavioral health in its request for letters of The community served by CHMC – a total population intent for the 2005 grant program, including: of around 1.2 million people – has the highest popula- • Outpatient mental health services that address depres- tion density, lowest median income ($23,000), highest sion, anxiety, and post traumatic stress proportion of immigrants, lowest educational levels, and • Mental health services for adults that address common highest unemployment and underemployment rates in sub-clinical problems such as acculturation, marital the county. difficulties, parenting problems, domestic violence, stress, and poverty California Hospital Medical Center is a 316-bed not- for-profit hospital that has been a member of the down- Six of the seven projects awarded grants in 2005 had a town Los Angeles community since 1887. The hospital behavioral health component: is an affiliate of the not-for-profit Catholic Healthcare • Amanecer Community Counseling Services was West (CHW), a system of 41 hospitals and medical cen- awarded $12,500 for its Indigent Adult Mental Health ters in California, Arizona, and Nevada. Services Program, which provides a range of service for the severely mentally ill, primarily Latino, indigent Program Overview adults living in Central/Downtown Los Angeles. Every three years, each Catholic Healthcare West hospi- • Jewish Family Services of Los Angeles Gramercy tal conducts a community health assessment and identi- Place Shelter was awarded $12,500 to be used for a fies strategic priorities based on this assessment. The comprehensive package of services being provided to CHW Community Grants Program awards grants to shelter clients, including critical mental health services address the priorities identified in the health assessment for homeless families with children. and/or the community benefit plans of CHW hospitals. • Immanuel Presbyterian Church was awarded CHW grant funds are to be used to provide services to $12,500 for its Community Yoga Classes. The classes underserved populations: the economically poor, will provide physical exercise as well as breathing and women and children, mentally or physically disabled, or relaxation techniques that help to reduce feelings of other disenfranchised populations. Each hospital iden- stress and anxiety and improve concentration. tifies nonprofit organizations in their service areas whose • Los Angeles Child Guidance Clinic was awarded projects advance the objectives of the grants program. $12,500 for its First Steps Program. This program used an evidence-based, home-based intervention In 2004, California Hospital Medical Center collaborated model and targets families with infants and toddlers with a group of local hospitals to conduct a community who are at risk of entering mental health or special

Practical Help for Hospital Leaders 5 Case Examples

education services in the future. organizations serving individuals and families located in • The Wellness Community-West Los Angeles was the hospital’s service area. The funds requested totaled awarded $12,500 for its Psychosocial Support for $467,500. Total funds available for the grants were Cancer Patients at CHMC’s Donald P. Loker Cancer $87,500. The hospital announced its new grantees at Center. The Wellness Community provides two psy- an awards dinner in December 2005. chosocial support groups to help cancer patients learn to manage the anxiety and uncertainty about their disease. Obstacles or Challenges • The Jumbo Shrimp Circus Academy was awarded The greatest challenge in the community grants pro- $12,500 for its Hope Street Youth Circus that involves gram is determining how to use the limited funds avail- young people age 8-18 in circus training. Circus train- able to most effectively support community organiza- ing provides physical activity, fitness training, and skill tions. There is a high level of competition for these development. Participants gain a sense of pride and grants; therefore, applicants must write strong letters of accomplishment in mastering tricks few people can do. intent and proposals in order to receive funding.

Program Impact Success Factors Impact is measured at the individual project level. Each The level of community need for behavioral health serv- grant project must have a strong evaluation component. ices contributes to the success of the program. There The applicant must describe how progress and success are many community organizations trying to meet this will be measured. At the completion of the grant, each need in creative ways. The Community Grants pro- grantee sends a report to the hospital and to CHW. gram provides a means for evaluating various community-based organizations and directing monies to those Program Funding with the most effective programs. All CHMC Community Benefits programs are funded through grants. The money available for the Community Lessons Learned and Advice to Others Grants program is based on a designated percentage of the For others interested in setting up similar programs, the total audited expenses of the hospital. Each hospital man- California Hospital Medical Center experience provides ages its own grants program, with the final review of proj- some helpful advice: ects and disbursement of funds administered by CHW. • The Community Grants Program is a superb way to help local community-based organizations achieve their goals. In 2005, CHMC sent information on the Community It requires limited staffing and operational support. Grants program to approximately 100 community organi- • The proposal evaluation process is important. Be sure zations, with a request for letters of intent. To process the you have individuals on your grant review team who letters of intent, the hospital grants program director con- are familiar with grants and who understand the fac- vened a grant review committee that included the president tors that contribute to a strong grant proposal. of the hospital’s foundation, the director of grants and contracts, the grants and contracts manager, the hospital’s Contact: director of mission integration, the hospital librarian, and Margaret Lynn Yonekura, MD the director of community benefits. Committee members Director of Community Benefits read and scored the letters of intent. Those projects with California Hospital Medical Center the highest scores were invited to submit full proposals, Los Angeles, CA which were also reviewed and scored by the committee. [email protected] 213-742-5974 CHMC received 38 letters of intent from nonprofit • • •

Collaborating to Address the Behavioral Health Needs of Homeless Children Memorial Hospital of South Bend, South Bend, IN

Summary mental, behavioral, and social needs for very young children By identifying a need for services targeted at children living in homeless families. in homelessness, Memorial Hospital of South Bend was able to partner with a local community organization to create Community and Hospital the Play, Exploration & Developmental Support program, a South Bend, IN, is located in the northernmost part of the unique program that addresses a complex range of develop- state in an area commonly referred to as “Michiana.” In

6 Case Examples 2005, the population of South Bend was estimated at monitor the progress of each child weekly. They also 97,070, with a median income of $31,867 per household. attend weekly interdisciplinary case management meet- Approximately 22.8 percent of the population lives below ings with Center staff and partner agencies. the Federal Poverty Level. Developmental screenings are an important element of the Memorial Hospital of South Bend is a 526-bed regional program because children with developmental delays are at referral center for cardiac, cancer, childbirth, emergency higher risk for behavioral problems. Also, the screenings medicine, and rehabilitation services. Memorial Health serve as a means of identifying children with special needs System Inc., established in 1984, serves as the parent com- and making appropriate referrals to community resources. pany of Memorial Hospital, as well as Memorial Health Foundation, Memorial Home Care, and Memorial Medical All the mothers and children in the program are guests at Group. the Center for the Homeless. Many of the mothers have been in abusive situations or were abused as children and are Program Overview at high risk to perpetuate the cycle. Through their exposure Memorial Hospital has developed a number of strategic to healthy role models and parenting experiences with their alliances or partnerships in the implementation of initiatives children in a safe, family-friendly environment, the risk of to aid in the creation of a healthier community. Their part- child abuse is reduced. nership with the Center for the Homeless has included several distinct initiatives, including the Play, Exploration & Program Impact Developmental Support (PEDS) program. The PEDS program has impacted the lives of more than 500 children and mothers over the 7.5 years of its existence. It has been estimated that families with young children con- Children have been provided nurturing relationships and stitute 40 percent of the homeless population. Children, in opportunities for developing trust, positive self-awareness, particular, are severely impacted by the consequences of and self-mastery skills. The program has increased the homelessness. They may experience poorer health; more mothers’ sense of confidence and competence when caring developmental delays; more anxiety, depression, and behav- for their children, enhanced their ability to nurture and pro- ioral problems; and lower educational achievement. It was mote their children’s growth and development, and this wide range of issues that attracted the attention of the increased their awareness of early intervention services. hospital, especially once a gap in services was identified for children from birth to age 3. Program Funding The main source of funding for PEDS is from Memorial’s Several meetings were held between Memorial and Center tithing program. Each year, 10 percent of the hospital’s bot- staff to discuss the needs of homeless children in this age tom line is set aside to help local organizations develop range. Subsequently, funding was solicited from the innovative programs that address a vast range of risks to Memorial Tithing Program to create PEDS, a unique pro- community health. Proposals are submitted to the gram that addresses a complex range of developmental, Community Health Action Group (CHAG), a team made behavioral, and social needs for very young children in up of community leaders and hospital administrators. homeless families. Risk factors for this population include CHAG members meet bi-monthly to review proposals, dis- premature births, developmental delays, exposure to drugs cuss resource allocation, review outcomes of funded partner- and alcohol, feeding disorders, exposure to impoverished ships, and share information about other community health environments, exposure to violence and abuse, sensory pro- initiatives. cessing disorders, and exposure to neglect. Studies have found that children who are homeless are more likely to Obstacles or Challenges have learning disabilities or emotional disturbance than The only challenges were those of any collaborative relation- children who are not homeless. ship. There were no internal obstacles because Memorial is very involved in and committed to projects that impact The PEDS curriculum, developed at Memorial Hospital, community health. follows a sensory integration model, with interventions that are culturally competent and family centered. Success Factors Occupational therapy student interns were the major Success factors for this project included the following: source of staffing for the program until the Center took The missions of both organizations (Memorial Hospital and over the program in 2005. Qualified staff with early the Center for the Homeless) were similar and very compat- childhood experience were hired and trained to continue ible. Staff who developed and worked on the project shared the model that had been already established. The PEDS the same values and worked toward the same vision. staff help with developmental screenings, make referrals There was significant community need. To obtain funding, and implement individualized intervention plans, and the team used a pilot project to highlight this need and

Practical Help for Hospital Leaders 7 Case Examples

demonstrate the potential impact of the program. ties and move from idea development and story telling When they established the program, the PEDS team identi- to resource development. fied the model that would work most effectively for the • Don’t get lost in the planning. Start with a small pro- environment in which it was used. totype, if possible, and focus on execution. Clarify roles, trust your partners, and don’t micromanage. Lessons Learned and Advice to Others • Seek a good community partner. Look for mission For others interested in setting up similar programs, the compatibility, executive leadership commitment, and experience of Memorial Hospital provides some helpful demonstrated innovation. Shared values and visions will advice, including: help your collaborative relationship weather any storms. • Think broadly about behavioral health services. Look • Hospital partnerships can help community organiza- for opportunities to address behavioral needs within tions get programs started so that, eventually, they can the context of more comprehensive programs. become self-sustaining. • Don’t duplicate services in your community. Collaborate with other organizations to pull together Contact: the right resources for the best programs. Be creative Suzanne Makielski, MS, OTR and innovative in your approach but don’t try to recre- Early Intervention Coordinator ate the wheel. There are many models already in place Memorial Hospital of South Bend and people are willing to share their experiences. South Bend, IN • Be clear about the purpose of your program. Use the right [email protected] model for the right purpose, for the right length of time. 574-647-1367 • Don’t start with finances. Instead, start with possibili- • • •

Meeting the Need for More Effective Treatment Options for Juvenile Sex Offenders Tanner Medical Center, Carrollton, GA Summary Program Overview Tanner Medical Center first became aware of the need Tanner Behavioral Health leadership first became aware for more effective treatment options for juveniles with of the need for more effective treatment options for sexual behavior problems through their behavioral juveniles with sexual behavior problems through their health needs assessment services. At the urging of local needs assessment services. At the same time, local juve- juvenile judges, they developed the Tanner Intensive nile judges began urging TBH to develop a program Program for Behavioral Change, a partial hospitalization that would provide a viable alternative to incarceration program with an intensive outpatient treatment compo- without putting the community at further risk. nent for adolescent sex offenders. Adolescent sex offenders were considered unsuitable for the partial hospitalization program because of the poten- Community and Hospital tial proximity to victims undergoing treatment. Local The city of Carrollton is located in west Georgia, a few outpatient programs tended not to be successful in miles east of Alabama and approximately 50 miles from achieving long-term behavioral change for this popula- Atlanta. In 2000, the population of Carrollton was tion. Because there were no available residential treat- 19,843, with a median income of $27,559 per house- ment programs for sex offenders in western Georgia, hold. Approximately 23.4 percent of the population referrals were often made to providers as far away as lives below the Federal Poverty Level. Atlanta, creating additional problems related to transportation and financing for treatment. Tanner Medical Center-Carrollton is a 202-bed acute inpatient hospital. Tanner Behavioral Health (TBH), a TBH was initially reluctant to consider a program of this component of Tanner Medical Center, serves adults, nature, due to the high level of liability involved and their adolescents, and children with emotional, behavioral, commitment to treating the victims of sexual abuse. After and chemical dependency problems. Services include an two years of research and consultation, and with full sup- adult inpatient unit; partial hospitalization and intensive port of the hospital governing board, the Tanner Intensive outpatient treatment for children and adults at two sep- Program for Behavioral Change (TIP) was opened in June arate sites; an in-home counseling program for children 2003. TIP is a partial hospitalization program with an and families; a crisis line; and mobile needs assessment intensive outpatient treatment component for males ages services. 12 to 17 who have committed sexual offenses. Originally

8 Case Examples established to address the needs of Carroll County, the apart, TIP had to address transportation issues early in the program now serves seven counties in western Georgia. program development process. They worked with local publicly-funded medical transportation providers to ensure The program’s treatment components include group, that patients have access to the services they need. individual, and family therapy; multi-family group therapy; polygraph assessments for treatment planning and Success Factors therapy; case management and collaboration with the • Strong support from the governing board and execu- Department of Children and Family Services, tive staff has been a key factor for success. Programs of Department of Juvenile Justice, and the school system; this type are highly labor intensive and tend to have medical and psychiatric oversight, including medication narrow margins. The board is committed to meeting management; and in-home/in-school monitoring and the needs of the community, not just achieving finan- treatment planning by a victim prevention specialist. cial success. • The program is a total wraparound, educating not just TIP reaches individuals who typically would not have the patient but those around him. The victim preven- received treatment for their sexual offending behavior. tion specialist helps create safer home environments, Without treatment, supervision, and safety planning, educates caregivers, and assists schools in supporting these patients have a moderate to high risk to re-offend. these youth while protecting other children. The goal of the program is to increase an offender’s • Treatment occurs in real time and in the community chance for success in life, decrease the likelihood of re- where patients are exposed to and stimulated by the things offense now and in the future, and protect members of that affect them. They are forced to deal with urges and the community from sexual victimization. cycles in real time and in their natural environment.

Program Impact Lessons Learned and Advice to Others In order to track the effectiveness of the program, TIP For others interested in this type of initiative, the Tanner monitors the recidivism of patients. To date, only 8 of 117 Medical Center experience provides some helpful advice: patients have re-offended. These results are exceptional • Research the need for this type of treatment program compared to national norms of adolescents at moderate to in your community. Talk with members of the juve- high risk for sexually re-offending after treatment. nile justice system, government and social services agencies, and school personnel to determine both the Program Funding level of need and the level of support in the commu- The program is supported primarily by reimbursement for nity. services provided. Most of the program participants are • Make sure you have a solid clinical approach and that Medicaid patients; however, because sex offenders occur you build in a measure of clinical accountability for across all social and economic levels, there are also patients patients. in the program covered by private insurance. • Continually educate community partners (law enforcement, school personnel, religious and social Obstacles or Challenges organizations, government and social services agencies, The greatest challenge has been securing adequate reim- and justice system personnel) on the need for and bursement for services. When the state of Georgia transi- benefits of treatment for juvenile sex offenders. tioned to a managed Medicaid arrangement with private • Commit to intensive training of your staff. Few staff are insurers in 2005, funding for the long-term treatment need- trained or skilled in treating sex offenders—a population ed for juvenile sex offenders became increasingly difficult to that is different in many ways from other behavioral obtain. Because the managed care organizations (MCOs) health patients. measured TIP against standard medical necessity criteria, • Secure the services of an experienced polygraph expert there were constant efforts to deny treatment or discharge who is certified for sex offenders. to a lower level of care. To combat these problems, TBH • Establish appropriate housing with separate, defined areas wrote medical necessity criteria specifically for TIP and so that offenders and victims do not cross paths. attempted to get buy-in from the MCOs. TBH leadership continue to devote considerable time and energy fighting Contact: for timely, consistent reimbursement of services and chal- Wayne Senfeld lenging multiple obstacles that result in denial of payments. Director Tanner Behavioral Health A second challenge was patient transportation. Consistent Carrollton, GA participation in therapy is a key factor for success; however, [email protected] many patients do not have the resources to attend therapy 770-838-8261 far from home. Because rural communities tend to be far • • •

Practical Help for Hospital Leaders 9 Case Examples

Recommendation 2a Hospital leaders should use a comprehensive financial and operational assessment to evaluate the benefits and economic value of behavioral health services to all operational components of the hospital.

Using Key Performance Indicators as a Tool for Demonstrating Value Northeast Hospital Corporation, Beverly, MA

Summary medical/surgical patient care was not just theoretical but Behavioral health leaders at Northeast Hospital also practical. They reviewed and revised protocols to Corporation developed a “dashboard” of key perform- make the program more responsive to physicians’ and ance indicators in order to provide information to exec- nurses’ needs. The team developed a strategy for utive leadership and governing board members regard- strengthening their connection to physicians by working ing trends in behavioral health service utilization and with the new hospitalist program to educate medical the value the service provides to the overall system of staff on the impact of behavioral health services in care. improving outcomes and reducing medical/surgical length of stay. Community and Hospital The North Shore region of Massachusetts is in Essex In order to remain competitive within the hospital sys- County, approximately 20 miles northeast of Boston. In tem, however, behavioral health services had to be 2005, the estimated population of the county was viewed as financially viable as well as clinically benefi- 721,625, with a median income of $57,164 per house- cial. Behavioral health leaders worked with financial hold. Approximately 11.4 percent of the population services staff to adapt the hospital’s profit and loss lives below the Federal Poverty Level. (P&L) statement for behavioral health services. To develop the necessary data sets, they reviewed with Northeast Hospital Corporation is a family of health finance staff the clinical care program differences care organizations, including two acute care hospitals between behavioral health and medical/surgical care, (Addison Gilbert Hospital in Gloucester and Beverly including cost structures, compensation structures, man- Hospital in Beverly) and a 62-bed behavioral health aged care “carve outs,” per diem rates, and reimburse- facility (BayRidge Hospital in Lynn). Both of the acute ment mechanisms. The behavioral health services P&L care hospitals have inpatient psychiatric units as well as dashboard statement that was developed included rev- partial hospitalization and outpatient services. enue trends and drivers, expense data, volume trends, payer mix trends, net gain (or loss) from operations, and Program Overview the contribution margin provided by the service line. As recently as eight years ago, leaders at Northeast Hospital Corporation were reviewing the sustainability This dashboard of indicators allows behavioral health of inpatient behavioral health services in a community leaders to review at a glance the operational and finan- hospital setting. Hospital financial margins were a chal- cial performance of all inpatient behavioral health serv- lenge and all services had to demonstrate value to the ices in the system. Using this tool, they can readily organization, both clinically and financially. Other identify areas where performance improvement is need- acute care hospitals in the area had closed inpatient ed in order to maintain clinically appropriate efficien- behavioral health units in order to develop more pro- cies. The data also allows them to see areas where serv- ductive service lines. Behavioral health leaders recog- ice volumes indicate a community need that may not nized that in order to demonstrate the value of their have been addressed. services, they needed to make certain the entire Northeast Hospital community understood the need for Behavioral health leaders use the P&L statement as both and benefits of behavioral health services. an educational and informational tool for hospital executive leadership and board members. The data is shared The first step focused on demonstrating the clinical on a monthly basis, providing an opportunity not only value of behavioral health services within the hospital. to highlight the range and volume of behavioral health The behavioral health team evaluated the existing con- services provided to the community but also to point sultation and liaison service to ensure that its value to out the financial contributions made by these services to

10 Case Examples the entire system of care. It also offers an opportunity Success Factors to routinely discuss the operational and financial chal- • In order to become an integral part of the system of lenges of behavioral health services. This open and care, behavioral health services leaders had to be sure transparent approach to information sharing builds that their program goals aligned with the overall goals mutual understanding and trust among hospital leaders, of the hospital and that, as a management team, they which become key factors in setting strategic direction were united in commitment to these goals. and facilitating effective problem solving. • Behavioral health services leaders looked for or created opportunities to demystify behavioral health services Program Impact to medical staff, executive management, and board Maintaining clear and consistent communications on members. the clinical and financial contributions of behavioral • Information technology systems that supported ade- health services has established these services as an inte- quate data collection and analysis were key to the suc- gral part of the overall system of care. The ability to cess of the strategy. demonstrate added value and contributions to the system has enabled behavioral health leadership to focus Lessons Learned and Advice to Others on program needs and enhanced services, rather than For others interested in demonstrating operational and having to defend the “status quo” of current levels of financial value of behavioral health services, the care. Northeast Hospital Corporation experience provides some helpful advice, including: Analysis of data from the P&L statement has led behav- • Use data sharing as a framework for educating internal ioral health leaders not only to implement operational stakeholders about behavioral health services. improvements but also to respond to the need for new • Make use of data not only to demonstrate success but programs and services. For example, the growing vol- also to identify challenges. Always being open about ume and increased length of stay of geriatric patients in your service, operational, and financial challenges may the behavioral health inpatient unit resulted in the be difficult, but it allows problem solving to occur in recent development of a distinct gero-psychiatric unit an atmosphere of mutuality rather than distrust. with a medical/behavioral health interface. This unit • Be proactive in communicating challenges or shortfalls has provided further support to the medical/ surgical in a timely manner. Be prepared to speak to anticipat- floors of the hospital, reducing more costly medical ed losses and steps you are taking to correct problems. lengths of stay, and has removed frail elderly from the • Present the whole picture of how your program is general psychiatric units where they may be at greater doing. Not painting the whole picture leads to more risk in an active, adult psychiatric unit. questions and less trust.

Obstacles or Challenges Contact: The behavioral health team recognized that they needed James Q. Purdy to collaborate closely with financial services staff in Vice President, Inpatient Behavioral Health order to gain the support needed to develop the Northeast Hospital Corporation P&L/benchmark formats. Over time, the teams have Beverly, MA developed a level of mutual commitment and a shared [email protected] vision of how behavioral health service performance 978-922-3000 x 2805 indicators could be useful to the entire hospital. • • •

Building Behavioral Health Services as a Strong Contributor to the Bottom Line St. Helena Hospital, St. Helena, CA Summary Community and Hospital St. Helena Hospital conducted a comprehensive review The city of St. Helena is located in the center of the of their behavioral health services in order to achieve Napa Valley, California’s premier wine-growing region. the clinical and operational levels required to become a From its inception, St. Helena has served as a rural agri- center of excellence within the organization. Their cultural center. In recent years, it has also become a goal was to build a firm financial base for behavioral business center for the wine industry. As of 2005, the health services while continuing to provide effective population in the immediate county was estimated at patient care. 127,445. The median income is $65,260 per house-

Practical Help for Hospital Leaders 11 Case Examples

hold. Approximately seven percent of the population “stepchild” mind-set. For years, staff had seen them- lives below the Federal Poverty Level. selves as the stepchildren of the organization, that is, peripheral to St. Helena’s core mission and mainstream St. Helena Hospital, located in St. Helena, is a 181-bed operation, when in fact the Center’s role was key to community hospital and a member of Adventist Health. A achieving both the hospital’s and the system’s mission of comprehensive range of acute care, behavioral health, and “healing the whole person – physically, emotionally, wellness programs draw patients throughout Northern and spiritually.” Staff needed to be continually reminded California. The Center for Behavioral Health includes two of the importance and value of their services so that campuses: a 21-bed adult unit and 39-bed chemical depend- they could broaden their vision of how the Center could ency unit in St. Helena, and a 61-bed inpatient psychiatric contribute to the hospital and to their communities. facility in Vallejo for adults, adolescents, and children. The greatest challenge is “keeping an eye on all the balls Program Overview at once.” The only way to do that is to have effective In contrast to other local hospitals that are reducing dashboard tools and highly skilled managers. Denials, behavioral health services or eliminating the service line census, and productivity are reviewed daily. Referrals altogether, St. Helena Hospital has experienced a 32 are followed on a weekly basis, and downtrends in uti- percent increase in its behavioral health patient volume lization are watched, so adjustments can be made as over the past five years. More strikingly, the hospital needed. At the end of each month, a broad range of realizes a positive margin in behavioral health services, utilization data and patient financial services key indica- demonstrating the economic contribution that these tors are reviewed. services can make to the organization. Success Factors The hospital’s Center for Behavior Health prioritized • Getting their expenses under control through day-to- the goal of establishing a firm financial base for behav- day management of the details ioral health services while continuing to provide safe • Understanding where referrals are coming from and and effective patient care. Four key strategies allowed managing those relationships the Center to turn the corner financially: • Having a medical staff that understands and supports • Get expenses under control by increasing productivity the goals of the hospital as well as improving supply management. • Consistently marketing to consumers and referral sources • Conduct thorough contract reviews, making sure that contract rates are competitive and that increases in rates Lessons Learned and Advice to Others are lining up with increases received by the health plans. For others interested in emulating the financial success • Evaluate the individual service lines in terms of their mis- of St. Helena’s Center for Behavioral Health, their expe- sion-centeredness, utilization levels, and profitability. rience provides some helpful advice: • Manage payer mix by implementing marketing • Be sure you have a leadership team with “can do” atti- methodologies that tend to drive payers to their serv- tudes; otherwise, your organization will be satisfied ices and position behavioral services as a Center of with the status quo and eventually stagnate. Excellence within St. Helena Hospital • Spend time, energy, and resources to develop relationships and maintain communications with payers and referral The Center’s second goal was to enhance the clinical serv- sources. ices of the organization, both by improving the services • Keep a close eye on trends and closely manage expens- already in place and developing new programs. The first es and referral relationships. step toward this goal was restructuring the leadership • The secret is in the details. Continually review and eval- team to ensure that the right skill set was in place and uate your operational and financial progress, so that you that they had the entrepreneurial mind-set necessary to can effectively communicate the benefits and economic build a successful behavioral health services organization. value of your services back to the organization.

Program Impact Contact: For the past three years, the Center has experienced Guy Qvistgaard, MS, MFT strong bottom lines, grown the business, and successful- Vice President ly managed productivity. It has also become a major Center for Behavioral Health player in behavioral health services in California. St. Helena Hospital St. Helena, CA Obstacles or Challenges [email protected] One of the obstacles to success in the Center for 707-649-4001 Behavioral Health was what has been identified as the • • •

12 Case Examples Recommendation 3 Hospital leaders should encourage and actively participate in (1) developing a community-wide and/or regional plan for persons with behavioral health disorders and (2) coordinating community agencies addressing behavioral health needs.

Creating an Integrated Delivery System for Behavioral Health Care AtlantiCare, Egg Harbor Township, NJ

Summary When the board of the mental health center voted to To achieve its vision of a seamless system of behavioral merge with AtlantiCare in 1994, the goal was to estab- health care for the residents of southeastern New Jersey, lish a stronger, more seamless behavioral health care AtlantiCare integrated the capabilities, facilities, informa- delivery system. By combining their capabilities, facili- tion systems, and resources of two health care organiza- ties, and resources, the two organizations could better tions. The merger has expanded outreach capability for serve the behavioral health needs of the region. In order psychiatric emergency services throughout the region. to maintain behavioral health as a strong focus within the system, AtlantiCare Behavioral Health was created as Community and Hospital a wholly owned subsidiary of AtlantiCare, with a sepa- Egg Harbor Township, NJ, is located in the geographi- rate board. This unique positioning ensured that behav- cal center of Atlantic County near Atlantic City, a major ioral health services would receive the proper level of tourist destination in the state of New Jersey. The pop- attention and importance needed in remaining respon- ulation of Atlantic County was estimated at 264,403 in sive to the behavioral health care needs of the communi- 2005. The average income in the county is $50,377 per ties served by AtlantiCare. household, with 8.9 percent of the population living below the Federal Poverty Level. To fully realize an integrated delivery system, AtlantiCare needed not only integrated services but also AtlantiCare Health System includes AtlantiCare an integrated clinical information system. Six years after Regional Medical Center, a 567-bed teaching hospital the merger, they acquired a system that could successful- with two campuses; AtlantiCare Health Services; ly support electronic medical records for both inpatient AtlantiCare Behavioral Health; the AtlantiCare and outpatient behavioral health services and interface Foundation; AtlantiCare Health Plans; and InfoShare. with the existing hospital information system. AtlantiCare is the region’s largest health care organiza- Developing a culture of electronic documentation in a tion and largest non-casino employer. paper-intensive environment presented challenges, but the ability to access treatment plans and track medica- Program Overview tions facilitated more informed treatment decision-mak- In 1994, leaders of AtlantiCare Health System had a ing across the continuum of care and improved patient vision for a more comprehensive, coordinated, and seam- safety practices around medication reconciliation, stan- less system of care for the residents of southeastern New dardized suicide risk assessments, and patient identifica- Jersey. They were concerned about the fragmentation in tion. the mental health system and committed to the value of integrated delivery systems as a key approach to improv- Program Impact ing the physical and behavioral health of the community. Following the merger, stakeholders almost immediately began to see improvements in the coordination and Atlantic City Medical Center was the area’s only inpa- delivery of care to the community. The use of a multi- tient psychiatric facility, with a 30-bed psychiatric unit disciplinary team approach allowed AtlantiCare to real- and psychiatric emergency screening and crisis program. ize the positive impact of behavioral health care across Atlantic Mental Health Center, a freestanding not-for- clinical areas. Within the organization, behavioral profit community mental health center, was the county’s health leaders have been able to demonstrate the clinical largest provider of outpatient mental health and addic- and economic benefits of integrating mental health serv- tion treatment services. The two organizations often ices into various hospital-based programs including car- found themselves serving same the population with lim- diac surgery, obstetrics care, bariatric surgery programs, ited communication and without a coordinated and trauma services. Currently, AtlantiCare Behavioral approach to care. Health is partnering with AtlantiCare’s Federally

Practical Help for Hospital Leaders 13 Case Examples

Qualified Health Center to integrate mental health and philosophical approaches of the two organizations were substance use treatment services in this primary care set- issues that had to be addressed. ting. They are also working with a multidisciplinary team designing a new cancer center to address the devel- Success Factors opment of behavioral health services for cancer patients. A strong governing board committed to behavioral health services and not averse to risk was essential to The merger of the two organizations laid the ground- developing an integrated behavioral health care delivery work for expanded outreach capability for psychiatric system. emergency services. Through AtlantiCare’s Psychiatric Intervention Program (PIP), mobile treatment teams Lessons Learned and Advice to Others service the entire region. The 24/7 teams respond to For others interested in creating an integrated delivery hospital emergency departments, nursing homes, and system for behavioral health care, the AtlantiCare expe- residences to conduct initial evaluations and determine rience provides some helpful advice: the most appropriate level of care for the patient. • Behavioral health services tend to be distributed Recently, the PIP collaborated with a local rescue mis- among small outpatient providers that have a long tra- sion and a homeless shelter to provide behavioral health dition of independent service; however, communities services at their locations. The Psychiatric Intervention are best served by integrated systems that coordinate Program is a key strategy for addressing overcrowding the delivery of care. Look for opportunities to conso- and inappropriate emergency department use. lidate services and reduce service fragmentation. • There are greater opportunities to improve the overall Program Funding health of the community as coordinated systems of care The Psychiatric Intervention Program is primarily fund- partner with the rest of the medical establishment and ed through annual community block grants for mental reach beyond traditional behavioral health services. health services secured through the state, with the bal- ance of support from public and private third party Contact: billings. Ted Stryker President Obstacles or Challenges AtlantiCare Behavioral Health The primary challenges in developing an integrated Egg Harbor Township, NJ behavioral health delivery system were the political and [email protected] control issues that tend to accompany mergers. 609-645-7601 ext.102 Concerns around loss of identity and differences in the • • •

Collaborating to Provide Prevention and Early Intervention Services Across a Region Central Peninsula Hospital, Soldotna, AK

Summary Central Peninsula Hospital is a borough-owned, not-for- Central Peninsula Hospital led the creation of a 10- profit facility located in Soldotna, with a service area of agency coalition that provides prevention and early over 25,600 square miles. The hospital is administered by intervention services in communities in the Central a corporation, CPGH, Inc., and operates through a lease Kenai Peninsula. Goals are to reduce the adverse effects and operating agreement with the Kenai Peninsula of substance abuse, especially during the prenatal period; Borough. reduce suicide and parasuicidal behaviors; and increase community protective factors among residents. Program Overview Central Peninsula Hospital is no stranger to regional col- Community and Hospital laboration. The hospital has been involved in three major Located at the heart of the Kenai Peninsula of Alaska, and successful collaborative efforts over the past several the city of Soldotna is a year-round recreation center. years, including helping fund a broad-based community Tourism is the fastest growing industry in the area. As organization called the Community Action Coalition of 2000, Soldotna’s population was 3,759. The median (CAC) for Prevention. Members of the coalition include income is $48,420 per household. Approximately 6.6 youth, parents, business leaders, media, schools, adoles- percent of the population lives below the Federal cent service agencies, law enforcement, faith-based Poverty Level. groups, civic organizations, health care providers, and

14 Case Examples mental health and substance abuse agencies. This coali- harnessed resources in a way that no organization or tion served as the cornerstone for the development of agency could have accomplished alone. prevention strategies on a much larger scale. The emphasis on adopting outcomes-based interven- The merger of mental health and substances abuse serv- tions has improved the quality of programs supported. ices in the state government provided an unparalleled Six of the participating agencies now have Substance opportunity to secure resources for expanded collabora- Abuse and Mental Health Services Administration tion. In an effort to foster the integration of behavioral (SAMHSA) Model or Promising Programs in place. health services in the community, the Alaska Department of Health and Human Services announced One example of a successful collaboration includes serv- the availability of grants for regional collaboration. ing over 30 families in the intensive, 14-week Central Peninsula took the lead in developing a propos- Strengthening Families Program, which has been staffed al for a 10-agency Community Prevention Team to pro- by employees of the hospital, Community Action vide prevention and early intervention services within Coalition, mental health center, and volunteers. Similarly, the Central Kenai Peninsula. As the project coordina- four organizations–mental health center, federally quali- tor, Central Peninsula Hospital anticipates receiving fied health center, hospital, and developmental disabilities funds for the third and final year of a $1.04 million provider–helped provide free community depression grant in fiscal year 2008. screenings for over 100 individuals the first year of the program. The diagnostic clinic for fetal alcohol spectrum Three goals were identified for the collaborative initia- disorders has provided over 40 trainings annually, includ- tive: reduce the adverse effects of substance abuse, espe- ing to staff at nearly all the agencies participating in this cially during the prenatal period; reduce the numbers of collaborative. Finally, the CAC conducted a state-of-the- suicide and parasuicidal behaviors; and increase com- art evaluation of the public schools in the region to assess munity protective factors among residents in the region. for substance use and belief patterns. This survey will be An integrated, comprehensive model of prevention tar- conducted every other year to determine whether inter- geting each of these areas was defined, using established ventions are having a positive impact. interventions that could be tailored to local needs. Program Funding Two approaches formed the basis for the project. The The Kenai Peninsula Community Prevention Team pro- first was a focus on an empirical methodology in the grams are funded through a three-year state grant, with development of the prevention plan. Coalition mem- the funds allocated on an annual basis. As the project bers looked for outcomes-focused and evidence-based coordinator, Central Peninsula Hospital provides the intervention programs that would yield valid measures organizational resources to manage the grant funds. of change. The second approach was the creation of Approximately 70 percent of the funds are distributed to formal interdisciplinary and inter-agency partnerships to the partner agencies. serve as vehicles for the interventions. These partnerships produced organized and coordinated interventions The collaborative has already begun building infrastruc- that increased efficiencies, reduced redundancies of ture to pursue additional funding beyond 2008. It is effort, extended the reach of individual programs, and anticipated that one or more grant applications will be broadened the base of review and oversight. submitted for 2009. Even in the absence of grant funding, some of the specific programs can be absorbed into Now in its third year, the Community Prevention Team existing revenue streams. meets at least monthly to identify needs and to discuss progress toward programmatic goals. Current projects Obstacles or Challenges include family and parenting programs, suicide education Although Central Peninsula Hospital had the account- in schools, brief depression and alcohol screenings by pri- ing infrastructure needed to oversee the grant funds, mary care providers, community-based depression screen- they did not have a structure for managing the types of ings and resiliency-building education, and focused inter- contractual relationships that were an integral part of the ventions for very high-risk incarcerated youth. initiative. There was a steep learning curve associated with developing protocols and processes that met the Program Impact audit needs of the hospital while facilitating the distribu- Because nearly all of the behavioral health organizations tion of funds among multiple agencies. and agencies in the region are involved in the coalition, they are able to capitalize on their combined knowledge Success Factors of populations, resources, and available expertise. The primary factor for the success of this collaborative Working collaboratively, the coalition has identified and effort was the level of concern felt by the participants.

Practical Help for Hospital Leaders 15 Case Examples

Coalition team members recognized that if they could not meet community needs in unconventional ways. work together, these services probably would not exist in • Multi-organizational coalitions may benefit from a their community. They were willing to take the long view, neutral mediator to facilitate funding decisions so that develop long-term relationships, and commit to interper- all the participants feel that they have equal standing. sonal transparency in order to establish effective preven- • When serving as the lead organization in a community tion programs that have lasting value for the community. coalition, the hospital has to demonstrate that its goal is not primarily financial gain but the improved health Lessons Learned and Advice to Others of the community. For others interested in setting up similar programs, the Central Peninsula Hospital experience provides some Contact: helpful advice: Matthew Dammeyer, PhD • In order for regional collaboration to succeed, there Director of Behavioral Health has to be a level of deep concern among service Central Peninsula Hospital providers related to unmet community needs. Soldotna, AK • Start small, with small collaborative projects; build on [email protected] experience and success. 907-714-4520 • Hospital leaders have to be willing to take risks to • • •

Building a Coalition to Address Substance Abuse Issues in an Urban Community Massachusetts General Hospital, Boston, MA

Summary for the one square mile of Charlestown are even more Trends in substance abuse-related hospitalizations and sobering. The rate of substance abuse-related hospital- deaths in the Charlestown area of Boston prompted the izations among Charlestown residents is more than Massachusetts General Hospital (MGH) to create a twice the rate of Boston overall. The number of drug- coalition of community leaders who work together to related deaths among Charlestown residents was nearly reduce substance abuse in the community by utilizing 50 percent higher than the city of Boston as a whole existing community resources and organizing programs from 1999-2002. to meet identified needs. In response to these alarming trends, business and com- Community and Hospital munity leaders, the police, social service agencies, the Charlestown is the second oldest neighborhood in Massachusetts General Hospital health center and Boston, MA. In 2000, the population of Charlestown providers, representatives of elected officials, residents, was 15,195. The median income was $56,145 per and others came together in the winter of 2004 to form household, with 18 percent of the families living below the Charlestown Substance Abuse Coalition (CSAC). the Federal Poverty Level. Thirty-seven percent of chil- Convened by MGH Charlestown and the MGH dren 18 years and under live below poverty level. Community Benefit Program, the coalition was further galvanized by the tragic overdose of two prominent Founded in 1811, the Massachusetts General Hospital is youth in April 2004, including the death of one. the third oldest general hospital in the United States and the oldest and largest in New England. Affiliated with Partners Following the success of the first community meeting Healthcare, the 902-bed medical center includes a main held in November 2004, CSAC conducted a compre- campus in Boston as well as five community health centers. hensive community assessment that included a commu- MGH Charlestown HealthCare Center offers comprehen- nity-wide survey, focus groups, and key informant inter- sive primary care for children, adolescents, adults, and sen- views. The survey, distributed to 7,000 households, iors from a location in the heart of Charlestown. revealed that 97 percent of respondents believe Charlestown has a medium to large substance abuse Program Overview problem. Respondents also indicated that the most According to the Massachusetts Department of Public effective strategies to combat this problem are to Health, hospital admissions for treatment of heroin increase police presence, change community norms, abuse in Massachusetts are three times the national aver- increase treatment resources, and provide prevention age and highest of all the New England states. As stag- and education services. Responses from focus groups gering as the Massachusetts numbers are, the statistics and interviews supported the survey results.

16 Case Examples A CSAC community forum was held to present the Obstacles or Challenges assessment results to the community. Over 120 resi- The greatest challenge in establishing the coalition was dents and interested parties attended, and many were getting key community stakeholders to the table. The shocked by the results. The meeting further stimulated community’s ability to build cohesiveness was limited community action through initiation of four work by factors such as: competition for financial resources; groups that focused on implementation of the four ownership issues related to changing demographics; the strategies identified by the survey as the most effective political undertones of being a small community in a ways to address the community’s substance abuse prob- larger city; and perceived racial, ethnic, and socioeco- lem. nomic divisions. In the beginning, there was a core group of community leaders who responded. Now the In 2005, CSAC formulated a comprehensive strategic challenge is to identify key stakeholders missing from plan using funds from a Massachusetts Department of the table and build on the coalition’s success to expand Public Health planning grant received through the collaboration. Boston Public Health Commission. The plan affirmed the coalition’s overall goal and defined four objectives: Success Factors • Change community norms, attitudes, and behaviors The primary factor for the success of this initiative was about alcohol and other substance use, while building the readiness of residents in the community to address community cohesion and collective response across all substance abuse issues. The problem of substance abuse sectors of the community. was so widespread that people could see it affecting • Increase safety of neighborhood and quality of life for their lives, the lives of their family members, and the all by decreasing the supply of drugs, levels of crime, future of their neighborhood. violence, and other consequences of substance abuse in the neighborhood through a collaborative effort A second factor contributing to success was that the hos- with law enforcement and judicial systems. pital and health center had a history of responsiveness to • Increase access and resources for successful treatment community needs. Because of its long-term presence in and recovery from substance abuse for Charlestown Charlestown, MGH was able to involve people in the residents and families afflicted with addiction. development of the coalition who had established rela- • Strengthen protective factors and decrease risk factors tionships in the community. Community activists saw of families, youth, and young adults through educa- MGH as an organization with the will and the resources tion, prevention, and intervention strategies. to sustain the initiative over time.

Program Impact Lessons Learned and Advice to Others The work of the CSAC has resulted in increased dia- For others interested in setting up similar programs, the logue and communication across organizations, as well experience of the Massachusetts General Hospital pro- as among residents and resident groups; greater willing- vides some helpful advice, including: ness of community residents to discuss substance abuse • Creating a successful coalition to address serious and other concerns openly; higher levels of resident par- behavioral health issues takes a lot of time. You may ticipation in CSAC and other community efforts and not see tangible results in the short term or even in events; and increased access to and engagement of the intermediate term. Effective solutions require a underserved populations. The CSAC is seen as a sustained commitment to the community. resource and community partner to community organi- • Look for ways to present the realities of the situation so zations and initiatives. that people become engaged in the initiative. The community assessment data were powerful and eye opening to Program Funding both residents and community leaders and served as a Primary funding for the coalition is through the MGH reminder to everyone that the bottom line was concern Community Benefits program, with additional funding for the children and families of their neighborhood. through grants. Recently, CSAC received a Drug Free Communities Support Program grant from the Contact: Substance Abuse and Mental Health Services Beth Rosenshein Administration, an agency of the U.S. Department of Director Health and Human Services. DFC grant funds are Charlestown Substance Abuse Coalition intended to “establish and strengthen collaboration MGH Charlestown HealthCare Center among communities, private nonprofit agencies, and Charlestown, MA Federal, State, local, and tribal governments to support [email protected] the efforts of community coalitions to prevent and 617-726-6684 reduce substance abuse among youth.” • • •

Practical Help for Hospital Leaders 17 Case Examples

Recommendation 3a Hospital leaders should work with community agencies and support services and with state and local governmental authorities to ensure that all patients are treated in the most appropriate setting so that the hospital’s backstop role is appropriately limited.

Partnering to Provide an Appropriate Setting for Care of the Seriously Mentally Ill St. Mary’s Hospital, Tucson, AZ

Summary tion services. Over the last several years, CPSA has Carondelet Health Network at St. Mary’s Hospital col- experienced growing need for available placement laborated with the local regional behavioral health options for individuals with severe and persistent mental authority to create an extended care unit for high-risk disorders. With a view to potential collaboration, CPSA patients as a diversion from the state hospital. The approached St. Mary’s Hospital regarding the need for interdisciplinary, inter-agency program helps to achieve community-based rehabilitation services for high-risk the best possible clinical outcomes for the seriously patients as a diversion from the state hospital. mentally ill and reduce the downstream costs associated with emergency department visits, hospital stays, and The hospital and the agency worked together to develop crisis management. a 16-bed, Level 1 subacute inpatient adult psychiatric unit. Most of the patients in the unit are on court- Community and Hospital ordered status and are assigned to the Extended Care Tucson, AZ, one of the oldest towns in the U.S., is the Unit for an average of 90 days. The goal of the inten- county seat of Pima County. The population of Tucson sive psychiatric rehabilitation program is to give patients was estimated at 507,362 in 2005. The county, which the skills to make lifestyle changes that will allow them covers 9,184 square miles, has a population of 902,720. to live successfully in the community. The average income in the county is $41,521 per household, with 14.7 percent of the population living below Using a strong interdisciplinary model, program staff the Federal Poverty Level. works closely with community service agencies to coordinate care. Weekly staff meetings bring together the The only hospital on Tucson’s west side, St. Mary’s entire interdisciplinary team to review the patient’s Hospital is a 402-bed facility with a full range of com- treatment plan and evaluate progress. The team prehensive inpatient and outpatient services. St. Mary’s includes psychiatrists, the nurse manager, the social is part of Carondelet Health Network, southern worker, and nursing staff from the inpatient unit; the Arizona’s oldest and largest not-for-profit health care case manager and psychiatrists from the local outpatient provider. services agency; the patient advocate; family members if available; and the clinical liaison from CPSA. Every Program Overview month, the patient attends and participates in treatment In Pima County, over 30,000 individuals receive some planning. type of publicly funded behavioral health service, most with diagnosed mental health disorders. It has been esti- As the partnership between CPSA and St. Mary’s mated that up to 25 percent of the 2,000 detainees in Hospital has evolved, the emphasis has been on finding the county jail are mentally ill or require mental health ways to collaborate more effectively to meet the needs of or substance abuse treatment. Individuals requiring patients. CPSA staff is proactive in identifying patients mental health or substance abuse services, particularly in the community who may benefit from the extended high-risk patients, often end up in a hospital or a hospi- care program, particularly those who are high-volume tal emergency department because of the shortage of users of community services. St. Mary’s program leaders outpatient, crisis, and residential services and facilities. have been responsive to requests for changes in the program, including incorporating a stronger focus on sub- As the Regional Behavioral Health Authority for south- stance abuse treatment, developing more individualized ern and southeastern Arizona, the Community treatment plans for patients with challenging or prob- Partnership of Southern Arizona (CPSA) coordinates lematic behaviors, and implementing a more effective publicly funded behavioral health treatment and preven- staffing pattern for care of those patients.

18 Case Examples Program Impact • Carondelet reviews evidence-based practice issues on The community, community agencies, and the court sys- an ongoing basis. There is a strong emphasis on con- tem have responded positively to the extended care pro- tinual learning and improvement. gram. Local judges often choose not to refer patients to • The partnering organizations are committed to each the state hospital because they view the extended care other and continually seek ways to extend and unit as a more desirable alternative. The success of this enhance their collaboration. program has led to discussions of additional models to • Program leaders listen to stakeholders – patients, fami- assist with the severely mentally ill population, including lies, staff, the community, and other agencies – and housing for those who need supervision. respond to their views, concerns, and issues.

The extended care program represents a small first step Lessons Learned and Advice to Others in addressing hospital emergency department over- For others interested in setting up similar programs, the crowding by providing appropriate community-based St. Mary’s Hospital experience provides some helpful services for people with serious mental illness. Increased advice: collaboration among agencies that care for the seriously • Determine at the outset what your mission and goals mentally ill helps to achieve the best possible clinical are for the unit. outcomes for these individuals and reduce the down- • Both partners need to continually evaluate the partner- stream costs associated with emergency department vis- ship, identify what is working and what is not work- its, hospital stays, and crisis management. ing, and find ways to make the collaboration successful. Program Funding • Put in place leaders who not only have strong clinical The program is funded by CPSA through their role as a skills but also have experience and expertise in devel- state Regional Behavioral Health Authority. oping and sustaining collaborative efforts. • Anticipate community needs and gaps in service that Obstacles or Challenges may impact admissions. • Finding leaders with the skill sets required to work in • Anticipate and plan for the milieu and treatment chal- a collaborative way with a community partnership. lenges that the mixing of special needs population • Identifying staff that possessed the skill set and philos- patients (e.g., developmentally delayed) with the seri- ophy needed for the population served. ously mentally ill population may present. • Balancing fiscal responsibility with patient care needs. • Anticipate the special needs of patients living together • The need for several private rooms was identified in for long periods of time with special attention to pri- the first year, but space constraints have prevented vacy, recreation, and private time. development of these rooms. Contact: Success Factors Margaret Edwards • Executive leadership of the parent organization, Director, Carondelet Behavioral Health Carondelet Health Network, is committed to success St. Mary’s Hospital in every venture. Tucson, AZ • Because Carondelet is a mission-based organization, [email protected] there is significant focus on attending to patients’ spir- 520-873-6567 itual needs as a component of care. Its mission values life and respects diversity. • • •

Coordinating Services to Patients in Urgent Need of Care through a Psychiatric ED University of New Mexico Hospitals, Albuquerque, NM Summary Community and Hospital By implementing a psychiatric emergency department Albuquerque is the county seat of Bernalillo County (ED), University of New Mexico Hospitals ensures that and the largest city in New Mexico. As of the 2005 patients in urgent need of behavioral health services receive census estimate, the city had a total population of them in the most appropriate setting. The psychiatric ED 488,133. The median income is $41,820 per house- also eases the pressure of overcrowding in the main ED hold. Approximately 13.7 percent of the population and helps the whole system to function more responsively. lives below the Federal Poverty Level.

Practical Help for Hospital Leaders 19 Case Examples

UNM Hospitals is the only academic medical center in tubes available if needed, but no continuous IVs or other New Mexico and an integrated hospital system that more invasive medical or surgical treatments. consists of University Hospital – a 384-bed acute, terti- ary care facility – as well as the Children’s Hospital of Psychiatric Emergency Services clinicians are trained in New Mexico, the UNM Cancer Research and avoiding restraint and seclusion, and children’s psychi- Treatment Center, UNM Psychiatric Center, UNM atric services have been very successful in aggression Children’s Psychiatric Hospital, UNM Carrie Tingley reduction. Adult patients are expected to take some Hospital, UNM School of Medicine, College of responsibility for their own crisis plans – clinicians work Nursing and Pharmacy, and the Health Sciences Center with them to develop a clear statement of their “hot Library. UNM Hospitals is also designated as a Level 1 buttons” and what kinds of actions might calm them regional trauma center. down if they get agitated or upset.

Program Overview The psychiatric crisis stabilization service, which allows UNM Hospitals has two emergency departments, one in a patient a 72-hour stay, helps prevent inpatient admis- the main hospital and a psychiatric ED in the Psychiatric sions. A comprehensive case management component Center. In the psychiatric emergency department, the of the program helps coordinate psychiatric and medical on-site psychiatric consultation team consists of a psychi- care, thereby supporting the individual’s ability to live in atrist (or clinical nurse specialist), nurses, licensed clinical the community. social workers, and licensed clinical counselors. The main ED’s psychiatric consultation team, which consists Obstacles or Challenges of psychiatrists and psychiatric residents, transfers Physician coverage is an ongoing challenge, even though patients with psychiatric emergencies to the psychiatric physicians are more plentiful because UNM Hospitals is ED, if appropriate. Police and ambulances transporting an academic medical center. Another continuing chal- individuals in need of emergency mental health treat- lenge is increasing overall awareness about the appropri- ment often bring them directly to the psychiatric ED. ate use of a psychiatric ED.

The UNM Psychiatric Emergency Services (PES) pro- Success Factors gram operates 24 hours a day and includes services such The successful implementation of the psychiatric ED less- as diagnostic psychiatric evaluations; crisis intervention; ened the burden of psychiatric emergencies on the main medication management for crisis stabilization and lim- ED, resulting in more cost-effective and appropriate ited follow-up care; referrals for medical, dental, legal, emergency care to patients struggling with mental illness. social, or substance abuse services; and admission to the Contributing to this success were the following factors: inpatient facility, when necessary. Crisis stabilization • Good movement and collaboration between the two services are also provided in a cooperative venture with emergency departments. the City of Albuquerque to provide shelter and stabiliza- • Immediate psychiatric consults. tion services including nursing and case management • A team approach at all levels. The medical director services for up to 72 hours. These services are provided brings all involved stakeholders into collaborative dis- at the Metropolitain Treatment and Assessment Center cussions for problem solving and planning. run by Bernalillo County. Referals into crisis stabiliza- • Awareness of the contribution made by different types tion come through PES. of clinicians. • On-site medical professionals on the psychiatric side (a As a Level 1 regional trauma center and a safety net hos- pediatrician for children’s psychiatric emergencies and pital for the area, the whole health system benefits great- a nurse practitioner for adults) supporting a “global ly from being able to move patients with psychiatric approach to the customer.” emergencies to the psychiatric ED. The separate emer- • Being located in a large city and a teaching hospital. gency department provides a safety valve that eases the pressure of overcrowding in the main ED. It also works Lessons Learned and Advice to Others better for patients, who are seen and treated more For others interested in setting up similar programs, the quickly and more appropriately. University of New Mexico Hospitals experience provides some helpful advice: To allow this system to function effectively, all psychiatric • Be explicit about admissions criteria for your psychi- clinical staff receive some medical training. A clinical atric ED. Define which patients will first require a nurse specialist is available in the psychiatric ED to help medical screening. stabilize a patient medically if the patient comes in with a • Choose clinicians carefully. Working with psychiatric medical issue – for example, diabetes – in addition to the patients demands a special kind of clinician, particu- psychiatric emergency. The psychiatric ED has feeding larly one who can de-escalate volatile situations.

20 Case Examples • Think at a systems level and provide appropriate train- Behavioral Health Hospitals and Programs ing to staff and physicians. University Hospitals Albuquerque, NM Contact: [email protected] Rodney McNease 505-272-2070 Administrator • • •

Solving Problems in the ED through a Coalition of Behavioral Health Stakeholders Utah Valley Regional Medical Center, Provo, UT

Summary sentative from the county jail was added to the group. Through the Coalition for Crisis Intervention at the Utah Valley Regional Medical Center, the hospital, local The initial meetings revealed high levels of frustration health and social service agencies, law enforcement, and among the participants. The area police agencies were other providers collaborated to ensure that behavioral frustrated because of the long wait times experienced by health patients in the emergency department receive the their officers, who usually accompanied the individual to appropriate level of care in the most appropriate setting. the ED. Because some of the small outlying municipali- ties have only a few officers on staff, the time they spent Community and Hospital waiting in the ED left a shortage in their home area for The city of Provo sits in the heart of Utah Valley police coverage. The local drug and alcohol agency was between the eastern shore of Utah Lake and the towering frustrated because they did not have the facilities to per- Wasatch Mountains. The second largest city in the state, form detoxification or to hospitalize substance abuse Provo is the county seat of Utah County, one of the patients – they only operated a residential program – so fastest growing counties in the country. In 2005 the they wanted the hospital to keep these patients. The hos- population of Provo was estimated at 101,164 and the pital was frustrated because it does not have a dedicated population of Utah County at 434,677. The median chemical dependency program, and these patients were income of the county is $47,428 per household. not appropriate for admission to a psychiatric unit. Approximately 12.2 percent of the population lives below the Federal Poverty Level. Not only were the professionals involved in the system experiencing frustration, but patients were falling Utah Valley Regional Medical Center (UVRMC) is a through the cracks because of the continuous disagree- 330-bed, not-for-profit hospital serving Utah County ments and friction among the organizations. and central and southern Utah. A part of Intermountain Health Care’s system of 21 hospitals, The coalition has seen a number of positive outcomes UVRMC has a full-service psychiatric unit with 20 from their collaboration: adult beds and seven child/adolescent beds. UVRMC’s • To improve the care for substance abuse patients, the drug emergency department is one of the largest and busiest and alcohol agency agreed to triage patients at their new in Utah, treating more than 45,000 patients each year. facility before sending them to the hospital. This approach reduced the number of patients coming to the ED. Program Overview • Hospital security had maintained that staying with psy The Coalition for Crisis Intervention at the UVRMC chiatric/substance abuse patients presented to the ED was began in 1999 as a diverse group of behavioral health the responsibility of law enforcement personnel, not hos- stakeholders who came together around a single issue: pital staff. The police agencies collaborated to obtain handling psychiatric and substance abuse patients in the legal advice on this issue and found they were not obli- emergency department (ED). Convened by the regional gated to stay with the patient, just to deliver the individ- administrative director for Intermountain’s Behavioral ual to the ED. The hospital security director secured Health Network, the coalition met on a monthly basis ini- approval to hire psychiatric technicians who now sit with tially and now meets quarterly. Representatives from the psychiatric/substance abuse patients in the ED. various police agencies in the county, the county health • Formerly, ED physicians were upset and uncooperative department, crisis workers in the hospital emergency in response to pressure from the drug and alcohol department, the sheriff’s department, the local public agency to provide drugs for discharged patients until the mental health agency, and the county substance abuse patients were stabilized. Drug treatment protocols that agency were among the early participants. Later, a repre- the ED physicians could accept were developed, and the

Practical Help for Hospital Leaders 21 Case Examples

physicians now provide some medications until the solve their problems. If they were going to be success- triage facility can take over. ful, they had to focus on solutions, not problems. • The local mental health agency and UVRMC agreed to share the costs of caring for medically indigent, Success Factors substance abuse patients admitted to the hospital. The The primary factor for the success of this project was the agency supports physician services, and the hospital willingness of coalition participants to stay focused on provides staff and hospital care. the purpose, to share and accept different points of view, • To increase the skill of law enforcement personnel in and to keep coming back to the table to seek solutions. responding to individuals in psychiatric crisis, the local police departments appointed a chairman to receive train- Lessons Learned and Advice to Others ing and operate a Crisis Intervention Team (CIT) pro- For others interested in setting up similar programs, the gram for all police agencies in the county. The CIT pro- Utah Valley Regional Medical Center experience program has been adopted in hundreds of communities vides some helpful advice: throughout the U.S. and has demonstrated successes in • Take the risk to be the leader in collaboration. You linking people with timely and effective mental health may think it’s going to cost a lot of money if you take services. Officers are taught about severe mental illnesses the lead, but that isn’t necessarily the case. Initiate the and how to respond to people experiencing psychiatric process, get people talking, and watch for results. crises in ways that defuse rather than escalate these crises. • Allow the coalition to evolve over time, as needed. Originally formed to address issues around psychiatric Program Impact and substance abuse patients, the Coalition for Crisis The work of the Coalition for Crisis Intervention has Intervention is now dealing with the appropriate treat resulted in improved collaboration and communication ment and disposition of mentally retarded patients in the between the hospital, local health agencies, law enforce- community. ment, the public mental health agency, and substance • Problem solving and training are ongoing efforts. The abuse treatment programs. Over the years, the coalition coalition continues to run into some of the same prob- has been successful in identifying key problems in the lems because of new staff in the participating organiza- system and coming up with viable solutions. tions or staff who are inadequately informed or trained.

Obstacles or Challenges Contact: The greatest obstacle faced by the coalition initially was Kenneth Tuttle, PhD the defensiveness of the participants when problems Regional Administrative Director were discussed. As a group, however, they recognized IHC Behavioral Health Network, Urban South Region that they all had problems when it came to resources for Provo, UT mental health services and that cooperation was the only [email protected] way they could make a significant impact on their com- 801-357-7147 munities. There was no additional funding available to • • •

Recommendation 3b Hospital leaders should create a formal plan that clearly defines its role and its established relationships for behavioral health with other providers, practitioners, and governmental and community agencies.

Affiliating to Coordinate Services and Improve the Delivery of Care Baptist Health Care and Lakeview Center, Pensacola, FL

Summary relationships but also allowed public and private funding Prior to their affiliation, Baptist Hospital, a general acute sources to be managed in a complementary manner. care hospital, and Lakeview Center, a community behavioral health center, had overlapping service areas and Community and Hospital service lines. The subsequent realignment of services not Pensacola is located in the westernmost part of the only created more efficient and effective organizational Florida panhandle and serves as the county seat for

22 Case Examples Escambia County. With a population estimated in Baptist Health Care to the communities it serves. 2005 at 274,663 and a median income of $40,384 per household, Escambia County is often referred to as Program Impact Florida’s poorest large county. Approximately 15.7 per- At the time of the affiliation in 1996, Lakeview Center cent of the county lives below the Federal Poverty Level. employed approximately 800 staff, with total revenues of approximately $37 million. Today, with total revenues Baptist Health Care (BHC), Pensacola, is a not-for- in excess of $120 million and approximately 2,300 staff, profit health care system composed of Baptist Hospital, Lakeview Center touches over 35,000 lives annually and three satellite acute care hospitals, and Lakeview Center, has expanded its services beyond well beyond that of tra- Inc (LCI). Baptist Hospital is the system’s flagship facil- ditional behavioral health. In the years since the affilia- ity with a primary service area of Escambia County. As tion, Lakeview’s vocational services division has grown part of its complement of 520 beds, Baptist Hospital significantly, now operating in five states and the has 68 beds licensed as inpatient psychiatric beds. District of Columbia with over 1,200 employees and Lakeview Center is a community mental health center revenues exceeding $30 million. offering a full continuum of behavioral health services for adolescents and adults. As part of the privatization of Florida’s Child Welfare system, Lakeview assumed the role of lead agency for a Program Overview four-county area in 2001. This project operates under a Although Baptist Hospital and Lakeview Center have fixed-price contract of approximately $33 million, always shared community service as a core value, the employs a staff of approximately 250 employees, and years prior to their affiliation through Baptist Health requires an extensive level of collaboration with numer- Care were primarily characterized by competition for ous community agencies across the service area. scarce behavioral health funding sources, interspersed Responsible for providing protective supervision, foster with brief periods of collaboration. There were overlap- care, and adoption services for approximately 5,500 ping service areas and overlapping service lines. abused or neglected children annually, Lakeview Center and Baptist Health Care have made a significant com- In 1995, leaders of the two organizations perceived the mitment to protect one of the community’s most valu- potential synergies and community benefit to be gained able resources: its children. from a formal alliance. Following a protracted period of negotiations, the affiliation of Lakeview Center with the Program Funding Baptist Health Care system was finalized in June 1996. In addition to the traditional payment sources of As a result of the alliance, services were realigned into a Medicare, Medicaid, and commercial insurers associated more efficient and effective organizational structure. with health care providers, Lakeview taps into a broad The visiting nurse association operated by Lakeview array of other funding sources: the Florida Department Center was transferred to BHC’s acute care system. The of Children and Families for mental health, substance mental health clinic and residential substance abuse abuse, and child welfare; Agency for Persons with treatment beds operated by BHC were transferred to Disabilities; Florida Department of Vocational LCI. In addition, Lakeview entered into a contractual Rehabilitation; Escambia County School Board; agreement with Baptist Hospital to manage the hospi- Escambia Board of County Commissioners; Santa Rosa tal’s 68 inpatient psychiatric beds. County School Board; Santa Rosa Board of County Commissioners; Florida Department of Health; Federal The realignment of service lines resulted in a system of Grants for Homeless; HUD Housing Assistance; and care that allows public and private funding sources to be Department of Defense for food service and custodial managed in a highly complementary manner. There is contracts with the Army, Air Force, and Navy. an efficient “braiding” of scarce resources into an efficient and comprehensive system of care distinguished by Obstacles or Challenges the lack of fragmentation so often associated with One potential obstacle facing hospital leaders who behavioral health services. Not only does this structure wish to pursue affiliations with behavioral health ensure that inpatient funding streams are managed effi- providers is that individual service lines may be ciently, but it also provides a comprehensive array of offered by several different providers or agencies with- recovery-based community services to individuals dis- in each community, rather than by a single provider charged from inpatient care. with a full continuum of services, as was the case with Lakeview Center. This fragmentation of services Affiliation with BHC has served to support and stimu- could result in affiliation or collaboration discussions late the continued growth of Lakeview Center. In becoming multi-organizational affairs, with an accom- return, this growth has enriched the contribution of panying increase in complexity.

Practical Help for Hospital Leaders 23 Case Examples

Success Factors to reduce administrative costs by combining and/or elim- The primary factors contributing to the success of the inating what is viewed as duplicative support costs. This affiliation were: may result in underestimating the specialized nature of • Vision and commitment of the leaders and board management and reporting systems found at many members of both organizations. behavioral health providers, particularly if a significant • A shared commitment to service excellence and com- portion of their funding comes from public sources. munity support. Unless there is an immediate critical need, give due con- • Both organizations were financially sound and recog- sideration as to when, if at all, you consolidate the com- nized as leaders in their respective fields. munity-based provider into the acute care system’s financial and information management systems. Lessons Learned and Advice to Others • Generally speaking, community-based behavioral For others interested in pursuing collaborative relation- health providers have relatively modest capital outlay ships with community behavioral health partners, the requirements, as compared to acute care hospitals. experience of Baptist Health Care and Lakeview Center provides some helpful advice, including: Contact: • One way to initiate a relationship with local providers Gary L. Bembry, CPA might be to begin a dialogue regarding advocacy Senior Vice President efforts to increase funding or support of community- Baptist Health Care based behavioral health services. This serves to meet President and CEO two goals: it develops a sense of trust between the Lakeview Center, Inc. acute care and community-based provider and it helps Pensacola, FL assure the acute care system that any potential affilia- [email protected] tion candidates are financially sound. 850-469-3702 • In affiliations or mergers there is often an immediate goal • • •

Collaborating with Community Physicians to Improve Access for Children with ADHD Cincinnati Children’s Hospital Medical Center, Cincinnati, OH Summary Program Overview Cincinnati Children’s Hospital Medical Center created Attention deficit hyperactivity disorder (ADHD) is one the Attention Deficit Hyperactivity Disorder (ADHD) of the most common behavioral disorders affecting chil- Collaborative to increase local physicians’ involvement dren. Approximately 9 percent of males and 3 percent in diagnosing and treating straightforward presentations of females are affected by the disorder, which is marked of ADHD. This arrangement improves patients’ access by inattention, hyperactivity, lack of concentration, and to care and emphasizes the hospital’s role as a referral impulsivity. point for more complex ADHD cases. In response to concerns expressed by community parents Community and Hospital and physicians regarding care for children with ADHD The Cincinnati metropolitan area includes 15 counties in the Cincinnati area, Cincinnati Children’s Hospital in Ohio, Kentucky, and Indiana with a total population Medical Center created a task force to determine the of over two million people. The population of the city scope of the problem and develop recommendations. proper was estimated at 287,540 in 2005. The average The task force soon realized that any approach to income in Cincinnati is $29,554 per household, with 25 addressing ADHD that was based at the medical center percent of the population living below the Federal would quickly reach capacity, so they began to look at Poverty Level. community-based options.

Cincinnati Children’s Hospital Medical Center The task force applied to the Cincinnati Children’s (CCHMC) is a 423-bed not-for-profit hospital. One of Patient Innovation Fund, a hospital-based grant pro- the largest hospitals in the tri-state region, Cincinnati gram that supports innovative projects to improve Children’s is committed to evidence-based pediatric care. patient care. They received a five-year, $1.8 million This ensures that the care and treatment provided are grant and created the ADHD Collaborative. This based on the best scientific information and medical quality improvement initiative is designed to improve practices available. access to evidence-based care for children in the com-

24 Case Examples munity with ADHD by helping community physicians Program Impact to develop more skill and confidence in making To date, all participating pediatric practices have substan- ADHD diagnoses. This increased role for physicians tially increased their adherence to evidence-based guide- reduces wait time for patients who would otherwise be lines. The collection of behavioral rating scales from par- referred to CCHMC to diagnose their condition. In ents and teachers has increased from an average of 38 addition, it reduces the need for CCHMC staff to be percent at baseline chart review to 95 percent. At base- involved in diagnosing and treating straightforward line, only 25 percent of children diagnosed with ADHD presentations of ADHD and, therefore, allows more met DSM IV criteria, but post training, the goal of 70 ready access to care for referrals of complex ADHD percent has been consistently achieved. Finally, the cases. change in care has resulted in 76 percent of patients showing a 25 percent reduction in symptoms on follow- Physicians who participate in the Collaborative receive up Vanderbilt rating scales by parents, and 85 percent of specialized training in diagnosing and managing patients showing a 25 percent reduction in symptoms on ADHD according to the evidence-based guidelines. follow-up Vanderbilt rating scales by teachers. The Collaborative team conducts chart reviews to obtain a baseline of how frequently the various compo- Program Funding nents of evidence-based care are delivered, such as col- See the program overview. lection of rating scales from both parents and teachers for diagnosis and ongoing monitoring of care, use of Obstacles or Challenges written care management plans, timely phone and The greatest challenge in implementing the project was office visits for titration of medication, and assessment recruitment of physicians to participate. Initially, the of side effects. Physician practices are given their per- pediatrician leading the Collaborative made personal formance data and taught to use quality improvement contacts with physicians he knew to get them involved. tools to organize their office to promote the implemen- Once those contacts were exhausted, they used direct tation of evidence-based guidelines. The team works mailings to send out a brochure describing the project with the physician practices to help them understand and enlisted the hospital’s physician representatives to and follow the evidence-based guidelines, such as how describe the Collaborative during their visits to commu- to score and interpret behavioral rating scales, when to nity pediatric offices. schedule follow-up appointments, and titration of medication. The team also makes suggestions regarding One of the obstacles to recruitment was the amount of billing and coding and provides data on third-party time the physician needed to invest to complete the reimbursement for ADHD-related visits. training. To overcome this barrier, the team has continually sought to reduce the number of training sessions. The primary incentive for physicians to participate in Currently, there are two sessions at the Medical Center the program is the priority access they receive to sub- and two sessions at the practice’s office. specialty services of psychiatry, psychology, and developmental and behavioral pediatrics at Cincinnati Success Factors Children’s through a consult phone line in the The main factor contributing to the success of the pro- Psychiatry Intake Response Center. The consult line gram was that primary care physicians in the communi- assists the primary care physician in obtaining access ty wanted to do a better job of providing care and to the appropriate subspecialty service for further eval- obtaining appropriate assistance and services for children uation and consultation or treatment for children with with ADHD and their families. Because Cincinnati ADHD and co-morbid conditions. Children’s relates well to community physicians and has built and fostered these relationships over time, it was In year three of the grant, there are 120 pediatricians evident to the physicians that the hospital wanted to participating in the ADHD Collaborative. The goal partner with them to develop and support a system that is to reach 70 percent (i.e., 238 physicians) of the worked for them and their patients. approximately 340 physicians on the medical staff at CCHMC who practice in the community. Once the Lessons Learned and Advice to Others program is fully implemented, the community will For others interested in setting up similar programs, the have a cadre of physicians who have the knowledge, experience of Cincinnati Children’s Hospital Medical skills, and tools to accurately assess ADHD and co- Center provides some helpful advice, including: morbid conditions, such as depression, anxiety, and • Enlisting a key opinion leader – in this case, a com- learning disabilities; offer appropriate medical manage- munity pediatrician – to lead the community initiative ment; set treatment goals; and coordinate care with the is a crucial factor to success. child’s school. • To ensure an adequate level of evidence-based ADHD

Practical Help for Hospital Leaders 25 Case Examples

care, it is important to work with the entire practice, not Division Director just the physicians, so that you can establish systems that Behavioral Medicine and Clinical Psychology support workflow and facilitate care management across Cincinnati Children’s Hospital Medical Center all office personnel, including schedulers, receptionists, Cincinnati, OH and nurses, as well as the physician. [email protected] 513-636-7116 Contact: Lori Stark, PhD • • •

Using Psychiatric Assessment and Liaison Services to Improve the System of Care John Muir Health, Concord, CA

Summary Overdose patients and those experiencing acute with- Behavioral health leaders at John Muir Health collabo- drawal were frequently placed in the acute care hospital rated with acute care hospitals in the system to develop intensive care units (ICUs), where staff could stabilize psychiatric assessment and liaison services. These servic- the patients, monitor the safe detoxification experience, es leverage behavioral health expertise in a collaborative and help minimize negative effects from withdrawal. In effort to improve operating efficiencies and enhance the ICUs and other medical/surgical units, however, patient care throughout the system. staff tended to be nervous about psychiatric and substance abuse patients – afraid of not doing the right Community and Hospital thing or concerned that someone might get hurt. Contra Costa is one of nine counties in the San Francisco- Oakland Bay Area. The ninth most populous county in In response to these and other issues, John Muir behav- California, it has one of the fastest growing workforces in ioral health leaders developed psychiatric assessment and the Bay Area. In 2005 the population of Contra Costa liaison services to assist with behavioral health patients was estimated at over one million. The median income in the acute care setting. The goal was to leverage was $69,487 per household, with 8.1 percent of the popu- behavioral health expertise in a collaborative effort to lation living below the Federal Poverty Level. improve operating efficiencies and enhance patient care throughout the system. The services provided to the John Muir Health is a locally owned and governed pri- acute care hospitals include: vate health system composed of three hospitals. John • Psychiatric assessment services. Registered nurses Muir Medical Center, Walnut Creek Campus, is a 321- (RNs) respond within one hour to provide assessments bed acute care facility that is designated as the only trau- of psychiatric patients who present to the hospital ma center for Contra Costa County. John Muir EDs. Medical Center, Concord Campus, is a 259-bed acute • Staff training for crisis intervention. ED staff are trained care facility serving Contra Costa and southern Solano in crisis prevention and intervention. Certified trainers counties. John Muir Behavioral Health Center, a 73- are available to conduct regular trainings of ED staff. bed acute psychiatric hospital, provides child, adoles- • Inpatient psychiatric consultation. Psychiatrists from cent, and adult inpatient and outpatient behavioral John Muir Behavioral Health Center are available on a health services and adult chemical dependency services. daily basis to consult on medical/surgical patients with psychiatric or chemical dependency issues. Program Overview • Liaison nurse service. An RN clinical specialist or John Muir Health emergency departments (EDs) were advanced practice nurse provides inpatient consulta- the recipients of both mental health and substance abuse tion to develop behavioral treatments plans with other patients whose aggressive or escalating behavior often clinicians. resulted in ED disruption and created anxiety among • Inpatient chemical dependency assessment and consul- staff. It was important to develop a consistent approach tation. Chemical dependency staff are available to throughout the system for handling these patients at a meet with medical/surgical patients regarding follow- clinical staff level, thus avoiding some of the negative up chemical dependency treatment. outcomes that can occur when a security approach to • Certified addictionologist. A physician certified by the behavioral problems is applied without clinical input. American Society of Addiction Medicine provides educa- Additionally, ensuring correct procedures for the appli- tion for staff of medical/surgical and intensive care units cation of involuntary holds in the ED were a concern. regarding detoxification protocols and complications.

26 Case Examples To address involuntary holds in the EDs, hospital repre- needs of the emergency departments and the extensive sentatives, physicians, ED staff, and county health lead- physician/nursing interaction required, the decision was ers formed a task force that clarified the criteria for made to use only RNs in the ED assessment role. In holds, developed policies and procedures, and prepared order to gain greater acceptance of the psychiatric nurse a video-based training program. ED physicians are liaison service, the liaison nurse spent several months required to participate in the training on an annual meeting with all of the appropriate disciplines to clarify basis and sign off on the policies and procedures. roles and boundaries.

Program Impact Success Factors John Muir Health has realized a number of benefits Because behavioral health care is an integral part of the from these services, including: mission of John Muir Health, the system has been • The use of psychiatric assessment in the ED has strongly supportive of the program. Behavioral health improved hospital emergency department throughput leaders have consistently educated colleagues and system by moving the patient to the most appropriate level of leaders on the value of behavioral health services and the care as quickly as possible and avoiding unnecessary importance of collaborative efforts in meeting the admissions. behavioral health needs of their community. • The services related to medical/surgical inpatients with behavioral health co-morbidities have reduced length of Lessons Learned and Advice to Others stay for these patients; decreased staff injuries and anxi- For others interested in setting up similar programs, the eties; improved patient care and the patient experience; John Muir Health experience provides some helpful enhanced patient safety; and reduced negative outcomes advice: such as delirium tremens, suicide attempts, and agitation. • Health systems that do not have a behavioral health • The training programs have not only improved the service or hospital should consider partnering with ability of ED staff to deal with patients in crisis but other hospitals or health systems for the components have also reduced liability regarding the application of of a psychiatric assessment and liaison service. involuntary holds. • Collaboration with local government and social service agencies is also important. Hospital and community Program Funding leaders should work together to ensure that behavioral To support the psychiatric assessment and liaison servic- health patients have access to community resources es, the acute care hospitals contract with behavioral and care. health services, which provides the nursing staff for the assessment service and contracts with independent psy- Contact: chiatrists for the consultation services. Elizabeth Stallings Chief Operating Officer Obstacles or Challenges John Muir Behavioral Health The development of each service component posed its Concord, CA own challenges. For example, when the ED assessment [email protected] service was begun, mental health counselors were used 925-674-4102 to provide the assessments. However, because of the • • •

Practical Help for Hospital Leaders 27 Case Examples

Recommendation 4 Hospital leaders should clearly communicate to public and private payers the costs required to care for behavioral health patients, especially those with chronic and severe conditions, and the costs to society of not treating those patients.

Ensuring Funding for Early-Intervention Services for Inner-City Children Bridgeport Hospital, Bridgeport, CT

Summary from the Connecticut Health Foundation. The goal of the The Child FIRST program at Bridgeport Hospital, program is to identify and assess children and families at Bridgeport, CT, provides early-intervention behavioral risk for emotional, developmental, and learning problems as health services and comprehensive supports for vulnera- early as possible. Each year, Child FIRST serves 900 vul- ble, underserved young children. Program leaders have nerable, underserved children from birth through five years developed consistent and varied funding streams by of age and their families, providing them with screening, emphasizing the fact that these services prevent condi- assessment, consultation, care coordination, and intensive tions that require much more costly and generally less home-based mental health treatment, as needed. effective services later on in these children’s lives. Program Impact Community and Hospital Research data demonstrate that Child FIRST has con- Situated around a harbor on the Long Island Sound, tributed to a statistically significant decrease in children’s Bridgeport is the largest city in Connecticut. According emotional and behavioral problems, a decrease in parental to the 2005 estimates, the city’s population is 132,011, depression and stress, and a decrease in protective service and the median income for a household in the city is involvement. There is improvement in language develop- $36,976. Approximately 17.9 percent of the population ment and in parent-children interactions in families with lives below the Federal Poverty Level. multiple challenges, as well as increase in access to services for all family members served by Child FIRST. Bridgeport Hospital is a 354-bed not-for-profit hospital and the principal affiliate of Bridgeport Hospital & Healthcare Program Funding Services, Inc. with Ahlbin Rehabilitation Centers and the In order to continue the services and expand the reach Bridgeport Hospital Foundation. The hospital is also a of this valuable program, Child FIRST leaders have member of the Yale New Haven Health System. tapped a variety of funding sources, local and national, public and private. In addition to grants from the Program Overview Connecticut Health Foundation, funds have been Babies born to inner city Bridgeport mothers face multiple secured from the Substance Abuse & Mental Health barriers to success. Over 25 percent of Bridgeport’s 13,600 Services Administration, the U.S. Department of Justice young children live below federal poverty levels. In the Office of Juvenile Justice and Delinquency Prevention, Bridgeport Hospital Pediatric Primary Care Center, more and the U.S. Department of Education. Through the than 50 percent of children screened under age six years Robert Wood Johnson Foundation (RWJF) Local have behavioral problems and more than 45 percent face Initiative Funding Partners Program, Child FIRST multiple environmental risks, including those related to received financial support from multiple organizations domestic violence, maternal depression, substance abuse, concerned with the welfare of young children and their unstable housing, inadequate health care, poor education, families, as well as matching funds from RWJF. illiteracy, unemployment, and teen- and single-parenting. While grant support has been a significant factor in estab- A considerable portion of behavioral health dollars invested lishing and sustaining Child FIRST, program leaders rec- in the later years of childhood is in interventions to address ognize that this “patchwork” approach to funding services conditions that could have been prevented through increased does not provide stability over time. For several years, interventions in early childhood. The challenge is to devel- Child FIRST leaders have worked to get access to state op consistent funding streams to support early intervention and federal dollars for the program through Medicaid. In services. Child FIRST (Child and Family Interagency 2005, Child FIRST became the first home-based, psy- Resource, Support, and Training) at Bridgeport Hospital chotherapeutic intervention for young children in was officially established in 2001 with a grant of $80,000 Connecticut to receive approval for Medicaid reimburse-

28 Case Examples ment for children with mental health diagnoses. Program Lessons Learned and Advice to Others leaders are now advocating for the use of Medicaid’s Early For others interested in setting up similar programs, the Periodic Screening, Diagnosis, and Treatment (EPSDT) experience of the Child FIRST program at Bridgeport program for reimbursement for screening, assessment, Hospital provides some helpful advice, including: and treatment for very young children who show “med- • Be sure that hospital leaders understand how your ical necessity,” but are not yet diagnosable. community-based program benefits both the hospital and the community. Although both grant funds and Medicaid reimbursement • This must be a collaborative effort if it is to be success- are essential components of the Child FIRST fiscal strat- ful. Build partnerships with all other community egy, neither provide support for all the services that the providers serving families with young children. program’s high-risk population needs. Longer term, the • Applying for grants or advocating before government goal is to secure funding for Child FIRST through state agencies requires a thorough knowledge of your target budget appropriations so that the services can be population and its behavioral health care needs. You expanded and developed in other locations in the state. must have a passion for your program and be able to Currently, research staff are analyzing data from a ran- convey that passion clearly and concisely. domized trial to prove the effectiveness of this model. • Understand the mission and the goals of each grant- They plan to conduct cost-benefit analyses in order to making organization to which you apply. Know what demonstrate to state agencies and the state legislature the organization wants, answer their specific questions, that investing resources on intervening at the earliest and provide the information they request. signs of problems can save thousands of dollars per child • Do not extend your program outside its mission. Find on costs for serious emotional disturbance, special educa- foundations whose interests align with yours. Avoid tion, foster care, juvenile justice, and teen pregnancy. developing fragmented services by chasing after money. • Never start a program without identifying the out Obstacles or Challenges comes that you want to measure. All funders – private • Securing funds through grants has been a time-con- and public – want to see outcomes. suming and labor-intensive process. • Always look ahead at how you will sustain the pro- • Making changes in the publicly funded health care gram. Think outside the box. system from the bottom up is difficult and complex. In Connecticut, Child FIRST program leaders have Contact: worked with seven different state agencies in advocat- Darcy Lowell, MD ing for behavioral health care dollars. Executive Director, Child FIRST Section Chief of Developmental and Behavioral Pediatrics Success Factors Bridgeport Hospital The support of hospital leadership is key to the success Bridgeport, CT of any community initiative. The connection of Child [email protected] FIRST to the hospital was an important factor for mak- 203-384-3626 ing contacts, building trust, and linking to clinicians. • • •

Negotiating with Payers and Legislators for Addiction Treatment Services Mercy Medical Center, Williston, ND

Summary Approximately 13.4 percent of the population lives To meet the addiction treatment needs of its region, Mercy below the Federal Poverty Level. Medical Center helped create a coalition to represent those needs to legislators and payers. The coalition spurred the Mercy Medical Center is an 87-bed regional medical facili- passage of legislation to cover residential services, which ty that serves approximately 50,000 people in western allowed Mercy to provide day treatment services to a popu- North Dakota and eastern Montana. In 1996, Mercy lation that is dispersed across a large service area. Medical Center became part of Catholic Health Initiatives.

Community and Hospital Program Overview Williston, ND, is the county seat of Williams County. In the 1980s, behavioral health care providers in North As of 2000, the population of Williston was 12,512 Dakota were faced with increasing costs, declining reim- with a median income of $29,962 per household. bursement, and growing payer restrictions on hospital

Practical Help for Hospital Leaders 29 Case Examples

stays and treatment options. Efforts to develop innova- ment services was subsequently passed. With this added tive treatment programs were stymied by insurers’ financial support for the guesting program, Mercy unwillingness to pay for the appropriate levels of care. Medical Center is able to more effectively meet the needs In response to these challenges, the North Dakota of a population dispersed across a large service area. Addiction Treatment Providers Coalition, a statewide network of both public and private organizations, was The success achieved by the coalition has stimulated created. Through the coalition, providers of substance Mercy to look for new opportunities to extend their abuse treatment services established a consolidated and services. Mercy has recently contracted with the state to coordinated approach for representing the needs of their provide addiction treatment for patients who are unable patients and their organizations to legislators and payers. to pay, with reimbursement provided on a capitated Leaders from Mercy Medical Center have played an basis. They have also contracted with an Indian reserva- active role in the coalition from its founding. tion to provide intensive levels of addiction care that are not available in the tribal program. One of the key needs identified by coalition members was more effective communication with Blue Cross Blue Shield Program Impact of North Dakota (BCBSND), the state’s largest insurer. To The impact of the coalition’s work has gone beyond that end, staff from Mercy worked with other coalition achieving success in the legislature and with the insur- members to develop a list of the providers’ leading con- ance companies. When the governor created the North cerns and shared this list with BCBSND. The goal was to Dakota Commission on Drug and Alcohol Abuse in ensure that both providers and insurers were on the same 2002, the coalition was asked to have a representative on page and speaking the same language with regard to the the commission. Staff from Mercy Medical Center costs and benefits of various treatment options and levels of served in that role. As a result of the commission’s work, care. In the late 1980s, the coalition was able to negotiate legislation was passed addressing treatment for metham- for more realistic allowable days of care so that individual phetamine abuse – a growing problem in the Midwest – providers did not have to be in continual conflict with the including matching funds for a federal grant supporting insurer over treatment coverage. specific methamphetamine treatment programs.

To increase their leverage, coalition members also began Obstacles or Challenges developing political contacts and educating legislators The greatest challenge the coalition faced in negotiating with regard to behavioral health services. In the North with legislators and payers was establishing credibility. Dakota legislature, individuals may testify in any com- In order to build credibility, coalition members had to mittee hearing. Mercy Medical Center leaders and prove themselves by making sure that any position they other coalition representatives often testify at hearings advanced related to treatment coverage was supported for legislation related to behavioral health services. Their by data and case examples. presence on the political scene ensures that legislators understand the issues from the providers’ as well as the Success Factors insurers’ point of view and are able to make well- Over the years, the coalition established credibility with informed decisions about proposed legislation. BCBSND, resulting in mutual trust and respect between providers and the insurer. Coalition members The work of Mercy Medical Center with the North have learned to wield their influence effectively, so that Dakota Addiction Treatment Providers Coalition has “paid if the insurers are not responsive, members feel confi- off” in very specific ways. In the early 1990s, Mercy tran- dent going to the insurance commissioners, their legisla- sitioned out of inpatient substance abuse services. To tors, and other power sources. meet the needs of their patients, the hospital developed a residential partial hospitalization/day treatment program. Lessons Learned and Advice to Others They use 14 beds in an open wing of the hospital for For others interested in this type of initiative, the Mercy overnight “guesting” of patients who travel long distances. Medical Center experience provides some helpful advice: • Before you appear before legislators or payers, set well- Initially, BCBSND payments covered only the day treat- defined goals for what you want to achieve. ment portion of the stay. In 2005, the coalition • Present your case from a negotiating, not adversarial, approached their contacts in the legislature to present the stance. case for coverage of the residential portion also. Meeting • Do your homework and be prepared. Be sure your posi- with resistance from BCBSND, coalition members were tion is well documented and supported by the facts. successful in gaining support from the state attorney gen- • Be honest and don’t try to embellish or distort the eral’s office. Legislation requiring insurance and managed facts. If you don’t know, don’t bluff. care companies to include coverage of residential treat- • Be proactive and stay ahead of the game. Use your

30 Case Examples contacts to get all the information you can about what Mercy Medical Center may be coming down the road. Williston, ND [email protected] Contact: 701-774-7409 Donald Wahus Manager, Behavioral Health • • •

Addressing the Costs of Fragmentation in the Behavioral Health Care System Ohio State University Medical Center, Columbus, OH

Summary ders of patients with significant medical problems. Hospital leaders at Ohio State University Medical As a further step toward integrated services, hospital Center have actively communicated with both internal leaders have advocated before legislators and county and external stakeholders the clinical and economic commissioners for centers of excellence where both med- benefits of developing better-coordinated systems of ical care and psychiatric care can be delivered. In Ohio’s care for behavioral health needs and the costs to the current system, patients with medical problems receive community of not doing so. care at community health centers, many of which do not provide psychiatric services. Those with psychiatric Community and Hospital problems go to community mental health centers. For Located near the geographic center of the state, patients who require both medical and behavioral health Columbus is the capital of Ohio. In 2005, the estimat- care, the system is complex and difficult to navigate. ed population was 693,983, with a median income of There is a lack of clinical coordination and communica- $40,405 per household. Approximately 18.5 percent of tion among agencies and providers. the population lives below the Federal Poverty Level. In order for integrated care to work, however, changes Ohio State University (OSU) Medical Center is central have to be made in the reimbursement system. Public and southeastern Ohio’s only academic medical center. payers and many private insurers will not cover charges Located on the OSU Medical Center campus, OSU for a medical visit and a psychiatric visit on the same Harding Hospital offers comprehensive behavioral day. OSU Medical Center leaders have begun to address health care services and programs for children and ado- this issue with the state department of mental health lescents, adults, and older adults. and the local behavioral health authority and have worked to convince legislators of the necessity of chang- Program Overview ing funding rules. They have also talked with some of Out of Ohio’s population of 11.4 million, it has been the large employers and managed care companies in estimated that more than 2 million individuals experi- Columbus, communicating the message that providing ence a mental disorder. Only about half of those who coverage for medical/psychiatric care on the same day is need mental health treatment actually receive services. beneficial to the patient, increases patient compliance, Expanding needs and limited resources have stressed the and ultimately saves money. publicly funded system. Fragmentation and lack of coordination of behavioral health services have added to Hospital leaders have communicated the clinical value the cost of care and created challenges for patients, and long-term cost-effectiveness of service integration to providers, and payers. internal stakeholders as well as external. Because primary care physicians are frequently the initial health care OSU Medical Center leaders have been on the forefront contact for patients with mental disorders, they are in a of advocacy for more integrated systems of care as a unique position to provide integrated care for persons strategy for improving care and reducing costs. They with coexisting medical/psychiatric illnesses. Each year, have worked closely with the Ohio Department of OSU Harding offers web-based continuing medical edu- Mental Health and the local Alcohol, Drug and Mental cation programs for primary care physicians on depres- Health (ADAMH) Board to develop better coordina- sion and chronic medical illness. They also conduct tion of inpatient and outpatient behavioral health serv- symposia directed toward both psychiatrists and primary ices and more integration of medical and behavioral care physicians on identifying and delivering emergency health care. A key message has been the high cost to psychiatric services to various populations. A psychiatric the community of not treating the mental health disor- consultation liaison program for medical/surgical

Practical Help for Hospital Leaders 31 Case Examples

patients at the medical center has been very successful. Lessons Learned and Advice to Others For hospital leaders interested in getting more involved Program Impact in communicating the cost of care, OSU Medical OSU Medical Center has realized a number of out- Center’s experience provides some helpful advice, comes in response to their ongoing efforts to communi- including: cate the value of integrated care: • No single component of the system can make the • The local ADAMH board has contracted with OSU changes that are needed for integrated care because Harding to provide psychiatric care to their patients each is responsible for a different aspect of care and with significant medical illnesses. financing. Bring them all to the table and help them • OSU recently partnered with the Ohio Department of understand that providing behavioral health care and Mental Health and the local ADAMH board to devel- coverage is good for the patient, good for the commu- op and fund a professor of public psychiatry position nity, and good for the economy. within the OSU Department of Psychiatry. The goals • Tailor your message to your audience. For employers, of this placement are to improve and expand the provide data that clearly show that the cost of behav- behavioral health workforce, provide community- ioral health care is small compared to the costs of focused training experiences, and create a center of employee absenteeism, loss of productivity, and extend- excellence for integrated care. ed medical care due to untreated psychiatric disorders. • OSU Department of Psychiatry was asked to create a When working with state or community agencies, system for psychiatric evaluation and treatment for focus on how system improvements and evidence- depression for all patients admitted to the OSU based care can deliver more effective and more efficient Medical Center’s heart hospital. services that reverse the higher costs of poor treatment. When talking with legislators, describe patients and Obstacles and Challenges their problems first, to create an emotional connection; The key challenge is convincing both public and private then produce data to support the need for change. payers that the cost to cover behavioral health services is not prohibitive and pays off in the long run. Contact: Radu Saveanu, MD Success Factors Executive Director OSU Medical Center staff have been successful in get- OSU Harding Hospital ting their message across because they consistently advo- Chair, Department of Psychiatry cate on many fronts — hospital administrators, physi- [email protected] cians, state and local agencies, legislators, employers, 614-293-8283 insurers, and managed care companies. • • •

Recommendation 4b Hospital leaders and their associations should become advocates for the public mental health system and its adequate funding.

Building a Coalition to Reform the Children’s Mental Health System Children’s Hospital Boston, Boston, MA Summary Community and Hospital Children’s Hospital Boston collaborated with four Boston is the capital of Massachusetts and the largest city other organizations to launch a long-term campaign in the New England states. In 2005, the population of calling for major reform of the state’s mental health Boston was estimated at 520,702. The average income care system for children. They are not only seeking in the city is $42,562 per household, with 22.3 percent legislative remedies, but are also working with state of the population living below the Federal Poverty Level. administrative offices and with private payers to reach their goal of a more effective children’s mental health Children’s Hospital Boston is a 347-bed comprehensive system. center for pediatric health care located in the Longwood

32 Case Examples Medical Area. In addition to serving its local commu- ments of each of the coalition’s recommendations. The nity, Children’s attracts patients from across the U.S. legislation calls for changes that will: and from more than 100 countries each year. • Identify mental illness earlier in children by reaching them in familiar and easily accessible settings, especial- Program Overview ly schools, early education programs, and pediatricians’ It has been estimated that more than 100,000 – 70 per- offices. cent – of the children and adolescents who need mental • Ensure that when identified, the illness is treated in health services in Massachusetts do not receive them. the least restrictive, appropriate setting. Inconsistent mental health policy among state agencies • Improve insurance coverage for children with mental and multiple but separate funding streams have resulted health needs. in a fragmented delivery system that is difficult to access • Restructure the oversight, evaluation, and provision of and navigate. children’s mental health services administered by the state. Children’s began to address mental health system reform issues internally and externally six years ago with the Leaders of the campaign will continue to work on inception of the Child and Adolescent Mental Health redrafting the bill and providing advocacy input and Advocacy Initiative (CAMHAI). CAMHAI reflects the support as needed. The outcome of legislative activity hospital’s belief that systemic advocacy and policy will not be determined for another year; however, the reform are crucial to improving child mental health in coalition is already anticipating needs related to imple- Massachusetts. CAMHAI engages and interacts with a mentation and evaluation of new legislation. broad array of external partners, including policymakers, provider coalitions, parents, and community advo- Coalition leaders view their partnership as a five-year cates, to further its agenda. project. They are not only seeking legislative remedies, but are also working with state administrative offices and In 2006, Children’s collaborated with the Massachusetts with private payers to reach their goal of an integrated Society for the Prevention of Cruelty to Children mental health care system for all children needing care. (MSPCC), Health Care For All, Health Law Advocates, Inc., and the Parent/Professional Advocacy League to Program Impact launch a long-term campaign calling for major reform Although it is too early to gauge the full impact of this of the state’s mental health care system for children. campaign, the coalition has succeeded in getting issues The campaign was introduced by the release of a paper, related to the children’s mental health system in the pub- “Children’s Mental Health in the Commonwealth: The lic eye and on the platform for public debate. One rec- Time is Now,” co-authored by Children’s and the ommendation advanced by the coalition – the need for a MSPCC. The paper describes a seriously flawed mental coordinator to oversee compliance in the implementation health care system and advances specific recommenda- of remedial plans and court orders in Rosie D. v. Romney tions for prevention, timely diagnosis, and appropriate – has already been put into action by the administration. intervention for children. Program Funding One of the events providing impetus for the campaign Initially, each partner organization contributed fiscal, was the decision in January 2006 in the Rosie D. v. personnel, and material resources to support the initia- Romney case. In that case, the U.S. District Court tive; however, as it became apparent that long-term judge ruled that the Commonwealth of Massachusetts resources were needed, the coalition began to consider violated the federal Medicaid Act by failing to provide alternative funding sources. In order to ensure that the appropriate home-based mental health care to an esti- partner organizations were not competing against each mated 15,000 children. This landmark decision and other in the philanthropic community, they developed a the subsequent remedies advanced by the funding consortium for the campaign. Children’s Commonwealth will significantly alter the mental Hospital Boston provides the organizational resources to health system for children with publicly funded insur- secure, manage, and distribute the funds. ance. The coalition seized the opportunity for a call to action to address the needs of all children needing men- Obstacles or Challenges tal health care and treatment, regardless of their insur- Because the behavioral health field tends to have a ance type or level of need. “siloed” and turf-based approach to system problem solving, organizations often advance their individual Just six weeks after the launch of the campaign, the “fixes” for the portion of the system that affects their coalition was successful in getting a bill introduced in primary constituents, rather than for the system as a both houses of the state legislature that incorporates ele- whole. The challenge for coalition leaders was to con-

Practical Help for Hospital Leaders 33 Case Examples

vince participating organizations to see beyond their ence provides some helpful advice, including: narrow interests and take a more holistic approach in • Be sure you have buy-in and support from your hospi- order to build an enduring platform for change. tal’s senior leadership for your advocacy campaign. • Before you begin, assess where you are and where you Success Factors need to invest your resources. You may need to start • Leaders at Children’s Hospital Boston view advocacy with building awareness or developing relationships as a core component of their mission. before you can advance a major campaign. • The hospital has a proven track record for advocacy on • Recognize and leverage opportunities created by a broad range of issues related to child and adolescent changing political climates, heightened public aware- health. ness of issues, media coverage of significant events in • Over the last several years, hospital advocacy leaders have the field, or synergies with potential partners. established strong relationships with other providers, con- • Keep your advocacy campaign focused on issues that sumer organizations, public and private agencies, govern- address the needs of your community or your target ment staff, philanthropic organizations, and others who population, not just the needs of your individual insti- share their interests and concerns. tution. Sound advocacy can bring solutions that ulti- • For a campaign of this magnitude, hospital leaders recog- mately address your hospital’s concerns. nized that it was important to get senior staff from each • Make sure that everyone at the coalition table has a of the partner organizations on board so that these indi- voice and that coalition leaders are skilled in building viduals could network and get others engaged. consensus even when partners disagree. • The coalition established at the outset that they wanted not to just heighten awareness of the problems but Contact: actually drive policy solutions. They consciously and Joshua Greenberg deliberately shaped every aspect of the initiative Director, State and Federal Relations toward that purpose. Children’s Hospital Boston Boston, MA Lessons Learned and Advice to Others [email protected] For hospital leaders interested in advancing major advo- 617-355-2834 cacy campaigns, the Children’s Hospital Boston experi- • • •

Supporting Advocacy for the Behavioral Health System Moses Cone Health System, Greensboro, NC

Summary beds and 30 child and adolescent beds) that features Leaders and staff at Moses Cone Health System are three outpatient center programs and space for outdoor strongly encouraged to become active in advocating for recreation opportunities. their areas of responsibility. Health system leadership have actively addressed the needs of behavioral health care at Program Overview local and regional levels and have cultivated relationships Involvement in health care advocacy efforts at all levels with elected officials, opinion leaders, and policymakers, as has been a long-standing tradition at Moses Cone well as local and national grassroots organizations. Health System. Members of the leadership team are encouraged to take active roles in advocacy and to be Community and Hospital leaders in civic and community organizations. Hospital Greensboro is located in central North Carolina, in the leaders participate in local and regional grassroots efforts heart of the Piedmont Triad Region. In 2005, through affiliation with agencies like the Mental Health Greensboro had an estimated population of 208,552, Association in Greensboro, the North Carolina with a median income of $36,733 per household. Psychiatric Association, and the North Carolina Approximately 17.3 percent of the population lives Hospital Association. below the Federal Poverty Level. In 2001, the North Carolina General Assembly passed Moses Cone Health System, Greensboro, NC, is a legislation that dramatically changed the delivery of multi-hospital system with a primary service area that publicly funded mental health care in the state, with the covers five counties. The Behavioral Health Center, also goal of shifting care to counties and the private sector located in Greensboro, is an 80-bed facility (50 adult and thereby reducing reliance on state hospitals. The

34 Case Examples impacts of reforming the delivery system – both antici- are key players in advocating for better financing and pated and unanticipated – have been key targets for better care for behavioral health patients. These organi- advocacy efforts at the local and state levels. zations include the Section for Psychiatric and Substance Abuse Services of the American Hospital Association In his role on the board of the Mental Health Association and the Committee on Behavioral Health Services within Greensboro, the Moses Cone Health System in General Healthcare Systems of the National Behavioral Health Center administrator helped prepare a Association of Psychiatric Health Systems. Moses Cone letter to all members of the General Assembly advocating Health System leadership emphasize the importance of a moratorium on further state-mandated terminations of being involved at every policy-making level because local mental health services and requesting additional behavioral health services are impacted by every level. funding to support the mental health system. Also sent to local newspapers and county commissioners, the letter Obstacles or Challenges pointed out that reforms have not only resulted in more The greatest challenge has been getting the attention of limited and less effective care for consumers of mental those who are in positions to make decisions or influ- health services, but at the same time have created prob- ence change, such as executives of non-health care busi- lems elsewhere, such as in hospital emergency depart- nesses, elected officials, and law enforcement personnel. ments, homeless shelters, and jails. Although the mora- Sometimes they are not knowledgeable and therefore not torium was not adopted, approximately $100 million was interested in behavioral health issues, but it is still neces- added to the budget of the state Division of Mental sary to keep trying to get the message across. Health, Substance Abuse and Developmental Disorders. Success Factors Moses Cone Health System leaders partner with other Moses Cone’s four essentials for successful advocacy are community leaders to speak out on those issues that are passion, commitment, perseverance, and involvement. the priorities of its community so that they can get attention from county commissioners, legislators, and Lessons Learned and Advice to Others other decision makers. Moses Cone, as the largest pri- For hospital leaders interested in getting more involved vate employer in Guilford County, has a wide range of in advocacy, Moses Cone Health System’s experience contacts and exposure in the community. They can provides some helpful advice, including: leverage those connections to build relationships with • If you feel strongly about a specific matter, it’s impor- local opinion leaders. tant to make it known. Get your own message out, rather than letting others communicate for you. For example, after hearing about a mental health court • Find out who the key opinion leaders and decision that had been established in a neighboring county, makers are and spend time with them. Moses Cone leadership approached local district court • Don’t wait for things to happen—make them happen. judges to gather support for a similar court in Guilford Be involved in creating the future. Don’t sit back and County. Mental health courts have a separate docket let others decide the future for you. for defendants, are handled by a designated judge, and • Develop strong relationships with state legislators so incorporate a non-adversarial, team approach. They that you can make sure they are getting the right mes- seek to reduce offenses by providing treatment for the sages. Any time you can supply one more piece of mentally ill rather than punishment. information to supplement – or counteract – other information they receive, you have a chance of creat- The judges were supportive, but there was no funding ing another advocate for behavioral health care. available. When the courts failed to obtain a grant from the state to fund this initiative, the Moses Cone Wesley Contact: Long Community Foundation was recommended as a Paul Jeffrey source of funding. With support from the Mental Vice President/Administrator Health Association and other providers, the foundation Wesley Long Community Hospital awarded the Guilford County Court System a $261,000 Moses Cone Health System grant over three years to launch the “alternative court.” Greensboro, NC [email protected] In addition to local involvements, Moses Cone leader- 336-832-1400 ship actively participates in national organizations that • • •

Practical Help for Hospital Leaders 35 Notes

36 Case Examples Recommendations Summary

Community Needs Assessment Recommendation 4a To supplement public and private insurance for behavioral health Recommendation 1 services, hospital leaders should seek additional and specialized Hospital leaders should ensure that assessments of the health funding from foundations, employers, community philanthropies, needs and resources in their community include specific attention grants, and governmental appropriations. to behavioral illness. Recommendation 4b Hospital leaders and their associations should become advocates for Hospital Behavioral Health Plan the public mental health system and its adequate funding. Recommendation 2 Hospital leaders should review and evaluate the organization’s behavioral Employer Practices health plan in light of identified community needs, the behavioral health needs of their patients, and available community resources. Recommendation 5 Recommendation 2a Hospital leaders should incorporate, as feasible and appropriate, the Hospital leaders should use a comprehensive financial and operational employer practices recommended by the National Business Group on assessment to evaluate the benefits and economic value of behavioral Health in “An Employer’s Guide to Behavioral Health Services” and health services to all operational components of the hospital. share the recommendations with other employers in their community.

Community Collaboration Advocacy Recommendation 3 Recommendation 6 Hospital leaders should encourage and actively participate in (1) Hospital leaders should encourage and be actively involved with their developing a community-wide and/or regional plan for persons with regional, state, and national associations to broaden their engagement behavioral health disorders and (2) coordinating community agencies and advocacy for behavioral health, including: addressing behavioral health needs. Recommendation 3a Promoting recognition that behavioral health is an essential Hospital leaders should work with community agencies and support component of positive health status; services and with state and local governmental authorities to ensure • Continuing to advocate for parity in behavioral health coverage; that all patients are treated in the most appropriate setting so that • Broadening the behavioral health advocacy agenda beyond payment; the hospital’s backstop role is appropriately limited. • Supporting initiatives to increase the supply of behavioral health Recommendation 3b clinicians, including psychiatrists, psychologists, advanced Hospital leaders should create a formal plan that clearly defines its practice nurses, and social workers; role and its established relationships for behavioral health with other • Encouraging primary care practitioners to identify and treat the providers, practitioners, and governmental and community agencies. behavioral health needs of their patients; • Obtaining adequate payment rates for Medicaid and Medicare Recommendation 3c patients with behavioral health disorders; Where inpatient acute beds for behavioral health patients are not available in a region, hospital leaders should seek governmental assistance • Assuring behavioral health is included in chronic care demonstration that would allow hospitals to collaborate across multiple institutions in projects supported by Medicare and other payers; order to develop needed regional inpatient behavioral health services. • Supporting the financial needs of the public mental health system and increased public accountability for its performance; • Monitoring major behavioral health initiatives (e.g., New Mexico’s Adequate Financing pooling of public funds) and sharing lessons learned with the membership, and Recommendation 4 Hospital leaders should clearly communicate to public and private • Forming behavioral health partnerships and joint initiatives at the payers the costs required to care for behavioral health patients, state and national level that mirror those needed in local especially those with chronic and severe conditions, and the costs to communities. society of not treating those patients.

Practical Help for Hospital Leaders 37 www.aha.org 9/07